Kevin E. Taubman

Creating functional autogenous vascular access in older patients

OBJECTIVE Arteriovenous fistulas (AVFs) are the preferred choice for hemodialysis vascular access (AV access); however, there is debate over the utility of AVFs in older patients, particularly concerning access maturation and functionality. We reviewed our AV access experience in patients ≥65 years of age. METHODS We analyzed consecutive AV access patients ≥65 years old with access operations between March 2003 and December 2009. All patients had ultrasound vessel mapping. In addition to overall outcomes review, the data for patients ≥65 years old were stratified into three 10-year increments by age for further analysis. We compared functional patency data for our older patients with those of our non-elderly patients aged 21 to 64 years treated during the same time period. RESULTS Four hundred sixty-one consecutive AV access patients new to our practice were included in this study. Ages were 65 to 94 years (mean, 73 years). Two hundred thirty-six (51.2%) were female, 276 (59.9%) patients were diabetic, and 103 (22.3%) were obese. One hundred seven (23.2%) patients had previous access operations. Radiocephalic AVFs were constructed in 29 (6.3%) patients, 99 (21.5%) patients had brachial artery inflow AVFs, 330 (71.6%) had proximal radial artery AVFs, and three were based on the femoral artery. Transposition AVFs were used in 124 (26.9%) patients. No grafts were used for AV access in any patient during the study period. Time to AVF use was 0.5 to 6 months (mean, 1.5 months). Primary, primary assisted, and cumulative patency for patients aged 65 to 94 years were 59.9%, 93.7%, and 96.9% at 12 months and 45.3%, 90.1%, and 94.6% at 24 months, respectively. Follow-up was 1.5 to 77 months (mean, 17.0 months). Subgroup age stratification (65-74 [n = 268], 75-84 [n = 167], 85-94 [n = 26] years) found no statistical difference in functional access outcomes. Primary, primary assisted, and cumulative patency rates were not statistically different in the elderly and non-elderly populations (P = .29, .27, and .37, respectively). One hundred fifty-six patients died during the study period, 1.3 to 61 months (mean, 20 months) after access creation. No deaths were related to access operations. CONCLUSIONS AVFs are feasible and offer functional and timely AV access in older patients. There was no difference in functional access outcomes for older patients with subgroup age stratification. AVF patency rates were not statistically different in the elderly and non-elderly populations. Cumulative AVF patency for patients ≥65 years of age was 96.9% at 12 months and 94.6% at 24 months.

Brachial vein transposition arteriovenous fistulas for hemodialysis access

BACKGROUND An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis, offering lower morbidity, mortality, and cost compared with grafts or catheters. Patients with a difficult access extremity have often lost all superficial veins, and even basilic veins may be obliterated. We have used brachial vein transposition AVFs (BVT-AVFs) in these challenging patients and review our experience in this report. METHODS The study reviewed consecutive patients in whom BVT-AVFs were created from September 2006 to March 2009. Most BVT-AVFs were created in staged procedures, with the second-stage transposition operations completed 4 to 6 weeks after the first-stage AVF operation. A single-stage BVT-AVF was created when the brachial vein diameter was > or =6 mm. RESULTS We identified 58 BVT-AVF procedures, comprising 41 women (71.0%), 28 diabetic patients (48.3%), and 29 (50.0%) had previous access surgery. The operation was completed in two stages in 45 operations (77.6%) and was a primary transposition in 13 patients. However, five of these were secondary AVFs with previous distal AV grafts or AVFs placed elsewhere; effectively, late staged procedures. Follow-up was a mean of 11 months (range, 2.0-31.7 months). Primary patency, primary-assisted patency, and cumulative (secondary) patency were 52.0%, 84.9%, and 92.4% at 12 months and 46.2%, 75.5%, and 92.4% at 24 months, respectively. Harvesting the brachial vein was tedious and more difficult than harvesting other superficial veins. No prosthetic grafts were used. CONCLUSION BVT-AVFs provide a suitable option for autogenous access when the basilic vein is absent in patients with difficult access extremities. Most patients required intervention for access maturation or maintenance. Most BVT-AVFs were created with staged procedures. Cumulative (secondary) patency was 92.4% at 24 months.

Accessible autogenous vascular access for hemodialysis in obese individuals using lipectomy

BACKGROUND Arteriovenous fistula are created less frequently in obese individuals, and fewer of these access procedures become functional. The authors review their experience with the excision of subcutaneous tissue (lipectomy) overlying upper arm cephalic vein arteriovenous fistulas in obese patients. METHODS Consecutive vascular access patients undergoing lipectomies for difficult access cannulation due to vein depth were reviewed. Cephalic vein depth was measured by ultrasound at 3 sites before lipectomy and again before the first cannulation. RESULTS Thirty patients were reviewed, with a mean body mass index of 40.2 kg/m² (range, 28-57.7 kg/m²). The mean age was 52 years. Seventeen patients were women, and 19 had diabetes. The mean preoperative vein depth of 15.8 mm (range, 6-30 mm) was reduced to 4.1 mm (range, 3-8 mm) (P ≤ .01). All fistulas were functional, and only 1 failed during a follow-up period of 2.2 to 53.2 months. CONCLUSIONS Lipectomy offers a relatively simple and successful method of extending direct autogenous vascular access to obese individuals.

Simple and durable resolution of steal syndrome by conversion of brachial artery arteriovenous fistulas to proximal radial artery inflow

Dialysis associated steal syndrome (DASS) is relatively uncommon but constitutes a serious risk for patients undergoing vascular access operations. We report two patients with DASS where brachial artery vascular access inflow was revised to the proximal radial artery for arteriovenous fistula (AVF) inflow. DASS was resolved in both patients with the permanent resolution of symptoms, in addition to the healing of ulcerations and ischemia. Both AVFs were immediately functional and durable.

Prevention of vascular access hand ischemia using the axillary artery as inflow

BACKGROUND Avoiding dialysis access-associated ischemic steal syndrome (DASS) in patients with upper extremity peripheral vascular occlusive disease while creating a functional hemodialysis vascular access may be challenging. We constructed an autogenous access with primary proximalization of the arterial inflow to prevent hand ischemia in patients at high risk for this complication. METHODS Patients requiring hemodialysis access with physical findings suggesting a high risk of access-related hand ischemia (absent radial, ulnar, and brachial palpable pulses associated with small calcified vessels by ultrasound examination) underwent a primary arteriovenous fistula transposition procedure utilizing the axillary artery for inflow. The arteriovenous fistula was either a reversed flow basilic vein transposition supplemented by valvulotomy (n = 22); a translocated reversed basilic vein (n = 4); a cephalic vein harvested into the forearm and placed in a loop configuration for axillary artery inflow (n = 3); or a translocated reversed saphenous vein (n = 1). RESULTS Thirty patients with a mean age of 60 years (range, 31-83 years) underwent successful primary axillary artery inflow procedures during a 3-year period. Of these, 23 (77%) were female and 25 (83%) were diabetic. Twenty-one (70%) had previous vascular access procedures and 10 (33%) were obese. No patient developed postoperative ischemia. Three individuals died 2, 14, and 19 months following surgery, none related to vascular access. Three accesses failed after 1, 5, and 7 months and could not be salvaged. Life-table primary, primary assisted, and cumulative patency rates were 57%, 78%, and 87% respectively at 1 year with a mean follow-up of 7 months (range, 1-25 months). Cephalic vein outflow was associated with fewer access failures, fewer interventions postoperatively, and lower rates of arm swelling (P < .01). CONCLUSIONS Creating a basilic vein transposition for vascular access utilizing axillary artery inflow is a good option for patients with severe peripheral vascular disease. It offers a high patency rate and the prevention of DASS. Retrograde basilic vein outflow through the median cubital and cephalic vein is associated with the best outcome and is the recommended configuration.

Alternative Autogenous Arteriovenous Hemodialysis Access Options

An autogenous arteriovenous hemodialysis access (AVF) remains the consensus-recommended vascular access for individuals requiring hemodialysis. Surgical options, strategies, and guidelines have been established by several organizations, including the National Kidney Foundation, the Fistula First Breakthrough Initiative, and the Society for Vascular Surgery. Establishing a successful AVF in a high percentage of patients requires a thorough knowledge of the many access options and clinical practice recommendations, in addition to a careful clinical history/physical examination, pre- and postoperative ultrasound, and further vascular imaging in select patients. The more common AVF configurations may not be possible in complex patients because of limited venous outflow, arterial insufficiency, or both. However, the vascular access surgeon may still be able to construct a successful AVF in these challenging patients by utilizing one of several alternative procedures. Avoiding prosthetic arteriovenous accesses and central venous catheter-based dialysis is feasible in most patients. This article reviews some of the alternative options for establishing successful AVFs.

Arteriovenous fistulas for hemodialysis access in children and adolescents using the proximal radial artery inflow site

INTRODUCTION Hemodialysis (HD) for children and adolescents with renal failure is increasingly common in the United States. Consensus opinion views an arteriovenous fistula (AVF) as the best long-term access option, although catheter-based HD remains the most common vascular access in children and has greater risks of complications and higher mortality rates than AVF access. This report reviews our experience with children and adolescents undergoing vascular access operations. METHODS We reviewed 721 consecutive vascular access patients who had vascular access surgery by a single surgeon during the previous 5 years. Ten patients 20 years or younger were included in this study. In addition to physical examination, each patient had preoperative vascular ultrasound mapping by the operating surgeon. A radiocephalic AVF (RC-AVF) at the wrist was the first choice for dialysis access when feasible; however, the patients in this report were generally seen after years of intravenous access and venipunctures that necessitated more proximal AVF constructions. A proximal radial artery AVF (PRA-AVF) was our most common choice for vascular access when an RC-AVF was not suitable. RESULTS Patient ages were 9 to 20 years (mean, 16). Seven were male. Renal failure was caused by glomerulnephitis in 4 patients, 3 had a history of obstuctive uropathy, 2 were diabetic and one had congenital nephrotic syndrome. Eight patients had PRA-AVFs created, 1 had an RC-AVF, and 1 patient required a transposition AVF. Follow-up was 4 to 56 months (mean, 32 months). Primary, primary-assisted, and cumulative patencies were 77.8%, 100%, and 100% at 24 months. No prosthetic grafts were used in any vascular access patient during the study period. CONCLUSION We found HD access in children and adolescents was reliably established through use of a PRA-AVF when an RC-AVF was not feasible. Access sites were often possible through the upper arm cephalic veins and/or with retrograde flow into the forearm. Cumulative (secondary) patency was 100% at 24 months.

Creating arteriovenous fistulas in patients with chronic central venous obstruction

Purpose Central venous obstruction Occlusion (CVO) has been considered a contraindication for creating a vascular access due to fear of developing a swollen extremity. However, many of these individuals developed large collateral veins and are asymptomatic. We report our experience constructing arteriovenous fistulas (AVFs) in these challenging patients. Methods Patients with a new AVF constructed in the presence of known CVO were identified. Venous imaging confirmed proximal obstruction and extensive collateral venous return. The AVF was constructed in the extremity with the most favorable ultrasound vessel mapping and collateral central venous outflow. Arterial inflow via the radial artery was utilized when feasible. Results AVFs associated with known CVO were constructed in 19 patients during an eight-year time period. The mean age was 53 years, 63% were female, and 58% diabetic. Arterial inflow was from the radial artery in 15 patients and the brachial or axillary artery in 5 individuals. Post-operative AVF flow volumes were 415-910 mL/min (mean = 640 mL/min). Eight patients (42%) developed some degree of arm edema. Two resolved without intervention. The others required inflow banding (n = 2), outflow branch coiling (n = 1), and/or recanalization with angioplasty (n = 4) of the CVO to resolve swelling. Mean follow-up was 14 months. Two AVFs failed at 8 and 16 months. Primary and cumulative patency rates were 49% and 100% at 12 months and 39% and 80% at 24 months, respectively. Conclusions CVO need not preclude the creation of a successful AVF. Extensive venous collaterals and avoiding high-flow AVFs are important elements for success. Cumulative patency was 80% at 24 months.

Variability in leg compression provided by gradient commercial stockings.

BACKGROUND Compression stockings are commonly prescribed by physicians for lower extremity edema and venous insufficiency. However, no data are available for clinicians to assess the relative quality of various brands, particularly low-cost generics now available directly to consumers through the Internet. We examined the actual compression provided by gradient stockings from multiple manufacturers. METHODS A total of 36 class 2 (20-30 mm Hg) mens medium-sized below-knee compression stockings from six different manufacturers (n = 6 of each brand) with approximately the same quality and materials were chosen to be studied. Identifying brand names were removed, and they were randomly and blindly tested by a technician in accordance with accepted industry standards. A calibrated constant rate of extension tensile instrument (Zwick Z010; Zwick Roell, Ulm, Germany) was used, and the tension generated by the stockings at the ankle and calf was measured using minimum, average, and maximum circumference sizes. All measurements were performed in duplicate. RESULTS The compression pressures generated by the stockings were almost all within the stated range of 20 to 30 mm Hg at the ankle, but all except one were below 20 mm Hg at the calf. There were also significant differences between manufacturers at both the ankle and the calf (P < .0001). The expected pressure reduction between the two locations varied, but one stocking had only a minimal 2 mm Hg (8%) gradient, which was significantly less than all of the other tested brands and below the recommended 20% to 50% reduction. Cost analysis demonstrated that the discount brands were significantly lower in price but provided absolute compression and pressure gradients similar to those of the more expensive brands. CONCLUSIONS There is significant variability among stockings, both in the absolute pressures and in the pressure gradients generated from the ankle to the calf, thought to be functionally important for venous flow. The cheaper stockings offered the same degree of compression and pressure gradient as the more expensive brands. These results suggest the need for manufacturing standards in the United States and a revision in labeling requirements to mandate more accurate and complete pressure disclosures.

Mastication Steal Syndrome

A 56-year-old woman presented with episodic vertigo, dizziness, and diplopia during meals and prolonged verbal presentations at work. Subsequent work-up included an eventual catheter-based angiogram revealing an ostial left external carotid artery (ECA) occlusion with reconstituted retrograde flow via a variant collateral branch from the dominant left vertebral artery. The findings demonstrate that repetitive activities involving craniofacial muscular systems supplied by the ECA result in a symptomatic arterial steal syndrome via the enhanced diverted flow from the collateral vertebral-basilar arterial system. A left ECA endarterectomy with reimplantation of the vessel was performed, and the patient has been episode free thereafter.