| Abstract|| |
This study reports our experience at the Chams Clinic, Sfax, Tunisia, with surgical revision of malfunctioning native arteriovenous fistula (AVF). The etiological diagnosis of inadequate access flow was determined by physical examination and a variety of clinical and physiological parameters. Between 1990 and 2006, surgical revisions were performed on 471 patients (mean age 52.8 years, 285 men and 186 women). There was radio-cephalic distal AVF malfunction in 299 patients (63%); the causes of malfunction in these patients included thrombosis in 47 and juxta-anastomotic vein stenosis or occlusion in 248 patients. The initial clinical success rate of all interventions was 98%. Post-intervention primary patency by Kaplan-Meier analysis at one, two, three, four, five and 10 years was 96%, 91%, 88%, 86%, 83% and 63%. Eighty-five patients had involvement of the brachial-cephalic proximal AVF. The post-intervention patency at six months, one, two and three years was 89%, 74%, 61%, 54% in these patients. There were 87 patients with the brachial-basilic upper arm AVF. The post-intervention patency at six months, one, two and three years was 94%, 84%, 64% and 55%. In conclusion, by surgical techniques, which are often simple, excellent results were obtained, and were much better than those obtained with angioplasty.
|How to cite this article:|
Moncef G. Surgical revision of failing or thrombosed native arteriovenous fistulas:A single center experience. Saudi J Kidney Dis Transpl 2010;21:258-61
|How to cite this URL:|
Moncef G. Surgical revision of failing or thrombosed native arteriovenous fistulas:A single center experience. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 May 26];21:258-61. Available from: http://www.sjkdt.org/text.asp?2010/21/2/258/60063
| Introduction|| |
Dysfunction of the arteriovenous fistula (AVF) is a common problem in hemodialysis patients and remains a major cause of morbidity and hospitalization. There are few reports regarding the surgical revision of failing native AVF. ,,,, In recent years, endovascular techniques have become the first-line treatment for AVF dysfunction and have replaced the classic surgical approach. ,,,, This study reports our experience with early surgical revision of malfunctioning native AVF without the interim use of central venous catheters.
| Materials and Methods|| |
Between 1990 and 2006, surgical revision of native AVFs was performed in 471 patients (mean age 52.8 years, 285 males and 186 females) at the Chams Clinic, Sfax, Tunisia. Of these patients, hypertension was present in 127 patients (26%) and diabetes in 84 (17%).
The diagnosis of inadequate access flow was suspected clinically and confirmed with Doppler-Echo or radiology. The dysfunction was further determined by a variety of clinical and physiological parameters including physical examination, patient biochemistry, urea kinetic modelling, and raised venous dialysis pressures. An increase in the pressure in the segment under the anastomosis in the arterialized vein tended, sometimes, to develop an anastomotic aneurysm.  No systematic fistula surveillance program was in place during this period.
The various surgical techniques used in our patients are as given under:
- thrombectomy: surgical removal of thrombus from the AV access
- outflow patch angioplasty: surgical revision of the venous stenosis with a prosthetic or autogenous patch to correct a stenosed outflow anastomosis
- primary repair: a stenotic area is resected and anastomosed end-to-end
- segmental access replacement: insertion of a short (3 to 5 cm long) interposition PTFE arte-riovenous graft or venous segment.
| Definitions of patency and success|| |
For the purpose of this study, fistulas were classified as successful, never used for dialysis, or failure. Technical success was defined as presence of thrill on palpation or a bruit on auscultation, 24-hours post-operatively. Post-intervention primary patency was defined as the period between performing a surgical or endovascular intervention and occurrence of thrombosis or re-stenosis.
| Results|| |
Types of AVF revised
a.) Radial-cephalic AVF at the wrist was seen in 299 patients (63.5%). The study focused on AVFs that were functioning, mature, virgin (with no previous surgical or endovascular procedure), and located in the lower half of the forearm with significant juxtaanastomotic venous stenosis (first 5 cm of the draining vein). The causes of inadequate arterial flow were thrombosis in 47 patients (10%) and juxta anastomotic vein stenosis or occlusion in 248 patients.
Early surgical revision was undertaken by the same surgeon under local anesthesia. The treatment consisted of the creation of a more proximal re-anastomosis of the cephalic vein to the radial artery, a few centimetres above the stenotic venous segment (neo-anastomosis).
The initial clinical success rate of all intervention was 98%. For thrombosed AVF (47 cases), the immediate success rates was 98% (46/47). The Kaplan-Meier method was used to calculate the post-intervention primary patency over 15 years [Table 1].
b.) There were 85 patients (18%) with the brachial cephalic upper arm AVF. The surgical interventions performed in these patients included the following:
The post-intervention primary patency over five years in these patients is shown in [Table 2].
- thrombectomy (n=11 patients)
- primary outflow correction (n=18)
- segment access replacement (n=42)
- anastomosis of cephalic vein to brachial vein (n=30 patients)
c.) Brachial-Basilic upper arm AVF was seen in 87 patients (18.5 %). The surgical inter-ventions performed in these patients included the following:
The post-intervention primary patency rate in these patients over five years is shown in [Table 3].
- thrombectomy (n=14 patients)
- primary repair (n=23) [revision of arterial anastomosis (n=12), anastomosis of basilic vein to brachial vein (n=4) and aneurysmal dilatation (n=8)]
- segment access replacement (n=63 patients; PTFE graft n=51, vein n=12)
| Discussion|| |
The results of our study demonstrate that surgical revision is an excellent form of treatment for the management of failing AVF, particularly in fistulas that have developed stenoses of the draining vein within 4 cm of the anastomosis. The results of our study compare favorably with those achieved by interventional radiologists [Table 4].
Reports of primary patency after percutaneous angioplasty of stenoses in native AVFs vary widely (16%-60% one-year primary patency). ,,, Even now, many experts, including dedicated interventional radiologists, consider surgery as the preferred treatment for juxta-anastomotic stenosis in forearm AVF. ,,,, The surgical correction of stenosis includes creation of a more proximal neo-anastomosis, vein-to-vein reanastomosis, vein patching, short vein or PTFE graft interposition, ,, or the anastomosis of the cephalic vein to the brachial vein, all of which are minimally invasive procedures in easily accessible vessels. Also, surgical correction is likely to be more durable than percutaneous transluminal angioplasty (PTA); the reported primary patency rates in surgical series are higher than after dilatation. ,,, Some investigators use PTA as the first-line treatment for these lesions because it is less invasive and produces excellent immediate primary results. Percutaneous angioplasty is less invasive than surgery; however, it carries a high re-stenosis rate (50% at 6 months) necessitating repeated angioplasty to maintain patency. ,, Surgery and endovascular treatment can extend the life of dialysis shunts. Our experience shows that surgical salvage is particularly successful in the case of juxta-anastomotic venous stenoses and we recommend surgical revision in such cases.
| Conclusion|| |
Revision of failing native elbow fistulas by surgical technique offers excellent results, which are better than angioplasty. Because the number of vascular access sites is limited, the preservation of each site for as long as possible is important for the long-term management of these patients. Transluminal dilatation may be performed in appropriate cases to obviate surgery.
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[Table 1], [Table 2], [Table 3], [Table 4]