Vol. 118, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
BOVINE GRAFTS IN VASCULAR ACCESS FOR HEMODIAL YSIS: LOOP VERSUS STRAIGHT FOREARM CONFIGURATION DAVID H. ZORNOW
EUGENE F. FUCHS
From the Danville Urologic Clinic, Danville, Virginia
Experience is described with 25 bovine grafts for vascular access and hemodialysis m 19 patients. Loop forearm grafts gave significantly better results than the straight fore, ration. It is suggested that the higher flow rate attendant upon the use of the brach more important to graft success than is the configuration of the graft itself. Because of the close relationship of hemodialysis and renal transplantation many urologists are finding themselves involved with vascular access. Indeed, many of the newer urologic textbooks include sections on the techniques of arteriovenous fistula. Unfortunately, some of the adjunctive procedures that become necessary when good peripheral vessels are not available have not been described in the urologic literature. Experience with 25 bovine heterografts in 19 patients is described.
uration occurred after 12 months in a graft that had never been used for dialysis. The etiology of this failure is not clear but might be related to the intimal or neointimal fibrous proliferation described by Imparato and associates. 2 Abscess formation secondary to percutaneous needle puncture has occurred on 2 occasions and has been handled by simple incision and drainage without loss of the functioning graft.
MATERIALS AND METHODS
Haimov and associates have described the use of the saphenous vein and bovine carotid artery to create a loop forearm fistula and noted poor long-term survival of the graft in each instance (42 per cent of saphenous veins open at 12 months and O per cent of bovine grafts functioning after 2 months).'3 The results of the straight forearm grafts in their series, on the other hand, were significantly better, 100 per cent of saphenous and 80 per cent of bovines being open at 12 months. These results led the authors to suggest that the loop configuration was "probably hemodynamically wrong". 4 Since that time Biggers and associates/ as well as Lefrank and Noon, have described good results using the forearm loop configuration for vascular access. Our results would support their contention that the loop bovine graft is a valuable method of vascular access in a patient who is not a candidate for arteriovenous fistula. In cases in which the brachia! or femoral artery has been used for arterial perfusion with the expected higher flow rates 91 per cent of the grafts are currently
The patient population consisted of 10 male and 9 female subjects. Nine patients had loop forearm grafts, 15 patients had straight forearm grafts and 1 patient had a loop leg graft. Vascular sutures of 6 and 7-zero prolene were used and the anastomoses were performed with the standard techniques described by Lefrank and Noon. 1 The specific procedures and results are described in table 1. RESULTS
Followup in these cases is from 2 to 16 months. There are 14 grafts currently functioning and being used for hemodialysis 3 times a week. The average interval on dialysis of the functioning grafts is 8.9 months, with a mean of 9 months. Three patients died with functioning grafts and 8 grafts failed, requiring secondary procedures. The over-all success rate is 68 per cent. Of the 8 grafts that failed 5 were considered to be early (within 1 month of the operation) and 3 were late failures. Since the late failures were not related to technical or perfusion difficulties the over-all initial success rate was 80 per cent. Of the 9 loop forearm grafts attempted 8 are still functioning or were functional when the patient died. The single failure occurred after 12 months and the patient subsequently died with a functioning loop forearm graft. The single loop leg graft was still functioning after 10 months. Followup for the loop grafts is from 2 to 16 months, with an average of 9.5 and a mean of 9.0. Fourteen straight forearm grafts were done between the distal radial artery and the cephalic or median cubital vein at the elbow. Seven of these grafts subsequently failed, resulting in a 50 per cent over-all success rate. A single brachia! artery to a distal cephalic vein graft was functioning after 2 months. Followup of the straight grafts is 2 to 15 months, with an average of 8.5 and a mean of 8.0. There were 5 early failures, all of which were in straight grafts and were believed to be secondary to either inadequate perfusion or technical problems with the anastomosis. Of the late failures 2 were secondary to thrombosis after multiple percutaneous punctures. The single failure with a loop config-
1. Procedure and results No. Cases
Loop: Brachia! artery to median cubital or cephalic vein
90 Femoral artery to saphenous vein Forearm straight: Radial artery to median cubital or cephalic vein
Brachia! artery to distal cephalic vein
2. Large versus small vessel perfusion Total No. Cases
Large vessels: Forearm loop Leg loop Forearm straight (brachia! to distal cephalic) Totals Small vessels: Straight (radial artery)
Accepted for publication March 18, 1977. 714
Functional No. (%)
BOVINE GRAFTS IN VASCULAR ACCESS FOR HEMODIALYSIS
or were functioning until the died (table 2) Small vessel perfusion (radial artery), on the other hand, resulted in a 50 cent over-all success rate. Five in this group initial failure of the straight bovine subsequently, had successful grafts perresults we noted with the straight bovine grafts seem to related to either technical problems or inadequate flow at the level of the distal radial artery.
that the distal radial artery perfusion will be maintain flow.
l. Lefrank, E. A. and Noon, G. P.: Surgical technique for creation
The use of the bovine ~~r,~~~~·-H seems to be an excellent alternative for vascular access in the patient who is not a candidate for conventional arteriovenous fistula. The loop h,ot,m•rsnc.-c,tfo in our series were significantly better than the forearm configuration. These results are in direct vv'"""v" to the experience of Haimov and associates. ·· a straight forearm graft should to switch to the loop configuration if it appears
of an arteriovenous fistula using a looped bovine graft. Ann. Surg., 182: 782, 1975. Imparato, A. M., Bracco, A., Kim, G. E. and Zeff, R.: Intimal and neointimal fibrous proliferation causing failure of arteri8l reconstructions. Surgery, 72: 1007, 1972. Haimov, M., Burrows, L., Baez, A., Neff, M. and Slifkin, Alternatives for vascular access for hemodialysis: experience with autogenous saphenous vein autografts and bovine heter--ografts. Surgery, 75: 447, 1974. Haimov, M. and Jacobson, J. H., 2nd.: Experience with the modified bovine arterial heterograft in peripheral vascu)ar reconstruction and vascular access for hemodialysis. A:;.n. Surg., 180: 291, 1974. Biggers, J. A., Remmers, A. R., Jr., Glassford, D. M., Lindley, J. D., Sarles, H. E. and Fish, J. C.: Bovine graft fistulas patients with vascular access problems receiving hemodi.alysis. Surg., Gynec. & Obst., 140: 690, 1975.