Sérgio Teixeira

Radio-cephalic fistula recovered with drainage to forearm basilic vein: Case Report

Dysfunction problems with vascular access are a concern to patients and dialysis units. The vascular surgeon should analyse such dysfunction and perform a careful assessment of the vascular network in order to find new fistula layouts. We introduce and discuss the case of creation of a radio‐cephalic fistula with outflow into the forearm basilic vein through rotation of the forearm basilic vein toward the cephalic vein in the forearm of an 88‐year‐old hemodialysis male patient. This technique enables extending fistula patency and improves cost efficiency.

Brachio-brachial Arteriovenous Fistula Superficialization with Short Skip Incisions

The exhaustion of superficial venous patrimony or reduced diameter of superficial veins usually prevents patients from having an arteriovenous fistula created. In such cases, using deep vessels can be a more viable option as opposed to an arteriovenous graft. We describe a new approach for the brachio-brachial arteriovenous fistula creation technique. It consists of 3 small incisions, thus causing minimal surgical damage. We have found it to be better tolerated by the patients and well received by dialysis nurses. This procedure also allows improved access for cannulation and more available puncture sites.

Radio-cephalic arteriovenous fistula recovered with drainage through the brachial vein: RC-AVF drainage into the brachial vein

Dysfunction of arteriovenous access for hemodialysis is a challenge for the vascular surgeon. Some patients have complex vascular access with problems that are difficult to solve. Careful analysis of the vascular network with ultrasound and dissection of the veins during surgery can help to identify the best option for each access. We introduce and discuss the case of creation of a radio‐cephalic fistula with outflow into the brachial vein in 64‐year‐old hemodialysis male patient. This technique enables extending fistula patency, arterializing the brachial vein, and improves cost efficiency.

Arteriovenous access banding revisited

Purpose The aim of this study is to validate the current applicability of arteriovenous access banding in high flow access (HFA) and/or haemodialysis access-induced distal ischaemia (HAIDI). Methods This retrospective study was conducted at the GEV (Grupo de Estudos Vasculares) vascular access centre. The clinical records of consecutive patients undergoing banding for HAIDI and HFA symptoms, between June 2011 and January 2015, were reviewed until April 2015. All vascular access patients’ consultation records and surgical notes were reviewed. We analysed and compared patients’ age, gender, comorbidities, symptoms and intraoperative ultrasound control. We defined technical failure as recurrence of symptoms, requiring new banding. Excessive banding, access thrombosis, rupture and false aneurysm development were registered as complications. Primary clinical success was defined as improvement of symptoms or effective flow reduction after banding, with no need for reintervention. If one reintervention was necessary, we have defined it as secondary clinical success. Results Overall, 119 patients underwent banding: 64 (54%) with HAIDI and 55 (46%) with HFA. The HAIDI group was significantly older (65 ± 13 years compared with 56 ± 22 years, p = 0.001) and had significantly greater number of patients with diabetes (56% vs 24%, p = 0.004). Primary success was achieved in 85 patients (71.4%) and the secondary success rate was 84.9%. Older age (p = 0.016) and intraoperative ultrasound control (p = 0.012) were significantly associated with primary success. Conclusions Our results do not corroborate the high incidence of thrombosis previously reported as associated with AV access banding and suggest that ultrasound control is crucial for preventing technical failure. The procedure was effective on both compared groups.

Radiocephalic Fistula Recovery Using the Brachial Vein and Forearm Basilic Vein: A Case Series and Literature Review: RC-AVF Recovery Using Different Veins

Vascular access dysfunction is a serious problem in dialysis units. Some patients have complex dysfunctions that are difficult to resolve. In this article, we report the case a of two patients with radiocephalic arteriovenous fistulae (RC‐AVF) who had stenosis/occlusion of the forearm median vein and where we used the basilic vein of the forearm as a solution. We reviewed the use of this surgical solution in RC‐AVF. Two male patients on hemodialysis exhibited stenosis/occlusion of the forearm median vein. The forearm basilic vein was isolated and rotated toward the forearm median vein in order to solve RC‐AVF problems. One patient had fistula thrombosis 5 months after the procedure, while for the other patient, the fistula continues to work without problems. Literature describes only a few cases using the forearm basilic vein or the brachial vein for fistula recovery. This procedure increased the patency of fistulas. This approach has been proven to be a good solution for solving outflow problems using the superficial or deep veins, increasing fistula patency and avoiding the need to place a central venous catheter and all the related complications.

The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition

Background: The definition of significant stenosis (SS) remains controversial. Methods: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). Results: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. Conclusion: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.

MP655COLOR DOPPLER ULTRASOUND ASSESSMENT OF JUXTA-ANASTOMOTIC STENOSIS IN RADIOCEPHALIC ARTERIOVENOUS FISTULAS: ENDOVASCULAR OR SURGICAL APPROACH

Background: Juxta-anastomotic stenosis (JAS) is a common complication of radiocephalic arteriovenous fistulas. There is diverging data as to the best therapeutic approach being angioplasty or surgery. Pre-operative color Doppler ultrasound (CDU) is accurately used for initial assessment of the vascular access and follow-up monitoring. The aim of this study was to evaluate immediate and long-term results of endovascular versus open surgical intervention of juxta-anastomotic venous stenosis of forearm radiocephalic fistulas and to test if CDU assessment can be used to ameliorate preoperative strategy and long-term outcomes. Methods: This retrospective cohort study included 63 patients with JAS radiocephalic fistulas referred to vascular access consultation. CDU was used to assess preoperative morphological, functional and hemodynamic stenosis characteristics and according to specific criteria, allocate patients to endovascular or surgical treatment. Results: Surgical revision was proposed in 68.2% of patients (N=43), namely the creation of a new proximal fistula (N=41), while angiographic evaluation was proposed in 31.7% of the cases (N=20). Mean follow-up time was 720±524 days with a maximum follow-up of 4.6 years. In the surgical group, primary patency was 92% and 84% at 6 and 12 months respectively, while in the endovascular group, it was 76% and 47% (p=0.013). There was no significant difference in the assisted primary patency between the interventional groups at 12 months: 94% in the endovascular vs. 93% in the surgical group (p=0.542). Conclusion: Pre-operative CDU assessment of JAS and specific allocation criteria with an access-centered approach choosing the best option in each fistula allowed the correct diagnosis of the lesion, improved the global results of the treatment and optimized the financial resources by reserving PTA for selected cases where surgery could be more difficult with higher risk of access loss.

Aneurysmal Degeneration of the Brachial Artery after Vascular Access Creation: Surgical Treatment Results

Abstract True peripheral artery aneurysms proximal to a longstanding arteriovenous fistula is a well‐recognized complication. Late aneurysmal degeneration is rare. This study analyzed the characteristics, therapeutic options, and outcomes of true donor brachial artery aneurysms (DBAA) after arteriovenous fistula (AVF) for hemodialysis. We retrospectively collected the data of patients with DBAA after AVF creation, surgically repaired between January 2001 and September 2015. We excluded patients with pseudoaneurysms, anastomotic aneurysms, and infected aneurysms. We recorded patients demographics, type of access, aneurysm characteristics, symptoms, treatment, and follow‐up. Ten patients were treated for aneurysmal degeneration of the brachial artery. Average aneurysm diameter was 37.5 mm. All cases had, at least, one previous distal AVF, ligated or thrombosed, at the time of diagnosis. The first access was created in mean 137 months before the diagnosis of DBAA. Nine patients had previous medical history of renal transplant and were under immunosuppressive therapy. All patients were symptomatic at the time of diagnosis. In all cases, the treatment was aneurysmectomy followed by interposition bypass. One patient developed a postoperative hematoma with the need of surgical drainage. At 50 months of follow‐up, one patient was submitted to percutaneous angioplasty due to an anastomotic stenosis. No other complications occurred during the entire follow‐up period (mean: 69 months). The pathogenesis underlying DBAA remains unclear. Increased blood flow after AVF creation, immunosuppressive therapy, and ligation/thrombosis of the AVF may contribute to aneurysm formation. Surgical treatment by aneurysmectomy and bypass, with autogenous conducts, is a safe and effective option.