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December 23, 2005
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Maher Hamish, MD, MSc, FRCS.
Charing Cross Hospital, London, United Kingdom.
OBJECTIVES:
End-stage renal failure (ESRF) haemodialysis patients frequently have complex venous drainage problems. Multiple access procedures cause central venous stenosis or occlusion, leaving venous drainage impaired. The consequences are: sub-optimal dialysis access function; and symptomatic facial and limb oedema secondary to brachio-cephalic vein and vena cava involvement. Three main surgical options exist:
1. Invasive anatomical venous bypass procedures, which may require thoracotomy;
2. Extra-anatomic arterio-venous Graft (AVG)
3. Extra- anatomic Veno-venous drainage bypasses procedures. in this work , I am looking at the results the extra- anatomic bypassess using axillo- iliac segment.
METHODS:
We report eight ESRF patients with complex renal access problems. Three patients had central venous occlusion, which were both symptomatic and compromising arterio-venous fistula drainage. In addition, radiological intervention had been unsuccessful. All these patients underwent veno-venous axillo-iliac bypass. In five further patients with limited remaining vascular access options, we performed axillo-iliac arterio-venous graft.
All patients were assessed pre-operatively with duplex ultrasonography and venography. The axillary artery or vein, and iliac vein were approached via infraclavicular and extra-peritoneal groin incisions, respectively. Polytetrafluoroethylene (PTFE) was used for the conduits. Anti-coagulation regimens were commenced post-operatively.
RESULTS:
Following venous diversion surgery, there was a dramatic improvement in the problematic facial and limb swelling experienced by the patients. There was no significant peri-operative morbidity. The veno-venous graft is still patent at 12 months in patient one, and at 6 months in the second patient and the third had been sited one month ago.
Regarding the AVG’s, the mean follow-up was 9.6 (4-14) months. At 6 months the primary patency rate was 80% and secondary patency rate was 100 %. Three patients had patent, usable grafts at 12 months. In two cases, graft occlusion was treated with successful thrombectomy.
CONCLUSIONS:
Axillary-iliac veno-veno diversion can overcome the symptoms and complications of superior vena cava and brachio-cephalic vein obstruction. Extra-anatomic, axillo-iliac arterio-venous graft fistulae formation is previously described but has not been widely used. However, we have found the procedure to have low morbidity and advocate its use in these complex cases.
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Axillo-Iliac Conduit for Haemodialysis Vascular Access
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Maher Hamish, MD, MSc, FRCS.
Charing Cross Hospital, London, United Kingdom.
OBJECTIVES:
End-stage renal failure (ESRF) haemodialysis patients frequently have complex venous drainage problems. Multiple access procedures cause central venous stenosis or occlusion, leaving venous drainage impaired. The consequences are: sub-optimal dialysis access function; and symptomatic facial and limb oedema secondary to brachio-cephalic vein and vena cava involvement. Three main surgical options exist:
1. Invasive anatomical venous bypass procedures, which may require thoracotomy;
2. Extra-anatomic arterio-venous Graft (AVG)
3. Extra- anatomic Veno-venous drainage bypasses procedures. in this work , I am looking at the results the extra- anatomic bypassess using axillo- iliac segment.
METHODS:
We report eight ESRF patients with complex renal access problems. Three patients had central venous occlusion, which were both symptomatic and compromising arterio-venous fistula drainage. In addition, radiological intervention had been unsuccessful. All these patients underwent veno-venous axillo-iliac bypass. In five further patients with limited remaining vascular access options, we performed axillo-iliac arterio-venous graft.
All patients were assessed pre-operatively with duplex ultrasonography and venography. The axillary artery or vein, and iliac vein were approached via infraclavicular and extra-peritoneal groin incisions, respectively. Polytetrafluoroethylene (PTFE) was used for the conduits. Anti-coagulation regimens were commenced post-operatively.
RESULTS:
Following venous diversion surgery, there was a dramatic improvement in the problematic facial and limb swelling experienced by the patients. There was no significant peri-operative morbidity. The veno-venous graft is still patent at 12 months in patient one, and at 6 months in the second patient and the third had been sited one month ago.
Regarding the AVG’s, the mean follow-up was 9.6 (4-14) months. At 6 months the primary patency rate was 80% and secondary patency rate was 100 %. Three patients had patent, usable grafts at 12 months. In two cases, graft occlusion was treated with successful thrombectomy.
CONCLUSIONS:
Axillary-iliac veno-veno diversion can overcome the symptoms and complications of superior vena cava and brachio-cephalic vein obstruction. Extra-anatomic, axillo-iliac arterio-venous graft fistulae formation is previously described but has not been widely used. However, we have found the procedure to have low morbidity and advocate its use in these complex cases.
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