Long-Term Preservation of Native Arteriovenous Dialysis Fistulas Alexandros Mallios,1,2 Alessandro Costanzo,1 Benoit Boura,1 Myriam Combes,1 Faris Alomran,1 Romain de Blic,1 and William C. Jennings,2 Paris, France, and Tulsa, Oklahoma
Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.
INTRODUCTION A surgically created arteriovenous fistula (AVF) is the preferred access for hemodialysis in patients with chronic renal failure.1 AVFs are associated with lower morbidity, mortality, and cost when compared with arteriovenous grafts (AVGs) and central venous catheters (CVCs).2,3 Problems may arise with AVFs that require intervention to maintain or assist in maturation of a functional vascular access. A common complication is the development of a stenotic venous outflow lesion(s) caused by intimal hyperplasia with subsequent dysfunction and potential thrombosis, usually occurring >3 months after access creation.4 These lesions may be found anywhere within the access conduit
1 Department of Vascular Surgery, Institut Mutualiste Montsouris, Paris, France. 2
Department of Surgery, University of Oklahoma, Tulsa, OK.
Correspondence to: Alexandros Mallios, MD, Department of Vascular Surgery, University of Oklahoma, 450 West 7th Street, Tulsa, OK 74119, USA; E-mail: [email protected] Ann Vasc Surg 2014; 28: 749–755 http://dx.doi.org/10.1016/j.avsg.2013.03.023 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: October 19, 2012; manuscript accepted: March 19, 2013; published online: December 19, 2013.
but are most often located in the juxta-anastomotic segment, the cephalic arch, or the central venous system. High AVF flow may result in symptomatic venous hypertension when outflow obstruction is present, or steal syndrome with ischemia distal to the anastomosis, particularly when accompanied by peripheral vascular disease.5 7 Treatment of these complications with preservation of the native AVF may be a challenging process requiring repeated interventions with a combination of open and endovascular techniques. Herein we present a series of complications in a single patient during a 5-year period, and we analyze the techniques used to maintain a functional hemodialysis access. Among these complications the most unusual was a central venous stent fracture, likely related to extrinsic pressure and motion associated with the adjacent innominate artery.
METHODS A 72-year-old woman, with a past medical history of type II diabetes, hypertension, atrial fibrillation receiving warfarin, epilepsy, and thyroidectomy, developed end-stage renal failure in 2006. Peritoneal dialysis was the initial renal replacement therapy, but was inadequate due to obesity and peritoneal adhesions. Hemodialysis was initiated 749
750 Mallios et al.
Annals of Vascular Surgery
Fig. 1. (A, B) The continuous pulsatile strain of the innominate artery on the stent likely led to the fracture. (C) Note the normal caliber of the stent ( yellow arrow) on the sagittal view at the level of the left common carotid
and subclavian arteries. (D) Note the compression of the stent ( yellow arrow) at the level of the fracture between the innominate artery and the sternum.
Fig. 2. (A) Coronal view of a computed tomography scan with maximum intensity projection (MIP). We see the fractured stent, occlusion of the left brachiocephalic vein, and thrombus extending to the left subclavian
and internal jugular veins. Although the stent protruded vertically in the superior vena cava, covering its entire surface, this did not lead to occlusion of the vessel. (B) Three-dimensional reconstruction of the same image.
through a right central venous‒jugular vein catheter 12 months later and a radiocephalic AVF was created in the left forearm. The AVF eventually required superficialization due to her obesity and difficulty with cannulation.
The patient developed arm discomfort and swelling secondary to cephalic arc stenosis 13 months later. The lesion responded to percutaneous transluminal angioplasty (PTA) with a 9 40-mm noncompliant balloon and the
Vol. 28, No. 3, April 2014
Fig. 3. (A) Two incisions were performed for the dissection of the internal jugular and brachial vein. (B) Venography shows the complete occlusion of left innominate vein and thrombus extending into the left subclavian
Long-term AVF preservation 751
and internal jugular veins. (C) Venous thrombectomy with a Fogarty catheter and simultaneous distal balloon inflation. (D) Final venography after dilation and placement of a balloon expandable covered stent.
Fig. 4. (A) The patient’s hand before the intervention. (B) The patient’s hand after the intervention.
swelling resolved. Symptoms of elevated venous pressure recurred after 6 months with increasing edema in her left arm. Fistulography demonstrated a subtotal occlusion of the left innominate vein and PTA was performed successfully with a 10 40-mm
balloon. Due to residual stenosis and elastic recoil, a 10 60-mm nitinol stent was placed. Intrastent stenosis occurred after 10 months and was retreated with a 9 40-mm noncompliant balloon PTA. Severe arm edema with a dysfunctional
752 Mallios et al.
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Fig. 5. (A) In June 2012, the patient presented with one more severe intrastent stenosis. She was treated with PTA using increasing balloon diameters (B, C) and placement of one more covered stent (D).
AVF recurred after only 6 months. Computed tomography angiography (CTA) with contrast injection and late image acquisitions demonstrated a complete fracture of the stent, intrastent occlusion of the innominate vein, and thrombus extending proximally into the left subclavian and jugular veins (Figs. 1 and 2). Under general anesthesia, and with two separate incisions, the internal jugular and brachial veins were prepared for open thrombectomy. A 0.035-in. hydrophilic wire was advanced successfully distal to the occlusion and a 10-mm balloon was inflated to prevent dislocation of thrombus and pulmonary embolism during the procedure. After several attempts to remove the entire thrombus, the residual stenosis persisted and therefore a 10 59-mm balloon expandable covered stent was placed (Advanta V12; Atrium, Hudson, NH, USA) and overdilated at a 12-mm diameter. The swelling subsided
significantly within the first postoperative week (Figs. 3 and 4). Four years after the original AVF construction, and after six interventions, the patient presented again with venous outflow hypertension manifested by prolonged bleeding after puncture and arm swelling. Access flow was measured at 1.5 L/ min. Fistulography demonstrated one more significant intrastent central venous stenosis that was treated with PTA and a new covered stent placement (Fig. 5). During this intervention, a proximal ligation of the radial artery was performed that successfully reduced AVF flow at 550 mL/min. Four months after this procedure the patient had an acute AVF thrombosis successfully treated by open thrombectomy. Fistulography demonstrated a severe stenosis below the elbow that was successfully treated during the same procedure with PTA using a 6 40-mm noncompliant balloon (Fig. 6).
Vol. 28, No. 3, April 2014
Long-term AVF preservation 753
Fig. 6. After thrombectomy, a fistulogram demonstrated severe stenosis below the elbow (A). It was dilated with a 6 40-mm noncompliant balloon (B), and the lumen was successfully restored (C).
Fig. 7. Timeline of the patient’s AVF events.
DISCUSSION Recurrent stenoses of a hemodialysis AVF occurs through a fibroproliferative response to endothelial dysfunction secondary to the dramatic increase in blood flow, turbulence, and associated shear stress in the vein wall.8 The localized development of these stenotic lesions may relate to the geometry of the fistula, surgical manipulation with repositioning of the venous conduit, and hemodynamics in the etiology of the process. Sivanesan et al.4 tried to identify locations that predispose to the formation of stenotic lesions. They studied 25 radiocephalic fistulae and the development location and progression of stenosis was noted in each case. They concluded that fistula failure is multifactorial and
the process leading to intimal hyperplasia is not well understood. Another report identified the most common site for radiocephalic AVF stenosis to be the juxta-anastomatic segment.9 In line with European best practice guidelines we perform AVFs as distally as possible when physical and ultrasound examinations have predicted success. Where no forearm vessels are available for access, an autogenous access in the upper arm is created due to superior patency and lower complication rates compared with prosthetic grafts.10 When a functional AVF is not feasible, an AVG is preferable to CVC-based dialysis.3 As described in this case, secondary patency of an AVF can be increased dramatically using endovascular procedures.11
754 Mallios et al.
It remains unclear whether long-segment stenoses should be treated radiologically or surgically. However, PTA of short-segment stenoses (2 cm). Some persistent stenoses cannot be dilated by conventional balloon angioplasty. These ‘‘resistant/elastic’’ stenoses may be treated with ultra‒ high-pressure balloons (up to 32 atm). Often, despite complete opening of the balloon of sufficient diameter, the dilated vessel wall may collapse immediately after removal of the balloon. This elastic recoil can be prevented by stent implantation, especially in central veins.12,13 In our practice, stent utilization is limited to recurrent restenosis at the same access site, or a nonsatisfactory fistulography after prolonged duration balloon angioplasty. Noncorrectable symptomatic outflow obstruction may also be treated successfully by precision banding with real-time flow monitoring.5 Ligation or coil occlusion of the radial artery distal to a radiocephalic AVF has been established as an effective treatment for the rare episodes of steal syndrome associated with these AVFs.14 The patient described in this report required eight different interventions (open, endovascular, and hybrid) within a period of 5 years (Fig. 7). An interesting complication was the fracture of the stent placed in the left innominate vein. Imaging demonstrated compression of the stent between the innominate artery and the manubrium. It is likely that the repetitive pulsatile strain caused fatigue of the metal and fracture of the stent. The long-term preservation of a native AVF can be challenging and often requires multiple procedures and a multidisciplinary approach.15 Vascular access abandonment of a dysfunctional AVF should be rare. In emergency situations, ligation is required and a CVC placement or prosthetic graft access is the only option. At our center, every effort is made to maintain a functioning AVF as long as possible before creating a new access at a different site. With the continuous improvement of available medical treatment for chronic renal insufficiency, it is common to have patients requiring hemodialysis access for several years. Therefore, we prefer to exhaust every possible means of maintaining the existing AVF. When this is no longer possible, a new access is planned, maximizing autogenous dialysis access for patients. CVC access is associated with more hospital admissions and higher costs as well as poorer survival and quality of life compared with AVF dialysis.16,17 Interestingly, patients undergoing kidney transplantation were found to have a higher long-term mortality rate if they were dialyzed using
Annals of Vascular Surgery
a CVC before transplantation compared with counterparts utilizing AVF dialysis.18 Avoidance of CVC dialysis is central to our algorithm of vascular access management. When an AVF is clearly failing we preserve it until a newly created access is functioning so we may avoid CVC placement. We believe that close surveillance and early secondary interventions are crucial for preserving a functioning AVF and avoiding the need for CVC placement. In conclusion, preservation of a native AVF can be challenging due to multiple complications that may require a multidisciplinary approach for correction of anatomic and functional abnormalities. Among the various complications that occurred in this patient, stent fracture and innominate vein thrombosis necessitated a hybrid approach. Decisions on fistula maintenance or abandonment are complex and must be considered on a case-by-case basis. Prolonging the life of a native AVF and avoidance of CVC catheter placement should be the goal of all vascular access surgeons. REFERENCES 1. Eknoyan G, Levin NW, Eschbach JW, et al. Continuous quality improvement: DOQI becomes K/DOQI and is updated. National Kidney Foundation’s Dialysis Outcomes Quality Initiative. Am J Kidney Dis 2001;37:179e94. 2. National Kidney Foundation‒K/DOQI clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis 2001;37(Suppl. 1):S137e81. 3. Fistula First: National Vascular Access Improvement Initiative. http://www.fistulafirst.org/. 4. Sivanesan S, Thien V, Bakran H, et al. Sites of stenosis in AV fistulae for hemodialysis access. Nephrol Dial Transplant 1999;14:118e20. 5. Jennings WC, Miller GA, Coburn MZ, et al. Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion. J Vasc Access 2012;13:157e62. 6. Anaya-Ayala JE, Pettigrew CD, Ismail N, et al. Management of dialysis access-associated ‘‘steal’’ syndrome with DRIL procedure: challenges and clinical outcomes. J Vasc Access 2012;13:299e304. 7. Scheltinga MR, Bruijninckx CM. Haemodialysis accessinduced distal ishaemia (HAIDI) is caused by loco-regional hypotension but not by steal. Eur J Vasc Endovasc Surg 2012;43:218e23. 8. Hofstra L, Tordoir JHM, Kitslaar PJEHM, et al. Enhanced cellular proliferation in intact stenotic lesions derived from human arteriovenous fistulas and peripheral bypass grafts. Does it correlates with flow parameters? Circulation 1996;94:1283e90. 9. Jennings WC, Kindred MG, Broughan TA. Creating radiocephalic arteriovenous fistulas: technical and functional success. J Am Coll Surg 2009;208:419e25. 10. Keuter X, De Smet A, Kessels A, et al. A randomized multicenter study of the outcome of brachial basilica arteriovenous fistula and prosthetic brachial‒antecubital forearm loop as vascular access for hemodialysis. J Vasc Surg 2008;47: 395e401.
Vol. 28, No. 3, April 2014
11. Ayez N, Fioole B, Aarts RA, van den Dorpel MA, et al. Secondary interventions in patients with autologous arteriovenous fistulas strongly improve patency rates. J Vasc Surg 2011;54:1095e9. 12. Vorwerk D, Adam G, M€ uller-Leisse C, et al. Hemodialysis fistulas and grafts: use of cutting balloons to dilate venous stenoses. Radiology 1996;201:864e7. 13. Trerotola SO, Stavropoulos SW, Shlansky-Goldberg R, et al. Hemodialysis-related venous stenosis: treatment with ultrahigh-pressure angioplasty balloons. Radiology 2004;231: 259e62. 14. Miller GA, Khariton K, Kardos SV, et al. Flow interruption of the distal radial artery: treatment for finger ischemia in a matured radiocephalic AVF. J Vasc Access 2008;9: 58e63.
Long-term AVF preservation 755
15. Turmel-Rodrigues L, Pengloan J, Bourquelot P. Interventional radiology in hemodialysis fistulae and grafts: a multidisciplinary approach. Cardiovasc Intervent Radiol 2002;25: 3e16. 16. McQuillan R, Trpeski L, Fenton S, et al. Modifiable risk factors for early mortality on hemodialysis. Int J Nephrol 2012;2012:435736. 17. Moist LM, Trpeski L, Na Y, et al. Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001‒ 2004. Clin J Am Soc Nephrol 2008;3:1726e32. 18. Goldfarb-Rumyantzev AS, Yoon JH, Patibandla BK, et al. The role of initial hemodialysis vascular access in the outcome of subsequent kidney transplantation. Clin Transplant 2013;27:210e6.
Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.
INTRODUCTION A surgically created arteriovenous fistula (AVF) is the preferred access for hemodialysis in patients with chronic renal failure.1 AVFs are associated with lower morbidity, mortality, and cost when compared with arteriovenous grafts (AVGs) and central venous catheters (CVCs).2,3 Problems may arise with AVFs that require intervention to maintain or assist in maturation of a functional vascular access. A common complication is the development of a stenotic venous outflow lesion(s) caused by intimal hyperplasia with subsequent dysfunction and potential thrombosis, usually occurring >3 months after access creation.4 These lesions may be found anywhere within the access conduit
1 Department of Vascular Surgery, Institut Mutualiste Montsouris, Paris, France. 2
Department of Surgery, University of Oklahoma, Tulsa, OK.
Correspondence to: Alexandros Mallios, MD, Department of Vascular Surgery, University of Oklahoma, 450 West 7th Street, Tulsa, OK 74119, USA; E-mail: [email protected] Ann Vasc Surg 2014; 28: 749–755 http://dx.doi.org/10.1016/j.avsg.2013.03.023 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: October 19, 2012; manuscript accepted: March 19, 2013; published online: December 19, 2013.
but are most often located in the juxta-anastomotic segment, the cephalic arch, or the central venous system. High AVF flow may result in symptomatic venous hypertension when outflow obstruction is present, or steal syndrome with ischemia distal to the anastomosis, particularly when accompanied by peripheral vascular disease.5 7 Treatment of these complications with preservation of the native AVF may be a challenging process requiring repeated interventions with a combination of open and endovascular techniques. Herein we present a series of complications in a single patient during a 5-year period, and we analyze the techniques used to maintain a functional hemodialysis access. Among these complications the most unusual was a central venous stent fracture, likely related to extrinsic pressure and motion associated with the adjacent innominate artery.
METHODS A 72-year-old woman, with a past medical history of type II diabetes, hypertension, atrial fibrillation receiving warfarin, epilepsy, and thyroidectomy, developed end-stage renal failure in 2006. Peritoneal dialysis was the initial renal replacement therapy, but was inadequate due to obesity and peritoneal adhesions. Hemodialysis was initiated 749
750 Mallios et al.
Annals of Vascular Surgery
Fig. 1. (A, B) The continuous pulsatile strain of the innominate artery on the stent likely led to the fracture. (C) Note the normal caliber of the stent ( yellow arrow) on the sagittal view at the level of the left common carotid
and subclavian arteries. (D) Note the compression of the stent ( yellow arrow) at the level of the fracture between the innominate artery and the sternum.
Fig. 2. (A) Coronal view of a computed tomography scan with maximum intensity projection (MIP). We see the fractured stent, occlusion of the left brachiocephalic vein, and thrombus extending to the left subclavian
and internal jugular veins. Although the stent protruded vertically in the superior vena cava, covering its entire surface, this did not lead to occlusion of the vessel. (B) Three-dimensional reconstruction of the same image.
through a right central venous‒jugular vein catheter 12 months later and a radiocephalic AVF was created in the left forearm. The AVF eventually required superficialization due to her obesity and difficulty with cannulation.
The patient developed arm discomfort and swelling secondary to cephalic arc stenosis 13 months later. The lesion responded to percutaneous transluminal angioplasty (PTA) with a 9 40-mm noncompliant balloon and the
Vol. 28, No. 3, April 2014
Fig. 3. (A) Two incisions were performed for the dissection of the internal jugular and brachial vein. (B) Venography shows the complete occlusion of left innominate vein and thrombus extending into the left subclavian
Long-term AVF preservation 751
and internal jugular veins. (C) Venous thrombectomy with a Fogarty catheter and simultaneous distal balloon inflation. (D) Final venography after dilation and placement of a balloon expandable covered stent.
Fig. 4. (A) The patient’s hand before the intervention. (B) The patient’s hand after the intervention.
swelling resolved. Symptoms of elevated venous pressure recurred after 6 months with increasing edema in her left arm. Fistulography demonstrated a subtotal occlusion of the left innominate vein and PTA was performed successfully with a 10 40-mm
balloon. Due to residual stenosis and elastic recoil, a 10 60-mm nitinol stent was placed. Intrastent stenosis occurred after 10 months and was retreated with a 9 40-mm noncompliant balloon PTA. Severe arm edema with a dysfunctional
752 Mallios et al.
Annals of Vascular Surgery
Fig. 5. (A) In June 2012, the patient presented with one more severe intrastent stenosis. She was treated with PTA using increasing balloon diameters (B, C) and placement of one more covered stent (D).
AVF recurred after only 6 months. Computed tomography angiography (CTA) with contrast injection and late image acquisitions demonstrated a complete fracture of the stent, intrastent occlusion of the innominate vein, and thrombus extending proximally into the left subclavian and jugular veins (Figs. 1 and 2). Under general anesthesia, and with two separate incisions, the internal jugular and brachial veins were prepared for open thrombectomy. A 0.035-in. hydrophilic wire was advanced successfully distal to the occlusion and a 10-mm balloon was inflated to prevent dislocation of thrombus and pulmonary embolism during the procedure. After several attempts to remove the entire thrombus, the residual stenosis persisted and therefore a 10 59-mm balloon expandable covered stent was placed (Advanta V12; Atrium, Hudson, NH, USA) and overdilated at a 12-mm diameter. The swelling subsided
significantly within the first postoperative week (Figs. 3 and 4). Four years after the original AVF construction, and after six interventions, the patient presented again with venous outflow hypertension manifested by prolonged bleeding after puncture and arm swelling. Access flow was measured at 1.5 L/ min. Fistulography demonstrated one more significant intrastent central venous stenosis that was treated with PTA and a new covered stent placement (Fig. 5). During this intervention, a proximal ligation of the radial artery was performed that successfully reduced AVF flow at 550 mL/min. Four months after this procedure the patient had an acute AVF thrombosis successfully treated by open thrombectomy. Fistulography demonstrated a severe stenosis below the elbow that was successfully treated during the same procedure with PTA using a 6 40-mm noncompliant balloon (Fig. 6).
Vol. 28, No. 3, April 2014
Long-term AVF preservation 753
Fig. 6. After thrombectomy, a fistulogram demonstrated severe stenosis below the elbow (A). It was dilated with a 6 40-mm noncompliant balloon (B), and the lumen was successfully restored (C).
Fig. 7. Timeline of the patient’s AVF events.
DISCUSSION Recurrent stenoses of a hemodialysis AVF occurs through a fibroproliferative response to endothelial dysfunction secondary to the dramatic increase in blood flow, turbulence, and associated shear stress in the vein wall.8 The localized development of these stenotic lesions may relate to the geometry of the fistula, surgical manipulation with repositioning of the venous conduit, and hemodynamics in the etiology of the process. Sivanesan et al.4 tried to identify locations that predispose to the formation of stenotic lesions. They studied 25 radiocephalic fistulae and the development location and progression of stenosis was noted in each case. They concluded that fistula failure is multifactorial and
the process leading to intimal hyperplasia is not well understood. Another report identified the most common site for radiocephalic AVF stenosis to be the juxta-anastomatic segment.9 In line with European best practice guidelines we perform AVFs as distally as possible when physical and ultrasound examinations have predicted success. Where no forearm vessels are available for access, an autogenous access in the upper arm is created due to superior patency and lower complication rates compared with prosthetic grafts.10 When a functional AVF is not feasible, an AVG is preferable to CVC-based dialysis.3 As described in this case, secondary patency of an AVF can be increased dramatically using endovascular procedures.11
754 Mallios et al.
It remains unclear whether long-segment stenoses should be treated radiologically or surgically. However, PTA of short-segment stenoses (2 cm). Some persistent stenoses cannot be dilated by conventional balloon angioplasty. These ‘‘resistant/elastic’’ stenoses may be treated with ultra‒ high-pressure balloons (up to 32 atm). Often, despite complete opening of the balloon of sufficient diameter, the dilated vessel wall may collapse immediately after removal of the balloon. This elastic recoil can be prevented by stent implantation, especially in central veins.12,13 In our practice, stent utilization is limited to recurrent restenosis at the same access site, or a nonsatisfactory fistulography after prolonged duration balloon angioplasty. Noncorrectable symptomatic outflow obstruction may also be treated successfully by precision banding with real-time flow monitoring.5 Ligation or coil occlusion of the radial artery distal to a radiocephalic AVF has been established as an effective treatment for the rare episodes of steal syndrome associated with these AVFs.14 The patient described in this report required eight different interventions (open, endovascular, and hybrid) within a period of 5 years (Fig. 7). An interesting complication was the fracture of the stent placed in the left innominate vein. Imaging demonstrated compression of the stent between the innominate artery and the manubrium. It is likely that the repetitive pulsatile strain caused fatigue of the metal and fracture of the stent. The long-term preservation of a native AVF can be challenging and often requires multiple procedures and a multidisciplinary approach.15 Vascular access abandonment of a dysfunctional AVF should be rare. In emergency situations, ligation is required and a CVC placement or prosthetic graft access is the only option. At our center, every effort is made to maintain a functioning AVF as long as possible before creating a new access at a different site. With the continuous improvement of available medical treatment for chronic renal insufficiency, it is common to have patients requiring hemodialysis access for several years. Therefore, we prefer to exhaust every possible means of maintaining the existing AVF. When this is no longer possible, a new access is planned, maximizing autogenous dialysis access for patients. CVC access is associated with more hospital admissions and higher costs as well as poorer survival and quality of life compared with AVF dialysis.16,17 Interestingly, patients undergoing kidney transplantation were found to have a higher long-term mortality rate if they were dialyzed using
Annals of Vascular Surgery
a CVC before transplantation compared with counterparts utilizing AVF dialysis.18 Avoidance of CVC dialysis is central to our algorithm of vascular access management. When an AVF is clearly failing we preserve it until a newly created access is functioning so we may avoid CVC placement. We believe that close surveillance and early secondary interventions are crucial for preserving a functioning AVF and avoiding the need for CVC placement. In conclusion, preservation of a native AVF can be challenging due to multiple complications that may require a multidisciplinary approach for correction of anatomic and functional abnormalities. Among the various complications that occurred in this patient, stent fracture and innominate vein thrombosis necessitated a hybrid approach. Decisions on fistula maintenance or abandonment are complex and must be considered on a case-by-case basis. Prolonging the life of a native AVF and avoidance of CVC catheter placement should be the goal of all vascular access surgeons. REFERENCES 1. Eknoyan G, Levin NW, Eschbach JW, et al. Continuous quality improvement: DOQI becomes K/DOQI and is updated. National Kidney Foundation’s Dialysis Outcomes Quality Initiative. Am J Kidney Dis 2001;37:179e94. 2. National Kidney Foundation‒K/DOQI clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis 2001;37(Suppl. 1):S137e81. 3. Fistula First: National Vascular Access Improvement Initiative. http://www.fistulafirst.org/. 4. Sivanesan S, Thien V, Bakran H, et al. Sites of stenosis in AV fistulae for hemodialysis access. Nephrol Dial Transplant 1999;14:118e20. 5. Jennings WC, Miller GA, Coburn MZ, et al. Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion. J Vasc Access 2012;13:157e62. 6. Anaya-Ayala JE, Pettigrew CD, Ismail N, et al. Management of dialysis access-associated ‘‘steal’’ syndrome with DRIL procedure: challenges and clinical outcomes. J Vasc Access 2012;13:299e304. 7. Scheltinga MR, Bruijninckx CM. Haemodialysis accessinduced distal ishaemia (HAIDI) is caused by loco-regional hypotension but not by steal. Eur J Vasc Endovasc Surg 2012;43:218e23. 8. Hofstra L, Tordoir JHM, Kitslaar PJEHM, et al. Enhanced cellular proliferation in intact stenotic lesions derived from human arteriovenous fistulas and peripheral bypass grafts. Does it correlates with flow parameters? Circulation 1996;94:1283e90. 9. Jennings WC, Kindred MG, Broughan TA. Creating radiocephalic arteriovenous fistulas: technical and functional success. J Am Coll Surg 2009;208:419e25. 10. Keuter X, De Smet A, Kessels A, et al. A randomized multicenter study of the outcome of brachial basilica arteriovenous fistula and prosthetic brachial‒antecubital forearm loop as vascular access for hemodialysis. J Vasc Surg 2008;47: 395e401.
Vol. 28, No. 3, April 2014
11. Ayez N, Fioole B, Aarts RA, van den Dorpel MA, et al. Secondary interventions in patients with autologous arteriovenous fistulas strongly improve patency rates. J Vasc Surg 2011;54:1095e9. 12. Vorwerk D, Adam G, M€ uller-Leisse C, et al. Hemodialysis fistulas and grafts: use of cutting balloons to dilate venous stenoses. Radiology 1996;201:864e7. 13. Trerotola SO, Stavropoulos SW, Shlansky-Goldberg R, et al. Hemodialysis-related venous stenosis: treatment with ultrahigh-pressure angioplasty balloons. Radiology 2004;231: 259e62. 14. Miller GA, Khariton K, Kardos SV, et al. Flow interruption of the distal radial artery: treatment for finger ischemia in a matured radiocephalic AVF. J Vasc Access 2008;9: 58e63.
Long-term AVF preservation 755
15. Turmel-Rodrigues L, Pengloan J, Bourquelot P. Interventional radiology in hemodialysis fistulae and grafts: a multidisciplinary approach. Cardiovasc Intervent Radiol 2002;25: 3e16. 16. McQuillan R, Trpeski L, Fenton S, et al. Modifiable risk factors for early mortality on hemodialysis. Int J Nephrol 2012;2012:435736. 17. Moist LM, Trpeski L, Na Y, et al. Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001‒ 2004. Clin J Am Soc Nephrol 2008;3:1726e32. 18. Goldfarb-Rumyantzev AS, Yoon JH, Patibandla BK, et al. The role of initial hemodialysis vascular access in the outcome of subsequent kidney transplantation. Clin Transplant 2013;27:210e6.
