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Contralateral HeRO Graft Insertion to Treat Severe Venous Hypertension and Preserve Arteriovenous Fistula Patency
Case Report Contralateral HeRO Graft Insertion to Treat Severe Venous Hypertension and Preserve Arteriovenous Fistula Patency Jonathan P. O’Doherty,1 Karl H. Holden,1 Abigail Johnson,1 Pat Cain,1 James Harding,2 and Phillip J. Yates,3 Leicester, Coventry, and Nottingham, UK
Background: Central venous stenosis and occlusion (CVO) is an increasing problem in the growing hemodialysis population. Sequelae include loss of access, loss of sites suitable for future venous access, and venous hypertension. Endoluminal techniques are often unsuitable to treat long-standing stenoses, and open surgery confers higher morbidity and is not appropriate in many patients. Case: We present a case of long-standing central venous stenosis with an ipsilateral functioning fistula but with significant symptoms and signs of venous hypertension. The stenosis was not considered appropriate for endoluminal treatment, and the patient was considered to be at too high risk for open surgery. The Hemodialysis Reliable Outflow (HeRO) (Merit Medical Systems, UT) device was used to bypass the fistula to the superior vena cava via the contralateral internal jugular vein. Conclusions: This case demonstrates the utility of the HeRO device in cases of long-standing CVO necessitating contralateral bypass. This technique confers the benefits of open surgery while minimizing the associated risks.
The increasing population of chronic hemodialysis patients is associated with an increasing prevalence of central venous stenosis and occlusion (CVO). Prophylactic treatment of nonsymptomatic CVO is generally not warranted because of the risks of procedure and high risk off recurrence with an associated need for repeat procedure.1 However, intervention is indicated in CVO with associated
arteriovenous fistula (AVF) dysfunction, thrombosis, or symptomatic venous hypertension, as access patency is threatened. Traditionally, endovascular approaches to CVO have been the mainstay of treatment with open surgery reserved for the most serious cases or those in which an extraanatomical solution is required. The Hemodialysis Reliable Outflow (HeRO) (Merit Medical Systems, UT) device offers a third potential solution to the management of CVO.
1
Department of Renal Transplant Surgery, Leicester General Hospital, Leicester, UK. 2 Department of Radiology, University Hospitals of Coventry and Warwickshire, Coventry, UK. 3 Department of Renal Transplant Surgery, Nottingham City Hospital, Nottingham University Hospitals, Nottingham, UK.
Correspondence to: Jonathan P. O’Doherty, MBChB, BSc, Department of Renal Transplant Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e3 https://doi.org/10.1016/j.avsg.2019.06.029 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: May 12, 2019; manuscript accepted: June 21, 2019; published online: - - -
CASE REPORT A 45-year-old lady with end-stage renal disease (ESRD) on hemodialysis was referred for vascular access clinic assessment of her swollen right forearm, arm, and shoulder on the ipsilateral side to her brachiocephalic arteriovenous fistula (BC-AVF). The patient had a 30-year history of ESRD, including 2 failed renal transplants, multiple AVFs, placement of multiple central venous catheters (CVCs), and a mechanical aortic valve replacement. She had a functioning right 1.e1
1.e2 Case Report
Fig. 1. Fistulography demonstrating (A) antegrade filling of brachial, ulna, and interosseous arteries. Filling of the radial artery (arrow 1.) occurs by delayed retrograde flow because of occlusion of radial artery origin. (B) The stenosed origin of the cephalic vein fistula (arrow 2.) is from the proximal radial artery.
BC-AVF providing dialysis of good quality. She reported increasing swelling, pain, and purple discoloration of her right arm developing during a period of 3 months. On examination, her right arm and forearm were grossly swollen with a circumference twice that of the contralateral arm and had a purple discoloration. The radial pulse was absent on the right-hand side; however, all other upper limb pulses were palpable bilaterally. There was a small area of tissue loss on her right index fingertip. Venous collateralization was noted around her shoulder. Her right BC-AVF had an excellent thrill and bruit. Duplex ultrasonography demonstrated that AVF actually originated from the radial artery close to the brachial artery bifurcation and not the brachial artery itself. Flow in the AVF was recorded as 850 mL/min with no significant outflow stenosis but a perianastamotic stenosis of 70e80%. Fistulography was performed to confirm fistula anatomy and assess fistula inflow and outflow patency. Arterial puncture fistulography demonstrated that the AVF anastomosis arose from the proximal radial artery but, because of occlusion of the radial artery origin, filling of the fistula occurred in a retrograde fashion up the radial artery from the palmar arch. Figure 1 shows (A) antegrade filling of the brachial, ulnar, and interosseous arteries and (B) delayed retrograde filling of the radial artery and the arm fistula. Furthermore, the fistula anastomosis was noted to be tightly stenosed. Puncture of the arm fistula demonstrated a morphologically acceptable cephalic vein fistula but a high-grade central venous stenosis at the confluence of right subclavian and internal jugular veins with associated collateralization (Fig. 2). Previous
Annals of Vascular Surgery
Fig. 2. Fistulography demonstrating morphologically matured cephalic vein fistula but central venous occlusion (arrow). imaging demonstrated and confirmed this occlusion to be of several years old. The patient’s constellation of symptoms was considered to be predominantly because of venous hypertension secondary to central stenosis. The patient was reviewed, and management options were discussed. The patient did not want to consider any option that resulted in the loss of her functional right arm fistula. After careful consideration, a contralateral HeRO graft insertion was offered and subsequently performed. Under general anesthesia, the HeRO graft venous component was inserted into the left internal jugular vein and advanced into the proximal SVC; the component was widely arced so that the connector could be positioned under the left clavipectoral fascia. The polytetrafluoroethylene portion of the graft was tunneled from the right clavipectoral fascia to the left clavipectoral fascia. The graft was anastomosed to the cephalic vein part of the AVF as it descended to the subclavian vein. Within 48 hr postsurgery, the swelling in the patient’s right arm had resolved, and symmetry in circumference and normal coloration was restored. Within 4 weeks, tissue loss on the index finger had healed. Five months after HeRO insertion, surveillance duplex scanning highlighted reduced flow in the graft with a stenosis at the anastomosis between graft and fistula. Figure 3 demonstrates the conformation of the HeRO graft and the stenosis. Migration of HeRO tip was also noted. Fistulography and angioplasty were performed on the stenosis and of the radial artery-cephalic vein anastomosis to improve inflow. Unfortunately, a month after angioplasty, the graft clotted, likely secondary to inflow stenosis. The patient was returned to theater and had a 6 mm Flixene graft (Maquet-Atrium, Hudson, NH) inserted from the brachial artery to the HeRO graft in the right clavipectoral groove. The graft has remained patent for a further 6 months with
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Case Report
1.e3
no further intervention required, with duplex scanning demonstrating a flow of >800 mL/min.
access flow and resolving the symptomatic venous hypertension was to create a bypass from the fistula outflow to the contralateral central veins. The use of the HeRO graft in this case prevented the need for open extra-anatomical bypass surgery. Technical considerations included the positioning of the fistula-graft anastomosis in the right clavipectoral groove to exclude shoulder movement from kinking the graft and positioning of the venous componentgraft connector to optimize the radius of the venous loop entering the right internal jugular vein. The HeRO device offers a low-risk minimally invasive technique of bypassing ipsilateral central venous occlusions via the contralateral central veins. The HeRO device is removable, and therefore insertion does not preclude further surgical options on the contralateral vasculature, such as necklace, teardrop, or arterioarterial grafting.
DISCUSSION
CONCLUSION
In CVO, percutaneous treatment is the initial modality of choice but is associated with primary patency rates as low as 20% at 1 year. Reconstructive surgical approaches to CVO have better primary patency rates, of up to 90%, but are associated with increased morbidity and mortality.1 The HeRO device is an additional method of maintaining access patency in the setting of CVO. The use of the HeRO graft has been shown to be cost effective when compared with long-term CVC use.2 Furthermore, the HeRO has at least equivalent patency rates when compared with arteriovenous grafts (AVGs) and lower infection rates than lower limb AVGs and CVCs.3,4 In the case presented previously, an endovascular approach to resolving the CVO was not possible because of long-standing and long segment complete occlusion. The only method of maintaining
This case demonstrates the utility of the HeRO device in cases of long-standing CVO necessitating contralateral bypass. This technique confers the benefits of open surgery while minimizing the associated risks.
Fig. 3. Fistulogram, performed at time of treatment of arrowed stenosis, shows conformation of HeRO graft.
REFERENCES 1. Forsythe R, Chemla E. Surgical options in the problematic arteriovenous haemodialysis access. Cardiovasc Intervent Radiol 2015;38:1405e15. 2. Al Shakarchi J, Inston N, Jones R, et al. Cost analysis of the Hemodialysis Reliable Outflow (HeRO) Graft compared to the tunneled dialysis catheter. J Vasc Surg 2016;63:1026e33. 3. Nassar G, Glickman M, McLafferty R, et al. A comparison between the HeRO graft and conventional arteriovenous grafts in hemodialysis patients. Semin Dial 2014;27:310e8. 4. Dageforde L, Bream P, Moore D. Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model. J Surg Res 2012;177:165e71.
Background: Central venous stenosis and occlusion (CVO) is an increasing problem in the growing hemodialysis population. Sequelae include loss of access, loss of sites suitable for future venous access, and venous hypertension. Endoluminal techniques are often unsuitable to treat long-standing stenoses, and open surgery confers higher morbidity and is not appropriate in many patients. Case: We present a case of long-standing central venous stenosis with an ipsilateral functioning fistula but with significant symptoms and signs of venous hypertension. The stenosis was not considered appropriate for endoluminal treatment, and the patient was considered to be at too high risk for open surgery. The Hemodialysis Reliable Outflow (HeRO) (Merit Medical Systems, UT) device was used to bypass the fistula to the superior vena cava via the contralateral internal jugular vein. Conclusions: This case demonstrates the utility of the HeRO device in cases of long-standing CVO necessitating contralateral bypass. This technique confers the benefits of open surgery while minimizing the associated risks.
The increasing population of chronic hemodialysis patients is associated with an increasing prevalence of central venous stenosis and occlusion (CVO). Prophylactic treatment of nonsymptomatic CVO is generally not warranted because of the risks of procedure and high risk off recurrence with an associated need for repeat procedure.1 However, intervention is indicated in CVO with associated
arteriovenous fistula (AVF) dysfunction, thrombosis, or symptomatic venous hypertension, as access patency is threatened. Traditionally, endovascular approaches to CVO have been the mainstay of treatment with open surgery reserved for the most serious cases or those in which an extraanatomical solution is required. The Hemodialysis Reliable Outflow (HeRO) (Merit Medical Systems, UT) device offers a third potential solution to the management of CVO.
1
Department of Renal Transplant Surgery, Leicester General Hospital, Leicester, UK. 2 Department of Radiology, University Hospitals of Coventry and Warwickshire, Coventry, UK. 3 Department of Renal Transplant Surgery, Nottingham City Hospital, Nottingham University Hospitals, Nottingham, UK.
Correspondence to: Jonathan P. O’Doherty, MBChB, BSc, Department of Renal Transplant Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e3 https://doi.org/10.1016/j.avsg.2019.06.029 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: May 12, 2019; manuscript accepted: June 21, 2019; published online: - - -
CASE REPORT A 45-year-old lady with end-stage renal disease (ESRD) on hemodialysis was referred for vascular access clinic assessment of her swollen right forearm, arm, and shoulder on the ipsilateral side to her brachiocephalic arteriovenous fistula (BC-AVF). The patient had a 30-year history of ESRD, including 2 failed renal transplants, multiple AVFs, placement of multiple central venous catheters (CVCs), and a mechanical aortic valve replacement. She had a functioning right 1.e1
1.e2 Case Report
Fig. 1. Fistulography demonstrating (A) antegrade filling of brachial, ulna, and interosseous arteries. Filling of the radial artery (arrow 1.) occurs by delayed retrograde flow because of occlusion of radial artery origin. (B) The stenosed origin of the cephalic vein fistula (arrow 2.) is from the proximal radial artery.
BC-AVF providing dialysis of good quality. She reported increasing swelling, pain, and purple discoloration of her right arm developing during a period of 3 months. On examination, her right arm and forearm were grossly swollen with a circumference twice that of the contralateral arm and had a purple discoloration. The radial pulse was absent on the right-hand side; however, all other upper limb pulses were palpable bilaterally. There was a small area of tissue loss on her right index fingertip. Venous collateralization was noted around her shoulder. Her right BC-AVF had an excellent thrill and bruit. Duplex ultrasonography demonstrated that AVF actually originated from the radial artery close to the brachial artery bifurcation and not the brachial artery itself. Flow in the AVF was recorded as 850 mL/min with no significant outflow stenosis but a perianastamotic stenosis of 70e80%. Fistulography was performed to confirm fistula anatomy and assess fistula inflow and outflow patency. Arterial puncture fistulography demonstrated that the AVF anastomosis arose from the proximal radial artery but, because of occlusion of the radial artery origin, filling of the fistula occurred in a retrograde fashion up the radial artery from the palmar arch. Figure 1 shows (A) antegrade filling of the brachial, ulnar, and interosseous arteries and (B) delayed retrograde filling of the radial artery and the arm fistula. Furthermore, the fistula anastomosis was noted to be tightly stenosed. Puncture of the arm fistula demonstrated a morphologically acceptable cephalic vein fistula but a high-grade central venous stenosis at the confluence of right subclavian and internal jugular veins with associated collateralization (Fig. 2). Previous
Annals of Vascular Surgery
Fig. 2. Fistulography demonstrating morphologically matured cephalic vein fistula but central venous occlusion (arrow). imaging demonstrated and confirmed this occlusion to be of several years old. The patient’s constellation of symptoms was considered to be predominantly because of venous hypertension secondary to central stenosis. The patient was reviewed, and management options were discussed. The patient did not want to consider any option that resulted in the loss of her functional right arm fistula. After careful consideration, a contralateral HeRO graft insertion was offered and subsequently performed. Under general anesthesia, the HeRO graft venous component was inserted into the left internal jugular vein and advanced into the proximal SVC; the component was widely arced so that the connector could be positioned under the left clavipectoral fascia. The polytetrafluoroethylene portion of the graft was tunneled from the right clavipectoral fascia to the left clavipectoral fascia. The graft was anastomosed to the cephalic vein part of the AVF as it descended to the subclavian vein. Within 48 hr postsurgery, the swelling in the patient’s right arm had resolved, and symmetry in circumference and normal coloration was restored. Within 4 weeks, tissue loss on the index finger had healed. Five months after HeRO insertion, surveillance duplex scanning highlighted reduced flow in the graft with a stenosis at the anastomosis between graft and fistula. Figure 3 demonstrates the conformation of the HeRO graft and the stenosis. Migration of HeRO tip was also noted. Fistulography and angioplasty were performed on the stenosis and of the radial artery-cephalic vein anastomosis to improve inflow. Unfortunately, a month after angioplasty, the graft clotted, likely secondary to inflow stenosis. The patient was returned to theater and had a 6 mm Flixene graft (Maquet-Atrium, Hudson, NH) inserted from the brachial artery to the HeRO graft in the right clavipectoral groove. The graft has remained patent for a further 6 months with
Volume
-, -
2019
Case Report
1.e3
no further intervention required, with duplex scanning demonstrating a flow of >800 mL/min.
access flow and resolving the symptomatic venous hypertension was to create a bypass from the fistula outflow to the contralateral central veins. The use of the HeRO graft in this case prevented the need for open extra-anatomical bypass surgery. Technical considerations included the positioning of the fistula-graft anastomosis in the right clavipectoral groove to exclude shoulder movement from kinking the graft and positioning of the venous componentgraft connector to optimize the radius of the venous loop entering the right internal jugular vein. The HeRO device offers a low-risk minimally invasive technique of bypassing ipsilateral central venous occlusions via the contralateral central veins. The HeRO device is removable, and therefore insertion does not preclude further surgical options on the contralateral vasculature, such as necklace, teardrop, or arterioarterial grafting.
DISCUSSION
CONCLUSION
In CVO, percutaneous treatment is the initial modality of choice but is associated with primary patency rates as low as 20% at 1 year. Reconstructive surgical approaches to CVO have better primary patency rates, of up to 90%, but are associated with increased morbidity and mortality.1 The HeRO device is an additional method of maintaining access patency in the setting of CVO. The use of the HeRO graft has been shown to be cost effective when compared with long-term CVC use.2 Furthermore, the HeRO has at least equivalent patency rates when compared with arteriovenous grafts (AVGs) and lower infection rates than lower limb AVGs and CVCs.3,4 In the case presented previously, an endovascular approach to resolving the CVO was not possible because of long-standing and long segment complete occlusion. The only method of maintaining
This case demonstrates the utility of the HeRO device in cases of long-standing CVO necessitating contralateral bypass. This technique confers the benefits of open surgery while minimizing the associated risks.
Fig. 3. Fistulogram, performed at time of treatment of arrowed stenosis, shows conformation of HeRO graft.
REFERENCES 1. Forsythe R, Chemla E. Surgical options in the problematic arteriovenous haemodialysis access. Cardiovasc Intervent Radiol 2015;38:1405e15. 2. Al Shakarchi J, Inston N, Jones R, et al. Cost analysis of the Hemodialysis Reliable Outflow (HeRO) Graft compared to the tunneled dialysis catheter. J Vasc Surg 2016;63:1026e33. 3. Nassar G, Glickman M, McLafferty R, et al. A comparison between the HeRO graft and conventional arteriovenous grafts in hemodialysis patients. Semin Dial 2014;27:310e8. 4. Dageforde L, Bream P, Moore D. Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model. J Surg Res 2012;177:165e71.