Case Report
AXILLOCEPHALIC ARTERIOVENOUS GRAFT :
A NEW ALTERNATIVE FOR HEMODIALYSIS
A tik e T e k e li, M .D .* / S erdar A kg ü n , M .D .* / C. Selim İsbir, M .D .*
A li C iv e le k , M .D .* / K oray A k , M .D .* / Feyyaz B altacıoğlu, M .D .**
* D e p a rtm e n t o f C a rd io v a s c u la r Surgery, S c h o o l o f M e d icin e , M arm ara U niversity, Is ta n b u l, Turkey.
” * D e p a rtm e n t o f R adiology, S c h o o l o f M e d icin e , M arm ara U n ive rsity, Is ta n b u l, Turkey.
ABSTRACT
D iffe re n t ty p e s o f v a s c u la r a c c e s s e s a re u se d fo r p a tie n ts w h o n e e d h e m o d ia ly s is d u e to c h ro n ic re n a l fa ilu re . T h e m o s t c o m m o n ly u s e d a re a rte rio v e n o u s fis tu la e (A V F ) w h ic h c a n b e c la s s ifie d a s a u to g e n ic o r p ro s th e tic g ra fts . P ro s th e tic a rte rio v e n o u s g ra fts c a n be p la c e d in to a n a to m ic o r, in c o m p lic a te d c a s e , in to e x tr a -a n a to m ic lo c a tio n s . In th is p a p e r, w e p re s e n t a p a tie n t w h o h a d th e A V F o p e ra tio n fo u r tim e s a n d th e fe m o r a l a r te r io v e n o u s g ra ft o p e ra tio n tw ic e a n d w e re p o rt a n a lte rn a tiv e h e m o d ia ly s is a c c e s s , " a x illo c e p h a lic g ra ft in te rp o s itio n ".
K ey
W o rd s :
A r te r io v e n o u s g ra ft, H e m o d ia ly s is a c c e s s , C h ro n ic re n a l fa ilu re .INTRODUCTION
In p a tie n ts w ith c h ro n ic re n a l fa ilu re re q u irin g h e m o d ia ly s is c a th e te r iz a tio n , a r te r io v e n o u s fis tu la e (A V F ), a n d p ro s th e tic a rte rio v e n o u s (A V ) s h u n t g r a fts a re u s e d fo r v a s c u la r a c c e s s . A m o n g th e s e , th e m o s t c o m m o n ly u s e d a re C im in o -B ris c ia ra d lo c e p h a lic fis tu la e . H o w e v e r,
p re v io u s v a s c u la r a c c e s s e s , s u b c la v ia n v e in th r o m b o s is o r in tr in s ic a rte ria l d is e a s e s p re c lu d e s th e u s e o f th is a c c e s s (1 ,2 ).
In p a tie n ts w ith te rm in a l s ta g e c h ro n ic renal fa ilu r e a n d th o s e w ith p e r ip h e r a l v a s c u la r d is e a s e , th e v a s c u la r a c c e s s e s m ig h t n o t be u s e d fo r lo n g e r d u ra tio n s , th u s c re a tin g a v e ry im p o rta n t p ro b le m fo r th e p a tie n ts (3). It is w e ll k n o w n th a t a u to g e n o u s A V F a re b e tte r th a n p r o s th e tic A V g r a fts . H o w e v e r in th e p a tie n ts w ith c o m p lic a tio n s , p ro s th e tic g ra fts a re u s e d v e r y o fte n b e c a u s e o f th e A V F d y s fu n c tio n a n d th ro m b o s is d u e to in s u ffic ie n t b lo o d flo w (4 ,5 ). B e s id e s th e u s u a l a n a to m ic p o s itio n s , p ro s th e tic g ra fts c a n a ls o b e u s e d in th e e x tr a - a n a to m ic lo c a tio n s . T h e s e c a n be c re a te d b e tw e e n th e b ra c h ia l a rte ry -ju g u la r v e in , a x illa ry a rte ry -ju g u la r v e in , b ra c h ia l a rte ry - c e p h a lic v e in a n d a x illa ry a rte ry -c o n tra la te ra l a x illa ry v e in (3 ,6 -9 ).
In d ia b e tic p a tie n ts w ith p e rip h e ra l v a s c u la r d is e a s e , th e u p p e r e x tre m ity is a s u ita b le lo c a tio n fo r b o th th e a u to g e n o u s fis tu la e a n d p ro s th e tic g ra fts b e c a u s e a th e ro s c le ro s is is n o t c o m m o n ly s e e n in th is a n a to m ic lo c a tio n .
(Accepted 30 May, 2000)
Marmara Medical Journal 2000;13(3) :153-155
Atike Tekeli, et al
CASE R E P O R T D IS C U S S IO N
A 49-year-old male with end stage chronic renal failure who required hemodialysis was referred to our department from another hospital for vascular access. He previously had the AVF operation for four times and the femoral AV graft operation twice. In his past history, he has had hypertension for twenty years regulated with medication, type 2 diabetes mellitus for 25 years, acute myocardial infarction eighteen years ago and an aortobifemoral bypass surgery due to atherosclerotic stenosis of terminal aorta nine years ago.
As the vascular accesses previously created could not be used due to thrombosis, an AV graft in extra-anatomic location was planned. The patient was placed in supine position under general anesthesia, a 5 cm horizontal incision was made from the distal portion of the clavicle for axillary artery and cephalic vein exploration. After heparinization a 6 x 70 mm. GORETEX (Gore&Associates, Flugstaff, Arizona, USA) e- PTFE graft was implanted in a loop fashion between the axillary artery and the cephalic vein. The patient was anticoagulated with warfarin postoperatively. The patient had an uneventful recovery and an angiography on the 7th day postoperatively showed a patent graft (Fig. 1).
F ig . I A x illo c e p h a lic arteriovenous graft: A new alternative for hemodialysis: Arraus show the ePTFE graft between axillary artery and cephatic vein.
Vascular access procedures are the lifeline of patients with end stage renal disease maintained on hemodialysis. The function of the access will greatly determine the quality of life that this patient population will enjoy.
In patients with end stage chronic renal failure associated with diabetes mellitus and peripheral vascular problems the patency of vascular accesses are negatively affected (3). In a study Fernstrom et al, showed that diabetes mellitus impairs the patency of AVF (10). Our patient previously had an aortofemoral bypass operation which enabled us to implant femoral AV graft which is the mostly used AV graft procedure in our clinic. Also all of his upper extremity (bilateral radial and brachial) AVF were trombosed. We thought that the extra-anatom ic AV graft implantation was a good alternative to the permanent subclavian catheter which was the last choice in this patient. The most common locations used for extra anatomic AV fistula are the upper extremity with a graft between the axillary artery and the brachial or antecubital vein, loop graft between axillary artery and vein. At first we planned a subclavian arteriovenous graft interposition which is a cross-sternal bridge AV fistula but the patient had a history of coronary artery disease and there was a possibility of median sternotomy for coronary artery bypass graft (CABG) operation. Thus an interposition done between subclavian artery and vein could cause a problem during median sternotomy. So we changed our plan, and decided to make a graft interposition between the axillary artery and the cephalic vein. In fact an interposition between the axillary vein and the axillary artery could be an alternative way but we saw that the cephalic vein was well developed thus we made an interposition between axillary artery and cephalic vein. In conclusion, we think that patients like our case who have no choice other than permanent catheter for hemodialysis access or who are unable to have CAPD, this extra-anatomic graft location might be a good alternative. Since grafts are foreign bodies, complications of these accesses are common. Reported one-ear patency rates vary from 65% to 75% (11,12). Thrombosis is the most common complication, swelling and infection are the other important complications seen with these
Axillocephalic arteriovenous graft
accesses. The treatment of these complications is challenging and requires excellent judgement, creativity and technical proficiency. The efficacy and durability of these grafts needs to be determined by the short and long term follow-up of many similar cases.
R EFERENCES
1. W ong V, W ard R, T a y la rJ , S e lv a k u m a r S, H ow TV, B a k ra n A. F a cto rs a s s o c ia te d w ith e a rly f a ilu r e o f a r te r io v e n o u s fis tu la f o r h a e m o d ia ly s is a cce ss: E u r J Vase E n d o va sc S u rg 1 9 9 6 ;1 2 :2 0 7 -2 1 3 .
2. R u b e n s F, W e llin g to n JL. B ra c h io c e p h a lic fis tu la : a u s e fu l a lte rn a tiv e fo r v a s c u la r access in c h r o n ic h e m o d ia ly s is . C a rd io v a s c S urg
1 9 9 3 ,1 :1 2 8 -1 3 0 .
3. O n o K, M u to Y, Yano K, Y ukizane T. A n te rio r c h e s t w a ll a x illa r y a rte ry to c o n tr a la te ra l a x illa r y v e in g r a ft f o r v a s c u la r a cce ss in h e m o d ia ly s is : A r t i f O rg a n s 1 9 9 5 ; 1 9 ; 1 2 3 3 -
1 2 3 6 .
4. H u m p h rie s AL J r, C o lb o rn QL, Wynn JJ. E le v a te d b a s ilic v e in a rte rio v e n o u s fis tu la : A m J S u rg 1 9 9 9 ; 1 7 7 :4 8 9 -4 9 1 . 5. H a kagaw a Y, O ta K, S a to Y, F u c h in o u e S, T e ra o k a S, A g is h i T. C o m p lic a tio n s in b lo o d a c c e s s f o r h e m o d ia ly s is : A r t i f O rg a n s 1 9 9 4 ;1 8 :2 8 3 -2 8 8 . 6. Polo JR, S a n a b ia J, Q a rc ia -S a b rid o JL, L u n o J, M e n a rg ue z C, E c h e n a g u is a A. B ra c h ia l-ju g u la r p o ly te tr a flu o r o e th y le n e fis tu la s fo r h e m o d ia ly s is : A m J K id n e y D is 1 9 9 0 ; 1 6 :4 6 5 - 4 6 8 . 7. M c C a n n RL. A x illa r y g ra fts f o r d if f ic u lt h e m o d ia ly s is a c c e s s . J Vase S u rg 1 9 9 6 ,2 4 :4 5 7 - 4 6 1 .
8. P olo JR, V azquez R, P olo J, S a n a b ia J, R ueda JA, L o pez-B aena JA. B ra c h io c e p h a lic ju m p g ra ft fis tu la : an a lte rn a tiv e fo r d ia ly s is use o f e lb o w c re a s e v e in s : A m J K id n e y D is 1 9 9 9 ;3 3 :9 0 4 -9 0 9 .
9. H ill SL, S e e g e r JM. The a rm as an a lte rn a tiv e s ite fo r v a s c u la r a cce ss fo r d ia ly s is in p a tie n ts w ith re c u rre n t a cce ss fa ilu re : S o u th M ed J
1 9 8 5 ;7 8 :3 7 -4 0 .
10. F e rn s tr o m A, H y la n d e r B, O lo fs s o n P, S w e d e n b o rg J. L o n g a n d s h o rt te rm p a te n c y o f ra d io c e p h a lic a rte rio v e n o u s fis tu la s . A cta C h irS c a n d 1 9 8 8 ;1 5 4 :2 5 7 -2 5 9 .
11. H a im o v M, B u rra w s L, B aez A, He i f M, S lifk in R. A lte r n a tiv e s f o r v a s c u la r a c c e s s f o r h e m o d ia ly s is : e x p e rie n c e w ith a u to g e n o u s s a p h e n o u s v e in a u to g ra fts a n d b o v in e h e te ro g ra fts : s u rg e ry 1 9 7 4 ;7 5 :4 4 7 .
12. O akes D, S pees EK Jr, L ig h t JA, Flye MW. A th re e y e a r e x p e rie n c e u s in g m o d ifie d b o v in e a rte ria l h e te ro g ra fts f o r v a s c u la r a cce ss in p a tie n ts re q u irin g h e m o d ia ly s is . A n n S urg
1 9 7 8 ,1 8 7 :4 2 3 .
