Robert E. Brown, William C. Jennings, John Blebea, Kevin Taubman, Ryan Messiner
Surgery, University of Oklahoma College of Medicine, Tulsa, OK.
OBJECTIVES: Constructing a successful hemodialysis vascular access in patients with upper extremity peripheral vascular occlusive disease while avoiding vascular access-related hand ischemia is a challenging surgical problem. We utilized 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 markedly calcified vessels by ultrasound examination) underwent a primary arteriovenous fistula (AVF) transposition procedure utilizing the axillary artery for inflow. The AVF was either a reversed flow basilic vein transposition supplemented by valvulotomy [n=18], 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=2], or a translocated reversed saphenous vein [n=1].
RESULTS: Twenty-five patients with a mean age of 57 years (range 26-83) underwent successful primary axillary artery inflow procedures during a 31 month period. Of these, 19 (76%) were female and 20 (80%) were diabetic. Seventeen (68%) had previous vascular access procedures and nine (36%) were obese. One access failed after 4 weeks and could not be salvaged. Two individuals died 2 and 14 months following surgery due to myocardial infarctions. Life-table primary, primary assisted, and cumulative patency rates were 79%, 95%, and 95% respectively at one year with follow-up ranging between 1-20 months (mean=6 months).
CONCLUSIONS: Creating an autogenous vascular access utilizing axillary artery inflow is a good option for patients with severe peripheral vascular disease, offering a high patency rate and the prevention of access-related hand ischemia.
AUTHOR DISCLOSURES: J. Blebea, Nothing to disclose; R. E. Brown, Nothing to disclose; W. C. Jennings, Nothing to disclose; R. Messiner, Nothing to disclose; K. Taubman, Nothing to disclose.
Posted April 2012