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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2001  |  Volume : 12  |  Issue : 2  |  Page : 172-174
Stretch Polytetrafluoroethylene Grafts for Hemodialysis Angioaccess: Three-year Experience


Department of Urology/Nephrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

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   Abstract 

We report the results of 90 stretch polytetrafluoroethylene (PTFE) grafts in 78 chronic renal failure patients over a 3-year period from 1995-1998. The grafts were used as primary access in 15% of the patients. The cumulative patency was 63.3% and there were no complications in 48.8% of the cases. Infection was encountered in 15.5% and thrombosis in 31.1% of the grafts. Intimal hyperplasia, venous anastomotic stenosis, improper puncture technique and subclavian vein stenosis were the major causes of failure of grafts. We conclude that stretch PTFE grafts as angioaccesses may provide good patency and durability.

How to cite this article:
Al Dayel AG, Al Oraifi I, Ezzibdeh MY, Egail SA, El Sayed E, Zallat AA, Al Zahrani S. Stretch Polytetrafluoroethylene Grafts for Hemodialysis Angioaccess: Three-year Experience. Saudi J Kidney Dis Transpl 2001;12:172-4

How to cite this URL:
Al Dayel AG, Al Oraifi I, Ezzibdeh MY, Egail SA, El Sayed E, Zallat AA, Al Zahrani S. Stretch Polytetrafluoroethylene Grafts for Hemodialysis Angioaccess: Three-year Experience. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2017 Nov 24];12:172-4. Available from: http://www.sjkdt.org/text.asp?2001/12/2/172/33807

   Introduction Top


The radial artery/cephalic vein fistulas, first described by Brescia and Cimino in 1966, [1] remain the first choice for hemo­dialysis angioaccess. Fistulas may not be possible when veins are poorly developed or destroyed as in patients with marked obesity or failure of a previous arterio-venous fistula. Stretch polytetrafluoroethylene grafts (PTFE) are now widely regarded as an acceptable alternative for angioaccess. [2] In this review we evaluate the durability and patency of the grafts in our hospital.


   Materials and Methods Top


Ninety stretch PTFE Gore-Tex grafts were placed in 78 chronic renal failure patients in our hospital during the period from December 1995 to December 1998 and all were included in this study. There were 43 males and 35 females with age ranging from 11 to 85 years (mean age of 53). The site and frequency of the grafts are shown in [Table - 1]. Sixty-two grafts were placed under axillary nerve block and 28 under general anesthesia. Revisions, when necessary, were done under local anesthesia with intra­venous sedation. All patients received 400 mg of intravenous Pefloxacin prior to, and continued for two days after, surgery. Tapered 4-6 mm and 4-7 mm. Grafts were used and they were allowed four weeks period for maturation. Indwelling internal jugular vein catheters were placed at the time of placement of the grafts for patients requiring acute dialysis. Grafts with non­functioning segments or poor flow were revised and used immediately after surgery.

Statistical Analysis

Survival of the grafts and cumulative patency rate were calculated using the life table technique.


   Results Top


No complication was encountered in 44 (48.8%) grafts. The cumulative patency rate was 83.3%, 74.4% and 63.3% after one, two and three years of follow-up, respectively.

Thrombosis occurred in 28 (31.1%) grafts, and was secondary to venous anastomotic stenosis in six, multiple stenotic segments in seven, improper puncture technique in four and no obvious cause in six. Subclavian vein stenosis due to previous cannulation was the cause of early occlusion in five grafts. Salvage thrombectomy was tried in 13 grafts and was successful in six [Table - 2].

There were 14 (15.5%) grafts in which infection developed. Early infection was detected in six grafts; three responded to intravenous antibiotics and three necessitated excisions of the functioning grafts due to severe infection. Late infection after maturity of the grafts was encountered in eight grafts; four were due to needle sepsis, two followed surgical revision of thrombosed grafts and two had infection secondary to systemic sepsis. Three grafts were salvaged by incision, drainage and revision while five were excised due to failure of treatment [Table - 2].

Pseudoaneurysm was encountered in three (3.3%) grafts, which resulted in graft failure in two and successful resection in the third. One graft (0.9%) necessitated ligation because of distal limb ischemia [Table - 2].


   Discussion Top


To our knowledge, this is the first report from Saudi Arabia about the follow-up of vascular access in dialysis patients who have synthetic grafts used for hemodialysis. Stretch PTFE grafts have become the predominant access for hemodialysis patients who are not candidates for an autogenous AV fistula. [3],[4],[5]

In our patients, we observed a high incidence of edema and pain after the operation; the use of the graft was postponed for four weeks to allow graft to adhere to the surrounding tissue. The early use of the graft did not gain a wide acceptance at the 3 rd Symposium on Vascular Access for Hemodialysis. [6] About 60% of the surgeons who attended that meeting had some experience with early use of PTFE, but only a small minority were advocates of their use as primary angioaccess tools in dialysis patients. [6] Initially, we were enthusiastic about utilizing straight grafts. The use of 4-mm. diameter grafts has reduced the high flow in them. Currently, loop graft configuration in the forearm is the procedure of choice especially in the elderly and diabetic patients. [5]

The overall survival of the grafts in this retrospective study at three-year was 63.3%, which is comparable to other reported series. [3],[4],[5] The most frequent complication encountered was thrombosis. Hypotension and subclavian stenosis were the cause of early thrombosis. Evaluation of the patency of the subclavian vein in patients with history of previous cannulation has become a standard in our hospital before placement of a permanent vascular graft. Late thrombosis is related mainly to intimal hyperplasia and reconstruction could salvage some occluded grafts if presented early after thrombosis.

Infection, as a result of insertion procedure, is a serious complication. [7],[8] Grafts often have to be removed if they fail to respond to antibiotic therapy. Infection related to repeated graft cannulation should be managed by drainage, appropriate antibiotics and rest of the infected segment. The aggressive salvage policy adopted in our patients restored to function 28% of malfunctioning grafts. The failure in the other malfunctioning grafts was related to complicated or late presentation.

We conclude that our experience with the stretch PTFE angioaccess indicates good patency and durability of these grafts and that surgical treatment of the complications is invaluable in salvaging some malfunc­tioning grafts.

 
   References Top

1.Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and surgically created arteriovenous fistula. N Engl J Med 1966;275:1089-92.  Back to cited text no. 1  [PUBMED]  
2.Tordoir JH, Herman JM, Kwan TS, Diderich PM. Long-term follow-up of the polytetrafluoroethylene (PTFE) prosthesis as an arteriovenous fistula for hemodialysis. Eur J Vasc Surg 1988;2:3-7.  Back to cited text no. 2  [PUBMED]  
3.Pontari MA, McMillen MA. The straight radial antecubital PTFE angio­access graft in an era of high-flux dialysis. Am J Surg 1991;161:450-3.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Raju S. PTFE grafts for hemodialysis access. Techniques for insertion and management of complications. Ann Surg 1987;206(5):666-73.  Back to cited text no. 4    
5.Ridge BA. PTFE grafts for hemodialysis. Vasc Forum 1993;1:55-6.  Back to cited text no. 5    
6.Panel discussion In: Henry ML, Ferguson RM, eds. Vascular access for hemodialysis, Ill Chicago: WL Gore & Associates, Inc., and Precept Press 1993;141.  Back to cited text no. 6    
7.Buckels JA, Ezzibdeh M, Barnes AD. The management of infected vascular access grafts in Koostra G, Jorning PG, (eds): Access Surgery. Lancaster, M.T. Press 1983;217-9.  Back to cited text no. 7    
8.Etheredge EE, Haid SD, Maeser MN, Sicard GA, Aderson CB. Salvage operations for malfunctioning polytetrafluoroethylene hemodialysis access grafts. Surgery 1983; 94:464-7  Back to cited text no. 8    

Top
Correspondence Address:
Mamun Y Ezzibdeh
Senior Consultant Urologist, Renal Transplant Surgeon, King Fahd Military Medical Complex, P.O. Box 946, Dhahran 31932
Saudi Arabia
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PMID: 18209369

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    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    References
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