Novel Approach To Avf With Irreparable Outflow Obstruction- Technique And Outcomes
Brandi Mize, MD, Young Lee, MD, Ronald Chang, MD, Guillermo A. Escobar, MD.
Emory University, Atlanta, GA, USA.
OBJECTIVES: When venous outflow obstruction cannot be resolved, severe swelling, pain and extremity dysfunction traditionally is followed by ligation and discarding a mature AV fistulas (AVF), leading to prolonged dialysis catheter dependence. This is especially devastating when there is no other suitable vein in the contralateral extremity. We wished to determine if using a mature (albeit potentially aneurysmal or thrombus-laden) AVF could be translocated to both treat the swelling and allow for early, autologous access and limit catheter dependence.
METHODS: We explanted mature AVF from patients with unresolvable venous outflow obstruction and translocated them to the contralateral extremity. Conduits were repaired (resection or plication of aneurysms, removal of calcified segments with end-to-end re-anastomosis, and/or underwent thrombectomy/endarterectomy) ex-vivo and re-implanted in the contralateral extremity.
RESULTS: 3 patients with severe swelling, pain and a disfigured extremity had occluded central veins, all failing multiple attempts at endovascular resolution. 100% achieved functional access after transposition. Mean time to use was 44 days (median 37). Primary patency mean 315 days (Median 300). None required re-intervention. All required repair or partial resection of AVF aneurysms prior to contralateral implantation. Mean surgical time was 7.96hrs. All patients had complete resolution of their original symptoms.
CONCLUSIONS: Translocation of mature venous conduits to new sites seem very successful even if they require repair/resection of aneurysmal portions. Surgical times are long and meticulous technical skill is needed to prepare and re-implant these large conduits. However, these are offset by a high success rate for both symptom resolution and creation of a functional fistula. In addition, there is short catheter dependence compared to traditional approaches of ligation, recreation and awaiting unpredictable AVF maturity (assuming there is another usable vein). We believe that discarding usable, autologous venous conduits should be discouraged despite the technical challenges. 
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