Axillary arteriovenous fistula for hemodialysis: case report

Abstracts

Na confecção de fístula arteriovenosa (FAV) para hemodiálise, condutos venosos autógenos demonstram performance superior quando comparados com material protético em relação à perviedade primária ou secundária. A prótese de politetrafluoroetileno (PTFE) é reservada para casos de falência de material autógeno e é geralmente utilizada em fístulas em membros superiores. Descrevemos o caso de uma paciente de 52 anos que, após falência de acessos para hemodiálise e impossibilidade de realização de diálise peritoneal em razão de peritonite bacteriana, foi submetida à confecção de FAV entre a artéria axilar direita e a veia cava inferior com prótese de PTFE de 6 mm. O acesso foi utilizado para hemodiálise 1 mês após sua criação e permanece pérvio após 24 meses. Até o momento, não houve complicações infecciosas, sinais de insuficiência cardíaca ou síndrome de roubo em membro superior direito.

Fístula arteriovenosa; falência de acesso; prótese de PTFE

CASE REPORT

Axillary arteriovenous fistula for hemodialysis: case report

Yosio Nagato; Carmen Neuda Alves Calixto; Marcelo Luiz Brandão; Luís Cavalcante Nagato; Guilherme de Oliveira Bessa; Leôncio Caetano Rodrigues Neto; Luciana Mara Nogueira Fonseca

Serviço de Cirurgia Vascular, Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, GO

Correspondence

Abstract

With regards to the creation of an arteriovenous fistula (AV fistula) for hemodialysis, autogenous venous grafts clearly show high performance when compared with prosthetic material in terms of primary or secondary patency. Polytetrafluoroethylene (PTFE) grafts for the reconstruction of AV fistulae must be restricted to cases of failure of the autogenous material, which is generally used in upper limb fistulae. We describe a case of a 52-year-old patient, who, after access failure for hemodialysis and the impossibility of performing peritoneal dialysis due to bacterial peritonitis, underwent the reconstruction of an AV fistula between the right axillary artery and the cava vein using a 6-mm PTFE prosthesis. One month after surgery, this AV fistula started to be used for hemodialysis. The AV fistula remains patent 24 months after its creation. No infectious complications, cardiac insufficiency symptoms, or steal syndromes of right upper limb were detected.

Keywords: Arteriovenous fistula, access failure, PTFE graft.

Introduction

Currently, there is a consensus that, for hemodialysis, autologous arteriovenous fistula (AVF) shows better medium- and long-term results when compared to other vascular substitutes, including polytetrafluoroethylene (PTFE) grafts, regarding patency and rate of postoperative complications.^1-3

Vascular access complications are the main causes of hospitalization in dialysis patients.^4,5 In the United States, prevalence of these complications is estimated to be 373 patients per million inhabitants,⁶ representing 20% of the total spending for hemodialysis.⁷

The ideal vascular access has an adequate blood flow, a long half-life and a low complication rate. In Europe, autologous AVF is considered the primary choice of a permanent vascular access, being used in about 80 to 90% of patients, whereas in the United States, autologous AVF represents only 20 to 30% of total cases.⁸ In this country, the spending for vascular access reaches up to 25% of the resources allocated to renal replacement therapy, and studies have shown a progressive reduction in the use of prosthetic grafts over the past decade, mainly due to high operational costs.⁹ In Brazil, autologous AVF is also the initial access of choice, and dialysis grafts are used in about 2% of the cases.¹⁰ The disadvantages of using autogenous access are the need for veins of larger diameter and longer maturation times (from 4 to 16 weeks), whereas PTFE graft can be used within 1 week after placement. However, this graft has a shorter survival, due to stenosis and thrombosis, and higher morbidity rates due to an increased possibility of infection.

The choice of a (often PTFE) prosthesis is restricted to cases of failed attempted creation of an autologous AVF or when such failure is preceded by unfavorable conditions in vascular bed, which is more frequent in elderly, obese and diabetic patients.

Case report

We describe a case of a 52-year-old woman, hypertensive, diabetic, with hypertensive nephrosclerosis, on dialysis therapy for 6 years. Throughout this period, usual accesses were used, such as central venous catheters and AVF in the upper and lower limbs. After access failure and the impossibility of performing peritoneal dialysis due to bacterial peritonitis, the patient underwent ultrasound (US) scanning for AVF creation. US scan revealed internal and external jugular vein occlusion, intense thickening of the right and left subclavian veins, right and left common femoral vein thrombotic occlusion, and patent inferior vena cava. Thus, we chose the creation of an AVF between the right axillary artery and the inferior vena cava with a 6-mm PTFE prosthesis, as shown in the following figures.

Under general anesthesia, axillary AVF was created with dissection of the right axillary artery (proximal third) and right retroperitoneal approach for dissection of the infrarenal vena cava. A subcutaneous tunnel was made along the anterior axillary line, followed by insertion of the 6-mm PTFE prosthesis. Both end-to-side anastomoses were made using 6-0 Prolene continuous suture.

One month after placement, this access started to be used for hemodialysis, remaining patent up to the present moment (24 months after its creation). No infectious complications, signs of heart failure or steal syndrome in the right upper limb were detected.

Discussion

In Brazil, in 2006, approximately 86,284 patients with end-stage chronic renal failure were treated by different dialysis procedures. In this year, prevalence of dialysis patients treated at a public health care facility was 46.20 cases per 100,000 inhabitants. Prevalence rates are higher among men and increase with age, rising from 13.11 per 100,000 inhabitants in individuals aged less than 30 years to 184.07 in individuals aged over 60 years.¹¹ The absolute number of patients increased 3.9% between 2006 and 2007.¹²

The progressive increase in the number of patients requiring long-term hemodialysis makes vascular access creation a common practice. Some patients with chronic renal disease have no available veins for AVF creation; in these cases, the use of synthetic material is required.

Upon the exhaustion of all autologous AVF possibilities, PTFE prosthetic graft is usually placed as an arm or forearm loop graft, or even as an axillary-brachial bypass graft. The upper limbs are the most commonly used surgical sites. The thighs are not often used due to a higher risk of infection. A successful procedure requires adequate arterial and venous blood flow. Rotation and angulation of the prosthesis should be avoided.

The most common complications of a permanent vascular access include fistula thrombosis, infection, venous hypertension, and aneurysmal degeneration.^13,14 Early failure of fistulas due to thrombosis is a limitation. Small and inconclusive studies have suggested that the use of antiplatelet agents may reduce the risk of thrombosis.¹⁵

In a review of the literature, we observed the lack of national studies on the use of prosthesis in cases of access failure for hemodialysis and on different possibilities of AVF creation. In this case report, we presented an alternative approach to be considered whenever necessary.

We reported a feasible alternative to severe cases of access failure, upon the exhaustion of all usual possibilities, with good patency 24 months after surgery.

References

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  Brasil, Ministério da Saúde, Departamento de Informática do SUS. DATASUS [site na internet]. http://www.datasus.gov.br/datasus/datasus.php
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Publication Dates

• Publication in this collection
  26 Mar 2010
• Date of issue
  Dec 2009

History

• Accepted
  13 Oct 2009
• Received
  10 Sept 2008