Evaluation of the Brachial Artery to Brachial Vein Bovine Heterograft Arteriovenous Fistula for Hemodialysis Edward A. Merk, MD, Newark,
New Jersey
Kenneth Swari, MD, FACS, Newark,
New Jersey
Since the introduction of the internal arteriovenous fistula by Brescia et al [I], many patients have been maintained on long-term hemodialysis. However, even the most experienced investigators report a failure rate of approximately 10 per cent for these fistulas, as reported by Cerilli and Limbert [2]. This has resulted in the development of the bovine carotid heterograft as an alternative for chronic hemodialysis. Material and Methods During the past year, twenty-one bovine arteriovenous fistulas were created at our institution. All procedures were performed in the operating room using local anesthesia or regional block. Seventeen fistulas were created between the brachial artery above the elbow and the brachial vein below the axilla..(Figure 1.) Three fistulas were constructed utilizing the superficial femoral artery and saphenous vein in the thigh, as described by Payne et al [3]. One fistula was created using the radial artery at the wrist and the cephalic vein in the forearm. The bovine heterografts used had an internal diameter of 6.5 mm. All anastomoses were performed end to side using a continuous suture of 6-O Prolenea.
From the Department of Surgery, New Jersey Medical School at Newark and Martland Hospital, Newark, New Jersey. Reprint requests should be addressed to Edward A. Merk, MD, Depattment of Surgery, Martland Hospital, Newark, New Jersey 07110.
Volume 134 July 1975
Results The patients have been followed up since creation of the fistulas. The only failure occurred in the fistula between the radial artery and cephalic vein in the forearm. The seventeen fistulas between brachial artery and brachial vein are all functioning. Wound infection developed in all three fistulas in the thigh, but in no instance did this require removal or revision of the fistula. The only serious complication was a laceration of one of the thigh grafts during insertion of the needle for hemodialysis. This required immediate exploration of the graft with suture of the laceration. At present this fistula is functioning adequately. Comments Many complications associated with the use of the bovine heterograft have been reported, including anastomotic breakdown, false aneurysm formation, skin erosion, hematoma formation, wound infection, vascular steal, and many others. Zincke et al [4] have reported three cases of vascular steal in thigh fistulas. There was no instance of vascular steal in our three cases nor in the seventeen arm heterografts. Haimov and Jacobson [5] have reported that vascular insufficiency developed in
7
Merk and Swan
Brcchiol Artery
Bovine lirtrrograft Brachial Vein
Figure 1. Bovine heterograft arferiovenous fistula, right arm.
three patients with arm heterografts. Two of these patients uitimately had gangrene of the fingers requiring amputation. However, the positive qualities of the heterograft, for example, its availability in standard internal diameters and appropriate lengths, have impressed us more than its complications. Another advantage is the favorable manner in which localized infection can be treated without sacrifice of the graft. In actual practice the intrinsic properties of the bovine heterograft are not what determine its use. At our institution we have used these only in patients in whom an adequate internal Cimino shunt could not be maintained. Several patients have received a bovine heterograft as a primary procedure because the forearm veins were obviously unsuitable for shunting; most of these patients have severe renal failure and multiple associated medical
problems. It is in this group of patients that we have found the bovine heterograft most useful. Concerning the location of the fistula, we prefer the brachial artery to brachial vein anastomosis for several reasons. First, the large size of the vessels makes the anastomosis technically more feasible, and even in the most debilitated patient these vessels are usually suitable for construction of the fistula. It has been our experience that flow in the radial artery is often inadequate to maintain patency of the graft. The reports of Payne [3] and Zincke [4] and their co-workers support this concept, since they have had high failure rates when the radial artery was used. We have also found that when the graft is placed in the arm it lies in a very superficial position, unlike many thigh fistulas which lie deeper in the subcutaneous tissue. Summary
The use of the bovine heterograft in the severely ill patient is reviewed. From personal experience and a review of the literature we believe the preferred site of placement is between the brachial artery and brachial vein in the arm. References 1. Brescia MJ. Cimino JE, Appel K. Hurroich BJ: Chronic hemodialysis using venipuncture and a surgically erected arteriovenous fistula. N Engl J Med 257: 1069, 1966. 2. Cerilli J. Limbert JG: Technique and results of the construction of arteriovenous fistulas for hemodialysis. Surg Gynecol Obstet 137: 922, 1973. 3. Payne JE, Chatterjee SN, Barbour BH, Berne TV: Vascular access for chronic hemodialysis using modified bovine arterial graft arteriovenous fistula. Am J Surg 126: 54, 1974. 4. Zincke H, Hirsche BL, Amamoo DG, Woods JE, Andersen RC: The use of bovine carotid grafts for hemodialysis and hyperalimentation. Surg Gynecol Obstet 139: 350. 1974. 5. Haimov M, Jacobson JH: Experience with the modified bovine arterial heterograft in peripheral vascular reconstruction and vascular access for hemodialysis. Ann Surg 160: 291, 1974.
The American Journal of Surgery
New Jersey
Kenneth Swari, MD, FACS, Newark,
New Jersey
Since the introduction of the internal arteriovenous fistula by Brescia et al [I], many patients have been maintained on long-term hemodialysis. However, even the most experienced investigators report a failure rate of approximately 10 per cent for these fistulas, as reported by Cerilli and Limbert [2]. This has resulted in the development of the bovine carotid heterograft as an alternative for chronic hemodialysis. Material and Methods During the past year, twenty-one bovine arteriovenous fistulas were created at our institution. All procedures were performed in the operating room using local anesthesia or regional block. Seventeen fistulas were created between the brachial artery above the elbow and the brachial vein below the axilla..(Figure 1.) Three fistulas were constructed utilizing the superficial femoral artery and saphenous vein in the thigh, as described by Payne et al [3]. One fistula was created using the radial artery at the wrist and the cephalic vein in the forearm. The bovine heterografts used had an internal diameter of 6.5 mm. All anastomoses were performed end to side using a continuous suture of 6-O Prolenea.
From the Department of Surgery, New Jersey Medical School at Newark and Martland Hospital, Newark, New Jersey. Reprint requests should be addressed to Edward A. Merk, MD, Depattment of Surgery, Martland Hospital, Newark, New Jersey 07110.
Volume 134 July 1975
Results The patients have been followed up since creation of the fistulas. The only failure occurred in the fistula between the radial artery and cephalic vein in the forearm. The seventeen fistulas between brachial artery and brachial vein are all functioning. Wound infection developed in all three fistulas in the thigh, but in no instance did this require removal or revision of the fistula. The only serious complication was a laceration of one of the thigh grafts during insertion of the needle for hemodialysis. This required immediate exploration of the graft with suture of the laceration. At present this fistula is functioning adequately. Comments Many complications associated with the use of the bovine heterograft have been reported, including anastomotic breakdown, false aneurysm formation, skin erosion, hematoma formation, wound infection, vascular steal, and many others. Zincke et al [4] have reported three cases of vascular steal in thigh fistulas. There was no instance of vascular steal in our three cases nor in the seventeen arm heterografts. Haimov and Jacobson [5] have reported that vascular insufficiency developed in
7
Merk and Swan
Brcchiol Artery
Bovine lirtrrograft Brachial Vein
Figure 1. Bovine heterograft arferiovenous fistula, right arm.
three patients with arm heterografts. Two of these patients uitimately had gangrene of the fingers requiring amputation. However, the positive qualities of the heterograft, for example, its availability in standard internal diameters and appropriate lengths, have impressed us more than its complications. Another advantage is the favorable manner in which localized infection can be treated without sacrifice of the graft. In actual practice the intrinsic properties of the bovine heterograft are not what determine its use. At our institution we have used these only in patients in whom an adequate internal Cimino shunt could not be maintained. Several patients have received a bovine heterograft as a primary procedure because the forearm veins were obviously unsuitable for shunting; most of these patients have severe renal failure and multiple associated medical
problems. It is in this group of patients that we have found the bovine heterograft most useful. Concerning the location of the fistula, we prefer the brachial artery to brachial vein anastomosis for several reasons. First, the large size of the vessels makes the anastomosis technically more feasible, and even in the most debilitated patient these vessels are usually suitable for construction of the fistula. It has been our experience that flow in the radial artery is often inadequate to maintain patency of the graft. The reports of Payne [3] and Zincke [4] and their co-workers support this concept, since they have had high failure rates when the radial artery was used. We have also found that when the graft is placed in the arm it lies in a very superficial position, unlike many thigh fistulas which lie deeper in the subcutaneous tissue. Summary
The use of the bovine heterograft in the severely ill patient is reviewed. From personal experience and a review of the literature we believe the preferred site of placement is between the brachial artery and brachial vein in the arm. References 1. Brescia MJ. Cimino JE, Appel K. Hurroich BJ: Chronic hemodialysis using venipuncture and a surgically erected arteriovenous fistula. N Engl J Med 257: 1069, 1966. 2. Cerilli J. Limbert JG: Technique and results of the construction of arteriovenous fistulas for hemodialysis. Surg Gynecol Obstet 137: 922, 1973. 3. Payne JE, Chatterjee SN, Barbour BH, Berne TV: Vascular access for chronic hemodialysis using modified bovine arterial graft arteriovenous fistula. Am J Surg 126: 54, 1974. 4. Zincke H, Hirsche BL, Amamoo DG, Woods JE, Andersen RC: The use of bovine carotid grafts for hemodialysis and hyperalimentation. Surg Gynecol Obstet 139: 350. 1974. 5. Haimov M, Jacobson JH: Experience with the modified bovine arterial heterograft in peripheral vascular reconstruction and vascular access for hemodialysis. Ann Surg 160: 291, 1974.
The American Journal of Surgery
