Nondialysis Uses for Vascular Access Procedures ALEXANDER M. GUBA, JR., M.D., MAJ, MC, GEORGE J. COLLINS, JR., M.D., F.A.C.S., LTC, MC, NORMAN M. RICH, M.D., F.A.C.S., COL, MC, LOUIS KOZLOFF, M.D., MAJ, MC, PAUL T. McDONALD, M.D., LTC, MC
Chemotherapeutic agents, blood products and hyperalimentation solutions have been administered and recurrent diabetic ketoacidosis has been treated via vascular access procedures in 13 patients during the period from 1972 through 1977. Bovine heterograft, saphenous vein graft and the direct arteriovenous fistulae have been successfully utilized in the construction of arteriovenous fistulae in patients requiring vascular access for nonhemodialysis purposes. Operative techniques and therapeutic usefulness are discussed.
CIMINO2 revolutionized the treatment of renal failure with their introduction of the arteriovenous fistula (AVF) for vascular access in 1966. This greatly simplified the problems associated with hemodialysis, and since then thousands of patients have benefited from repeated hemodialysis. Many techniques now exist for providing vascular access. The most commonly used ones are the external arteriovenous shunt and the saphenous vein arteriovenous fistulae in the forearm or lower extremity. In addition to saphenous vein, mandrils,l bovine heterografts,6 umbilical veins,4 and prosthetic conduits such as polytetrafluoroethylene711,12 and Dacron®10 have been used to create arteriovenous fistulae. While the most common need for vascular access procedures is in patients with chronic renal failure, advances in oncology, medical treatment of diabetes mellitus, intravenous hyperalimentation for short gut syndrome, and treatment of hematologic disorders have created a subpopulation of patients requiring a readily available route for administration of medications or blood products. In some instances, the drugs administered cause sclerosis of veins. In others, previous thromboses or body habitus make use of the patient's own veins impossible. In such cases, creation of an arteriovenous fistula greatly facilitates therapy.9 B RESCIA AND
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Reprint requests: Alexander M. Guba, Jr., M.D., MAJ MC, Peripheral Vascular Surgery Service, Walter Reed Army Medical Center, Washington; D.C. 20021. Submitted for publication: February 6, 1979.
From the Peripheral Vascular Surgery Service, Walter Reed Army Medical Center, Washington, D.C., The Division of Surgery, Walter Reed Army Institute of Research, Washington, D.C., and the Uniformed Services University of the Health Sciences,
Bethesda, Maryland
This report summarizes the experience of the Peripheral Vascular Surgery Service, Walter Reed Army Medical Center during the past four years with patients who have had indications other than hemodialysis for vascular access procedures. Materials and Methods The records of all patients undergoing vascular access procedures for indications other than dialysis were reviewed. Our first experience with these procedures for indications other than hemodialysis was in November 1973, and all cases from then until November 1977 are included in the review. The parameters considered pertinent to the review were age and sex of patients operated upon, primary diagnosis, indications for the procedure, type of procedure performed, morbidity, patency rates, and impact of the procedure on management of the specific disease state for which it was performed. Results In all, 13 patients ranging in age from 15 to 66 had vascular access procedures performed during the four year period from 1973 to 1977. The average age was 40. Three were men and ten were women. The diseases for which the procedures were performed are outlined in Table 1. Overall, 14 bovine heterografts were used for construction of AVF's in 12 patients, while three saphenous vein grafts were used in two patients. As shown in Table 1, some patients had more than one fistula created. Seven distal forearm, radial artery to cephalic vein fistulae were created in four patients. Nine of the ten patients needing vascular access for chemotherapy had bovine heterograft AVF's placed in
0003-4932179/0700/0072 $00.65 C J. B. Lippincott Company
72
VASCULAR ACCESS PROCEDURES
Vol. 190-oNo. I
TABLE 1. Primary Diagnoses and Indications for Access Procedures
Patient
Primary Disease
1 2 3 4 5 6 7 8 9 10 11 12 13
Hodgkin's disease Gastric carcinoma Esthesioblastoma (orbit) Acute myelocythemic leukemia Carcinoma of breast Hodgkin's disease Carcinoma of lung (Oat cell) Acute myelocythemic leukemia Multiple myeloma Malignant teratoma Short gut syndrome Diabetes mellitus Osler-Weber-Rendu syndrome
Indication
Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy
Chemotherapy Hyperalimentation Insulin administration Transfusions
the arm. Anastomoses were done end-to-side from the brachial artery to either the cephalic vein, basilic vein, or brachial or axillary vein. The remaining patient had a radiocephalic fistula performed at the wrist level. The patient with short gut syndrome had a bovine heterograft fistula placed in the arm initially. Patient 12, a 20-year-old diabetic had an initial attempt at creation of a fistula using bovine heterograft. This thrombosed in the early postoperative period. Because of her need for long-term access, an AVF using saphenous vein as the conduit was placed in the arm. Multiple revisions of the initially created AVF' s were necessary in some patients. In others, it became necessary to create an additional fistula in a different location. In all, 30 procedures were performed. The initial technique, number of revisions needed to maintain patency, and the total period of therapeutic usefulness in each patient is shown in Table 2. Despite the need to revise the fistulae in some patients and to create new fistulae in others, the access route has been
73
useful in most patients. By providing continuous venous access, patient 11, with short gut syndrome, has been able to receive hyperalimentation at home for seven years. Patient 12, a difficult to manage juvenile diabetic, has been successfully resuscitated from frequent episodes of ketoacidosis via the AVF. Blood withdrawal for frequent laboratory tests has been greatly simplified in her case by the presence of the AVF. Several patients have been able to complete courses of chemotherapy, and others are continuing to receive chemotherapy. Some of the procedures were done under general anesthesia, but most were done under regional or local anesthesia with sedation. The morbidity associated with the procedures was minimal. Two patients developed erythema and tenderness over bovine heterografts without evidence of infection. Both were treated with short courses of prednisone and responded rapidly. There were no deaths related to the procedures. Discussion Patients requiring vascular access for reasons other than dialysis frequently have difficult medical problems. Many have diseases with poor long-term prognoses. Superficial veins are most often not available for creation of access routes because of thrombosis secondary to repeated venipuncture and/or injection of sclerosing agents. In addition to the limited availability of veins for creating fistulae, venous outflow may also be limited. This jeopardizes the chances for long-term patency of fistulae that are successfully created. Another factor possibly contributing to decreased patency rates of fistulae in such patients is the administration of sclerosing agents such as hyperosmolar hyperalimentation solutions and chemothera-
TABLE 2. Types of Access Procedures and Follow-up
Patient
Initial Location
1 2 3 4 5 6 7 8 9 10 11 12 13
Right arm Left arm Left arm Left forearm Left forearm Left arm Left forearm Right forearm Left arm Left arm Right arm Right arm Left forearm
Initial Material Used Bovine Bovine Bovine Bovine Bovine Bovine Bovine
heterograft heterograft heterograft heterograft heterograft heterograft heterograft
D.A.V.F.t D.A.V.F. D.A.V.F. D.A.V.F. Bovine heterograft D.A.V.F.
* In five patients it was necessary to create a new access route. t Patient expired of massive gastrointestinal hemorrhage despite
Number of Revisions*
Total Therapeutic Usefulness
0 0 0 2 0 1 0 0 1 0 9 3 I
7 months 1 month 7 months 4 months 3 months 3 weeks 5 months Undetermined 7 months 4 months 7 years 20 months I dayt
multiple transfusions. t Direct arteriovenous fistula (radiocephalic or brachio-basilic).
74
Ann. Surg. * July 1979
GUBA AND OTHERS
peutic agents through the fistulae. In addition the fact that there is a thrombotic predisposition in patients with malignancies is well known and may account, in part, for the rather high incidence of thrombosis in our patients.5'8'13 In our experience, both bovine heterografts and autogenous saphenous veins can be effectively used as arteriovenous conduits. Saphenous vein may be superior for long-term use. However, the bovine heterograft is certainly of use in selected patients. With bovine heterografts, the procedures can be performed under local anesthesia through limited incisions. The role of the direct, side to side, arteriovenous anastomosis (radiocephalic or brachio-basilic fistula) in these types of patients is not clear. In patients with good long-term prognoses, a chronic fistula may be advantageous. In oncology patients requiring immediate access, the direct fistula requiring a maturation period may not be ideal. Our results with radiocephalic forearm fistulae for nondialysis indications have been dismal because of early thrombosis and we no longer use them. In this regard, it is important to point out that there is no "ideal" access procedure and one should be familiar with several such procedures. The medial brachial vein seems to be a rather constant anatomic structure of adequate size. Because of this and the excellent qualities of the brachial artery as a donor vessel, we have tended to favor use of the brachial artery-brachial vein fistula over the last several years. In our experience, the most common cause of failure of bovine AVF's is pseudointimal and/or neointimal proliferation at the bovine-vein anastomosis. When fistulae do fail, thrombectomy or thrombectomy with patch angioplasty may result in a functional fistula. However, repeated efforts to maintain patency of a fistula with inadequate arterial inflow or venous outflow will not be successful. Platelet inhibitory drugs such as aspirin, persantin, and sulfinpyrazone may prove to be useful adjuvants for improving long-term patency, but further studies are needed to define their
exact role. The central high flow fistulae described by Buckley and coworkers may also be useful when the primary fistula has failed.3 With advances in medical oncology and the expanded use of intravenous hyperalimentation, the number of patients who could benefit from arteriovenous fistulae is sure to increase in the future. In fact, higher patency rates should be obtained if fistulae were constructed earlier in the course of disease at a time when venous outflow is sufficient to ensure adequate run-off.
References 1. Beemer, R. K. and Hayes, J. F.: Hemodialysis Using a Mandril Grown Shunt. Trans. Am. Soc. Artif. Int. Organs, 19:43, 1973. 2. Brescia, N. J., Cimino, J. E., Appel, K. and Hurwich, B. J.: Chronic Hemodialysis Using Venipuncture and Surgically Created Arteriovenous Fistula. N. Engl. J. Med., 275:1089, 1966. 3. Buckley, C. J., Manning, L. G. and Page, C. P.: Experience with Central High Flow Arteriovenous Fistulas in Patients Requiring Chronic Parenteral Chemotherapy on Hemodialysis. Am. J. Surg., 136:730, 1978. 4. Dardik, H., Ibrahim, 1. M. and Dardik, I.: Arteriovenous Fistulas Constructed with Modified Human Umbilical Cord Vein Graft. Arch. Surg., 111:60, 1976. 5. Edwards, E. A.: Migrating Thrombophlebitis Associated with Carcinoma. N. Engl. J. Med., 240:1031, 1949. 6. Johnson, J. M. and Kenoger, M. R.: Bovine Graft Arteriovenous Fistula for Hemodialysis. Am. J. Surg., 128:728, 1974. 7. Johnson, J. M., Baker, L. D. and Williams, T.: Expanded polytetrafluoroethylene-A Subcutaneous Conduit for Hemodialysis. Dialysis Transplant., 5:52, 1976. 8. Kenney, W. E.: The Association of Carcinoma in the Body and Tail of the Pancreas with Multiple Venous Thrombi. Surgery, 14:600, 1943. 9. Lempert, N., Knight, E. and Karmody, A.: Vascular Access for Cancer Chemotherapy. JAMA, 237:1964, 1977. 10. Levowitz, B. S., Flores, L., Dunn, I. and Frumkin, E.: Prosthetic Arteriovenous Fistula for Vascular Access in Hemodialysis. Am. J. Surg. 132:368, 1976. 11. Mohaideen, A. H., Avram, M. M. and Mainzer, R. A.: Polytetrafluoroethylene Grafts for Arteriovenous Fistulae- Preliminary Report. N. Y. State J. Med., 76:2152, 1976. 12. Pasternak, B. M., Paruk, S., Kogan, S. and Levitt, S.: A Syn-
thetic Vascular Conduit (Expanded PTFE) for Hemodialysis Access-A Preliminary Report. Vas. Surg., 11:99, 1977. 13. Thomson, A. P.: Thrombosis of the Peripheral Veins in Visceral Cancer. Clin. J., 67:137, 1936.
Chemotherapeutic agents, blood products and hyperalimentation solutions have been administered and recurrent diabetic ketoacidosis has been treated via vascular access procedures in 13 patients during the period from 1972 through 1977. Bovine heterograft, saphenous vein graft and the direct arteriovenous fistulae have been successfully utilized in the construction of arteriovenous fistulae in patients requiring vascular access for nonhemodialysis purposes. Operative techniques and therapeutic usefulness are discussed.
CIMINO2 revolutionized the treatment of renal failure with their introduction of the arteriovenous fistula (AVF) for vascular access in 1966. This greatly simplified the problems associated with hemodialysis, and since then thousands of patients have benefited from repeated hemodialysis. Many techniques now exist for providing vascular access. The most commonly used ones are the external arteriovenous shunt and the saphenous vein arteriovenous fistulae in the forearm or lower extremity. In addition to saphenous vein, mandrils,l bovine heterografts,6 umbilical veins,4 and prosthetic conduits such as polytetrafluoroethylene711,12 and Dacron®10 have been used to create arteriovenous fistulae. While the most common need for vascular access procedures is in patients with chronic renal failure, advances in oncology, medical treatment of diabetes mellitus, intravenous hyperalimentation for short gut syndrome, and treatment of hematologic disorders have created a subpopulation of patients requiring a readily available route for administration of medications or blood products. In some instances, the drugs administered cause sclerosis of veins. In others, previous thromboses or body habitus make use of the patient's own veins impossible. In such cases, creation of an arteriovenous fistula greatly facilitates therapy.9 B RESCIA AND
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Reprint requests: Alexander M. Guba, Jr., M.D., MAJ MC, Peripheral Vascular Surgery Service, Walter Reed Army Medical Center, Washington; D.C. 20021. Submitted for publication: February 6, 1979.
From the Peripheral Vascular Surgery Service, Walter Reed Army Medical Center, Washington, D.C., The Division of Surgery, Walter Reed Army Institute of Research, Washington, D.C., and the Uniformed Services University of the Health Sciences,
Bethesda, Maryland
This report summarizes the experience of the Peripheral Vascular Surgery Service, Walter Reed Army Medical Center during the past four years with patients who have had indications other than hemodialysis for vascular access procedures. Materials and Methods The records of all patients undergoing vascular access procedures for indications other than dialysis were reviewed. Our first experience with these procedures for indications other than hemodialysis was in November 1973, and all cases from then until November 1977 are included in the review. The parameters considered pertinent to the review were age and sex of patients operated upon, primary diagnosis, indications for the procedure, type of procedure performed, morbidity, patency rates, and impact of the procedure on management of the specific disease state for which it was performed. Results In all, 13 patients ranging in age from 15 to 66 had vascular access procedures performed during the four year period from 1973 to 1977. The average age was 40. Three were men and ten were women. The diseases for which the procedures were performed are outlined in Table 1. Overall, 14 bovine heterografts were used for construction of AVF's in 12 patients, while three saphenous vein grafts were used in two patients. As shown in Table 1, some patients had more than one fistula created. Seven distal forearm, radial artery to cephalic vein fistulae were created in four patients. Nine of the ten patients needing vascular access for chemotherapy had bovine heterograft AVF's placed in
0003-4932179/0700/0072 $00.65 C J. B. Lippincott Company
72
VASCULAR ACCESS PROCEDURES
Vol. 190-oNo. I
TABLE 1. Primary Diagnoses and Indications for Access Procedures
Patient
Primary Disease
1 2 3 4 5 6 7 8 9 10 11 12 13
Hodgkin's disease Gastric carcinoma Esthesioblastoma (orbit) Acute myelocythemic leukemia Carcinoma of breast Hodgkin's disease Carcinoma of lung (Oat cell) Acute myelocythemic leukemia Multiple myeloma Malignant teratoma Short gut syndrome Diabetes mellitus Osler-Weber-Rendu syndrome
Indication
Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy
Chemotherapy Hyperalimentation Insulin administration Transfusions
the arm. Anastomoses were done end-to-side from the brachial artery to either the cephalic vein, basilic vein, or brachial or axillary vein. The remaining patient had a radiocephalic fistula performed at the wrist level. The patient with short gut syndrome had a bovine heterograft fistula placed in the arm initially. Patient 12, a 20-year-old diabetic had an initial attempt at creation of a fistula using bovine heterograft. This thrombosed in the early postoperative period. Because of her need for long-term access, an AVF using saphenous vein as the conduit was placed in the arm. Multiple revisions of the initially created AVF' s were necessary in some patients. In others, it became necessary to create an additional fistula in a different location. In all, 30 procedures were performed. The initial technique, number of revisions needed to maintain patency, and the total period of therapeutic usefulness in each patient is shown in Table 2. Despite the need to revise the fistulae in some patients and to create new fistulae in others, the access route has been
73
useful in most patients. By providing continuous venous access, patient 11, with short gut syndrome, has been able to receive hyperalimentation at home for seven years. Patient 12, a difficult to manage juvenile diabetic, has been successfully resuscitated from frequent episodes of ketoacidosis via the AVF. Blood withdrawal for frequent laboratory tests has been greatly simplified in her case by the presence of the AVF. Several patients have been able to complete courses of chemotherapy, and others are continuing to receive chemotherapy. Some of the procedures were done under general anesthesia, but most were done under regional or local anesthesia with sedation. The morbidity associated with the procedures was minimal. Two patients developed erythema and tenderness over bovine heterografts without evidence of infection. Both were treated with short courses of prednisone and responded rapidly. There were no deaths related to the procedures. Discussion Patients requiring vascular access for reasons other than dialysis frequently have difficult medical problems. Many have diseases with poor long-term prognoses. Superficial veins are most often not available for creation of access routes because of thrombosis secondary to repeated venipuncture and/or injection of sclerosing agents. In addition to the limited availability of veins for creating fistulae, venous outflow may also be limited. This jeopardizes the chances for long-term patency of fistulae that are successfully created. Another factor possibly contributing to decreased patency rates of fistulae in such patients is the administration of sclerosing agents such as hyperosmolar hyperalimentation solutions and chemothera-
TABLE 2. Types of Access Procedures and Follow-up
Patient
Initial Location
1 2 3 4 5 6 7 8 9 10 11 12 13
Right arm Left arm Left arm Left forearm Left forearm Left arm Left forearm Right forearm Left arm Left arm Right arm Right arm Left forearm
Initial Material Used Bovine Bovine Bovine Bovine Bovine Bovine Bovine
heterograft heterograft heterograft heterograft heterograft heterograft heterograft
D.A.V.F.t D.A.V.F. D.A.V.F. D.A.V.F. Bovine heterograft D.A.V.F.
* In five patients it was necessary to create a new access route. t Patient expired of massive gastrointestinal hemorrhage despite
Number of Revisions*
Total Therapeutic Usefulness
0 0 0 2 0 1 0 0 1 0 9 3 I
7 months 1 month 7 months 4 months 3 months 3 weeks 5 months Undetermined 7 months 4 months 7 years 20 months I dayt
multiple transfusions. t Direct arteriovenous fistula (radiocephalic or brachio-basilic).
74
Ann. Surg. * July 1979
GUBA AND OTHERS
peutic agents through the fistulae. In addition the fact that there is a thrombotic predisposition in patients with malignancies is well known and may account, in part, for the rather high incidence of thrombosis in our patients.5'8'13 In our experience, both bovine heterografts and autogenous saphenous veins can be effectively used as arteriovenous conduits. Saphenous vein may be superior for long-term use. However, the bovine heterograft is certainly of use in selected patients. With bovine heterografts, the procedures can be performed under local anesthesia through limited incisions. The role of the direct, side to side, arteriovenous anastomosis (radiocephalic or brachio-basilic fistula) in these types of patients is not clear. In patients with good long-term prognoses, a chronic fistula may be advantageous. In oncology patients requiring immediate access, the direct fistula requiring a maturation period may not be ideal. Our results with radiocephalic forearm fistulae for nondialysis indications have been dismal because of early thrombosis and we no longer use them. In this regard, it is important to point out that there is no "ideal" access procedure and one should be familiar with several such procedures. The medial brachial vein seems to be a rather constant anatomic structure of adequate size. Because of this and the excellent qualities of the brachial artery as a donor vessel, we have tended to favor use of the brachial artery-brachial vein fistula over the last several years. In our experience, the most common cause of failure of bovine AVF's is pseudointimal and/or neointimal proliferation at the bovine-vein anastomosis. When fistulae do fail, thrombectomy or thrombectomy with patch angioplasty may result in a functional fistula. However, repeated efforts to maintain patency of a fistula with inadequate arterial inflow or venous outflow will not be successful. Platelet inhibitory drugs such as aspirin, persantin, and sulfinpyrazone may prove to be useful adjuvants for improving long-term patency, but further studies are needed to define their
exact role. The central high flow fistulae described by Buckley and coworkers may also be useful when the primary fistula has failed.3 With advances in medical oncology and the expanded use of intravenous hyperalimentation, the number of patients who could benefit from arteriovenous fistulae is sure to increase in the future. In fact, higher patency rates should be obtained if fistulae were constructed earlier in the course of disease at a time when venous outflow is sufficient to ensure adequate run-off.
References 1. Beemer, R. K. and Hayes, J. F.: Hemodialysis Using a Mandril Grown Shunt. Trans. Am. Soc. Artif. Int. Organs, 19:43, 1973. 2. Brescia, N. J., Cimino, J. E., Appel, K. and Hurwich, B. J.: Chronic Hemodialysis Using Venipuncture and Surgically Created Arteriovenous Fistula. N. Engl. J. Med., 275:1089, 1966. 3. Buckley, C. J., Manning, L. G. and Page, C. P.: Experience with Central High Flow Arteriovenous Fistulas in Patients Requiring Chronic Parenteral Chemotherapy on Hemodialysis. Am. J. Surg., 136:730, 1978. 4. Dardik, H., Ibrahim, 1. M. and Dardik, I.: Arteriovenous Fistulas Constructed with Modified Human Umbilical Cord Vein Graft. Arch. Surg., 111:60, 1976. 5. Edwards, E. A.: Migrating Thrombophlebitis Associated with Carcinoma. N. Engl. J. Med., 240:1031, 1949. 6. Johnson, J. M. and Kenoger, M. R.: Bovine Graft Arteriovenous Fistula for Hemodialysis. Am. J. Surg., 128:728, 1974. 7. Johnson, J. M., Baker, L. D. and Williams, T.: Expanded polytetrafluoroethylene-A Subcutaneous Conduit for Hemodialysis. Dialysis Transplant., 5:52, 1976. 8. Kenney, W. E.: The Association of Carcinoma in the Body and Tail of the Pancreas with Multiple Venous Thrombi. Surgery, 14:600, 1943. 9. Lempert, N., Knight, E. and Karmody, A.: Vascular Access for Cancer Chemotherapy. JAMA, 237:1964, 1977. 10. Levowitz, B. S., Flores, L., Dunn, I. and Frumkin, E.: Prosthetic Arteriovenous Fistula for Vascular Access in Hemodialysis. Am. J. Surg. 132:368, 1976. 11. Mohaideen, A. H., Avram, M. M. and Mainzer, R. A.: Polytetrafluoroethylene Grafts for Arteriovenous Fistulae- Preliminary Report. N. Y. State J. Med., 76:2152, 1976. 12. Pasternak, B. M., Paruk, S., Kogan, S. and Levitt, S.: A Syn-
thetic Vascular Conduit (Expanded PTFE) for Hemodialysis Access-A Preliminary Report. Vas. Surg., 11:99, 1977. 13. Thomson, A. P.: Thrombosis of the Peripheral Veins in Visceral Cancer. Clin. J., 67:137, 1936.
