William C. Jennings

The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access

Recognizing the impact of the decision making by the dialysis access surgeon on the successful placement of autogenous arteriovenous hemodialysis access, the Society for Vascular Surgery assembled a multispecialty panel to develop practice guidelines in arteriovenous access placement and maintenance with the aim of maximizing the percentage and functionality of autogenous arteriovenous accesses that are placed. The Society commissioned the Knowledge and Encounter Research Unit of the Mayo Clinic College of Medicine, Rochester, Minnesota, to systematically review the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance. The panel then formulated practice guidelines in seven areas: timing of referral to the access surgeon, operative strategies to maximize the placement of autogenous arteriovenous accesses, first choice for the autogenous access, choice of arteriovenous access when a patient is not a suitable candidate for a forearm autogenous access, the role of monitoring and surveillance in arteriovenous access management, conversion of a prosthetic arteriovenous access to a secondary autogenous arteriovenous access, and management of the nonfunctional or failed arteriovenous access. For each of the guidelines, the panel stated the recommendation or suggestion, discussed the evidence or opinion upon which the recommendation or suggestion was made, detailed the values and preferences that influenced the groups decision in formulating the relevant guideline, and discussed technical remarks related to the particular guideline. In addition, detailed information is provided on various configurations of autogenous and prosthetic accesses and technical tips related to their placement.

Fistula First Breakthrough Initiative: Targeting Catheter Last in Fistula First

An arteriovenous fistula (AVF) is the optimal vascular access for hemodialysis (HD), because it is associated with prolonged survival, fewer infections, lower hospitalization rates, and reduced costs. The AVF First breakthrough initiative (FFBI) has made dramatic progress, effectively promoting the increase in the national AVF prevalence since the program’s inception from 32% in May 2003 to nearly 60% in 2011. Central venous catheter (CVC) use has stabilized and recently decreased slightly for prevalent patients (treated more than 90u2003days), while CVC usage in the first 90u2003days remains unacceptably high at nearly 80%. This high prevalence of CVC utilization suggests important specific improvement goals for FFBI. In addition to the current 66% AVF goal, the initiative should include specific CVC usage target(s), based on the KDOQI goal of less than 10% in patients undergoing HD for more than 90u2003days, and a substantially improved initial target from the current CVC proportion. These specific CVC targets would be disseminated through the ESRD networks to individual dialysis facilities, further emphasizing CVC avoidance in the transition from advanced CKD to chronic kidney failure, while continuing to decrease CVC by prompt conversion of CVC‐based hemodialysis patients to permanent vascular access, utilizing an AVF whenever feasible.

Primary Breast Lymphoma: The Role of Mastectomy and the Importance of Lymph Node Status

Objective:To construct and analyze a database comprised of all reported cases of primary breast lymphoma (PBL) that include treatment and follow-up information published during the last 3 decades. Summary Background Data:PBL accounts for 0.4% of breast malignancies and 2% of extranodal lymphomas. Surgical therapy has varied from biopsy to radical mastectomy. Chemotherapy and radiation therapy have been used as adjuvant or primary therapy. A standard consensus treatment of PBL is not available. Methods:We reviewed all published PBL reports from June 1972 to March 2005. A database was compiled by abstracting individual patient information, limiting our study to those reports that contained specific treatment and outcome data. Patient demographics such as survival, recurrence, and time to follow-up were recorded, in addition to surgical, radiation, and/or chemotherapy treatment(s). Results:We found 465 acceptable patients reported in 92 publications. Age range was 17 to 95 years (mean, 54 years). Mean tumor size was 3.5 cm. Diffuse large cell (B) lymphoma was the most common histologic diagnosis (53%). Disease-free survival was 44.5% overall. Follow-up ranged from one to 288 months (mean, 48 months). Treatment by mastectomy offered no survival benefit or protection from recurrence. Treatment that included radiation therapy in stage I patients (node negative) showed benefit in both survival and recurrence rates. Treatment that included chemotherapy in stage II patients (node positive) showed benefit in both survival and recurrence rates. Histologic tumor grade predicted survival. Conclusions:Mastectomy offers no benefit in the treatment of PBL. Nodal status predicts outcome and guides optimal use of radiation and chemotherapy.

Proximal radial artery as inflow site for native arteriovenous fistula

BACKGROUNDnMost vascular surgeons favor an initial radial-cephalic anastomosis at the wrist for dialysis access when possible. As populations age and more chronically ill patients are offered dialysis, this native arteriovenous fistula (NAVF) is less frequently available. A brachial-cephalic anastomosis is generally considered to be the second choice for NAVF site. We report our experience in a series of patients where the proximal radial artery (PRA) serves as the primary inflow vessel.nnnSTUDY DESIGNnWe reviewed 139 consecutive dialysis access operations performed by the senior author. One hundred fourteen had an NAVF constructed. Seventy-three of these procedures in 71 patients involved the PRA as arterial inflow and are the subject of this report.nnnRESULTSnMean age was 57 years. Thirty-six of the 71 were men. Seventy-one percent of the patients were diabetic and more than half had previous access surgery. Twenty-nine patients underwent preoperative ultrasonographic evaluation for feasibility and planning of the NAVF fistula. The 1-month patency rate for patients undergoing PRA fistula was 98%. Cumulative patency was 80% during the followup period of up to 42 months. No infectious or ischemic complications were noted during the study period.nnnCONCLUSIONSnWe find the anterior position and mobility of the PRA offers a simple and tension-free anastomosis to the median antebrachial vein or one of its tributaries. This anastomotic site frequently allows dialysis in both the forearm and upper arm. The PRA allows for adequate arterial inflow while avoiding the risk of steal syndrome found with brachial artery fistulas. More extensive procedures or use of prosthetic grafts can be avoided.

Primary and staged transposition arteriovenous fistulas.

BACKGROUNDnThe use of catheters or prosthetic grafts for vascular access has significantly higher mortality and morbidity risks, in addition to higher costs, than arteriovenous fistulas (AVF). Many patients have a difficult access extremity due to complex medical illnesses, previous vascular access procedures, intravenous catheters, diabetes, vascular disease, female sex, age, and other complicating factors. Transposition AVFs (AVF-T) have been used for these individuals to avoid catheters and grafts. We report our experience with primary and staged basilic vein AVF-Ts and staged brachial vein AVF-Ts.nnnMETHODSnFrom our database of consecutive vascular access operations, we reviewed patients from May 2003 to September 2006 for all upper extremity AVF-Ts. A primary AVF-T was used when the basilic vein was continuous with a minimum diameter of 4 mm and of adequate length. When the basilic vein was 2.5 to 4 mm, the procedure was staged. The proximal radial artery was used for inflow, if possible. When the basilic vein was not suitable, a radial vein or brachial vein anastomosis was performed as the first stage of a planned brachial vein AVF-T. The second stage operations of staged AVF-Ts were generally done 4 to 6 weeks after the primary AVF construction. All patients were evaluated with preoperative ultrasound imaging by the operating surgeon.nnnRESULTSnFrom a database of 412 consecutive vascular access patients, 78 upper extremity transposition procedures were identified. Of these, 57 patients (73.1%) were women, 44 (56.4%) were diabetic, and 46 (59.0%) had previous access surgery. Fifty-eight operations were staged procedures. The basilic vein was used in 68 AVF-T, the brachial vein in six, and cephalic vein in four. The anastomosis was based on the proximal radial artery in 60 patients. Mean follow-up was 18 months (range, 3-48 months). Primary patency, primary assisted patency, and cumulative patency were 45.7%, 93.5%, and 96.0% at 12 months and 27.6%, 86.5%, and 88.9% at 24 months, respectively. No prosthetic grafts were used in the study period.nnnCONCLUSIONnBoth primary and staged AVF-T procedures were successfully used in patients with difficult access extremities. AVF-Ts were durable, although many required an interventional procedure for maturation or maintenance. Cumulative (secondary) patency was 96.0% at 12 months and 88.9% at 24 months. The absence of an adequate basilic vein does not preclude the use of a staged AVF-T because the brachial vein offers a suitable alternative.

Creating functional autogenous vascular access in older patients

OBJECTIVEnArteriovenous 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.nnnMETHODSnWe 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.nnnRESULTSnFour 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.nnnCONCLUSIONSnAVFs 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

BACKGROUNDnAn 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.nnnMETHODSnThe 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.nnnRESULTSnWe 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.nnnCONCLUSIONnBVT-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.

Creating Radiocephalic Arteriovenous Fistulas: Technical and Functional Success

BACKGROUNDnThe radiocephalic arteriovenous fistula (RC-AVF) at the wrist is the recommended first choice for hemodialysis access. Several authors have reported early thrombosis or failure of RC-AVFs to mature in up to 20% to 57% of patients. We report a consecutive series of individuals in whom physical and ultrasonography (US) examinations predicted success with RC-AVFs.nnnSTUDY DESIGNnRecords of all patients who underwent vascular access operations by the communicating author from June 2003 through June 2008 were reviewed to identify those individuals with RC-AVF procedures. Physical examination and US screening criteria for creating a RC-AVF included a continuous and uninterrupted outflow vein diameter > or = 2.5 mm and a normal radial artery inflow examination with vessel diameter > or = 2.0 mm. A venous branching point at the wrist was identified to create a broad patch for the RC-AVF anastomosis.nnnRESULTSnWe reviewed 796 consecutive vascular access operations, identifying 75 RC-AVFs created in 74 patients. Patient ages were 20 to 82 years (mean 57 years). Eighteen were women and 42 were diabetic. Mean followup was 14.5 months. Primary, primary-assisted, and cumulative (secondary) patency were 58.3%, 96.2%, and 100%, respectively, at 12 months and 48.1%, 91.5%, and 95.7%, respectively, at 24 months.nnnCONCLUSIONSnRC-AVF at the wrist remains our first choice for vascular access in the subset of patients meeting specific preoperative criteria by physical and United States examinations. Cumulative patency was 100% at 12 months and 95.7% at 24 months. Although RC-AVF construction technique is important, careful patient selection is believed to be the critical element in creating functional and durable RC-AVFs.

Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion

Purpose Vascular access patients with central vein (CV) stenosis or occlusion may have significant symptoms. Treatment is generally by balloon angioplasty, with or without stenting. However, CV lesions may not be correctable and when treated, tend to recur. Surgical bypass of CV obstruction is a major procedure and ligation of the access may leave the patient dependent on catheter dialysis. We review a precision inflow banding procedure to limit vascular access flow and pressure for symptomatic patients with CV obstruction while preserving access functionality. Materials and Methods All individuals with symptomatic CV occlusive disease who underwent an autogenous vascular access inflow restriction procedure by the two senior authors were identified. All had failed attempts to correct CV lesions by angioplasty and stent placement. A precision banding procedure was used for access inflow reduction with the addition of real-time intravascular flow monitoring. Results Twenty-two patients were identified. Ages were 22–72 years (mean=43 years). Nine patients (40.9%) were women, and 8 (36.4%) obese. Mean access flow was 1640 mL/minute before banding decreased to 820 mL/minute after banding (P<.01). All patients had access salvage. Swelling resolved promptly in 20 patients and was markedly improved in two individuals. Three patients underwent aneurysm repair with simultaneous inflow banding and decreased intra-access pressure after flow restriction. Two fistulas failed at eight and 13 months. Mean follow-up was 8 months. Conclusions The symptoms of hemodialysis vascular access patients associated with non-correctable central venous lesions resolved successfully and their access was maintained using a precision inflow banding procedure.

Secondary Arteriovenous Fistulas: Converting Prosthetic AV Grafts to Autogenous Dialysis Access

As existing arteriovenous grafts (AVGs) fail, the National Kidney Foundation KDOQI Guidelines and the AV Fistula First Breakthrough Initiative (“Fistula First”) project recommend that each patient be re‐evaluated for conversion to an arteriovenous fistula (AVF). AVFs created following failure of an AVG have been termed secondary fistulas (SAVF). We review our experience and outcomes converting AVGs to SAVFs, utilizing the mature outflow vein of the AVG when possible, otherwise creating a new AVF at a remote site. We reviewed two groups of consecutive patients undergoing operations for vascular access at different centers. Group 1 had a SAVF protocol in place during the study period with specific criteria for timing SAVF construction. Patients from group 2 were referred for evaluation by nephrologists or dialysis nurses as access problems were recognized, without a formal protocol in place. All patients had preoperative ultrasound or contrast imaging in addition to physical examination. Indications for creating a SAVF were AVG thrombosis, dysfunction, erosion, bleeding, or steal syndrome involving the existing AVG. The simple presence of a functional AVG without evidence of dysfunction was not an indication for conversion to a SAVF. SAVFs were classified according to location and the potential for utilizing the existing mature AVG outflow vein. Group 1: 40 consecutive patients, age 26–78 (meanu2003=u200362), 42% were female; 55% were diabetic. These patients had 1–22 previous access operations (meanu2003=u20033). 92.5% underwent SAVF surgery prior to loss of the AVG, minimizing catheter use. Cumulative patency was 92.5% at 1u2003year and 87.5% at 2u2003years. Group 2: 102 consecutive patients, age 24–87 (meanu2003=u200355), 52% were female; 50% were diabetic. These patients had 1–50 previous access operations (meanu2003=u20033). Only 19.3% were referred for SAVF surgery prior to loss of the AVG or outflow vein. Cumulative patency was 94.4% at 1u2003year and 91.6% at 2u2003years. Failure, dysfunction, or complications of AVGs may be resolved by conversion to a SAVF. Further, the limited lifespan of AVGs and the superiority of AVFs dictates that a plan be in place to transition the AVG patient to an AVF. Most, if not all, hemodialysis patients whose access is an AVG will have one or more anatomic sites and vessels suitable for an autogenous SAVF. Vessel mapping is critical in the evaluation of failing AVGs and in preparation for a SAVF. Cumulative patency rates exceeded 90% at 12u2003months for SAVFs in both patient groups in this report. The need for catheters was dramatically less in the patient group with an established SAVF conversion plan.