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Femororenal Arteriovenous Graft: A Viable Option for Hemodialysis Access
Femororenal Arteriovenous Graft: A Viable Option for Hemodialysis Access Azeem R. Khan, Lea M. Blackwell, Shawn J. Stafford, Addison D. Thompson, Roderick J. Romero, Colin D. Goodier, Diane Kwan, Imtiaz R. Khan, Jon V. Schellack, and Paul E. Perkowski, New Orleans, Louisiana
There has been a significant increase in the number of patients with end-stage renal disease. The limited number of kidney transplants necessitates that most patients become dependent upon chronic dialysis. Due to the numerous complications associated with temporary access catheters, permanent arteriovenous access is more beneficial for long-term vascular access. However, with the restricted availability of sites for permanent vascular access, it is important to have a variety of possibilities. In this case report, we present an alternative choice for an arteriovenous graft, left common femoral artery to left renal vein, in a patient with limited vascular access options.
Numerous diseases cause renal insufficiency, and dialysis has been used as a life-saving therapy in the setting of both acute and chronic renal failure for decades. Currently, approximately 325,000 patients undergo dialysis in the United States and the prevalence of end-stage renal disease (ESRD) is increasing annually. Hypertension and diabetes account for greater than 50% of new ESRD patients.1 Due to the very limited availability of kidney transplants, the number of patients requiring dialysis is likely to increase.2 Hemodialysis (HD) requires vascular access, and each vascular access site has a limited time of usage. When a particular site fails, a new site has to be established, thus decreasing the total number of possibilities for future access. It has been reported that as many as 2% of deaths in the dialysis patient population occur secondary to the lack of vascular access.3
Presented at the Annual Meeting of the Gulf Coast Vascular Society, New Orleans, LA, October 7, 2006. Section of Vascular Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA. Correspondence to: Azeem Khan, MD, 820 Sherwood Forest Blvd., Baton Rouge, LA 70815-5262, USA, E-mail: [email protected] Ann Vasc Surg 2008; 22: 136-139 DOI: 10.1016/j.avsg.2007.07.030 Ó Annals of Vascular Surgery Inc. Published online: January 10, 2008
136
Immediate HD access is usually created by the insertion of various types of dialysis catheters but is often fraught with complications including central vein thrombosis, infection, and failure to function.4,5 A more desirable access option is to create permanent HD access using autologous vein to make arteriovenous fistulas (AVFs) or arteriovenous grafts (AVGs) with synthetic materials. The classically described venous sites for AVF include cephalic, basilic, saphenous, and femoral veins. Alternative venous sites for access with AVG, which have been described previously, include the axillary, femoral, iliac, and jugular veins and the right atrium.6-8 A drawback of permanent access is the inability to immediately use HD. According to Dialysis Outcome Quality Initiative (DOQI) guidelines, AVFs require a waiting period of approximately 2-3 months to allow for maturation of the fistula. The most commonly used synthetic material for AVG is polytetrafluoroethylene (PTFE). PTFE AVGs require a waiting period of approximately 3-4 weeks to allow the body to form a fibrous coating around the AVG in order to prevent postaccess hemorrhage and thrombosis.9 A new prosthetic access graft composed of polyurethaneurea (Thoralon, created by Bard Peripheral Vascular, Tempe, AZ) is now available, which can be accessed within 24 hr of placement, contrary to the traditionally used PTFE grafts.10
Vol. 22, No. 1, 2008
Case reports 137
This case report describes an additional immediate access technique for permanent access in a patient with limited HD access possibilities.
CASE REPORT A 43-year-old male presented with a thrombosed right common femoral artery to right common femoral vein AVG and without HD for 3 days. The patient had a medical history significant for ESRD, chronic HD for 9 years, hypertension, and hepatitis C. Even though an extensive previously conducted laboratory investigation revealed no evidence of a hypercoagulable state, multiple venous occlusions were present, including the central brachiocephalic vein, superior vena cava, most of the inferior vena cava, and right renal vein. There was patency, however, of the left renal vein and marginal patency of the distal infrarenal inferior vena cava, as demonstrated by venography (Fig. 1). Surgical history included multiple permanent AVF, AVG, and temporary vascular catheters in the bilateral neck and upper and lower extremities. Medications included coumadin (for which the last dose had been 2 days prior to presentation), omeprazole, neurontin, and multivitamins. The patient was incarcerated and a one pack per day smoker for over 25 years. Numerous attempts at placement of a temporary percutaneous catheter in both the neck and groin were unsuccessful. Emergent thrombectomy of the right femoral AVG was done, followed by an AVG revision, which involved a bovine patch angioplasty of the previous arterial anastomosis. Shortly after the surgery, HD was initiated, but it was aborted secondary to poor venous outflow. Low-flow HD was attempted the next day but was also inadequate. At this juncture, it was decided to take the patient to the operating room for creation of a new AVF with the placement of a Bard Vectra Thoralon Vascular Access Graft (diameter 6.0 mm, length 50 cm, cat. 10002-6050-001) in the proximal left thigh, the only extremity without a previous permanent HD access in place. This graft was chosen due to its unique characteristics of rapid hemostasis and early access, 24 hr after implantation.10 Through a standard vertical groin incision the common femoral artery was exposed and an end-to-side arterial anastomosis was created at the left common femoral artery (Fig. 2B). The Vectra graft was then superficially tunneled as a loop in the proximal thigh and anastomosed end-to-end to a ringed expanded PTFE (ePTFE) graft (diameter 6.0 mm, length 80 cm, cat. F8006TW; Bard Peripheral Vascular) at the superior level of the inguinal incision. The ringed ePTFE graft was then tunneled retroperitoneally through the inguinal canal to the left renal vein. A midline abdominal incision was required to expose the left renal vein. At operation the infrarenal vena cava was thickened due to postphlebitic changes. An end-to-side venous anastomosis was created between the PTFE graft and the left renal vein (Fig. 2A).
Fig. 1. Venography demonstrating total occlusion of both the superior (A) and inferior (B) vena cava. The inferior approach was through a severely diseased left iliac system, revealing patency of the left renal vein.
The AVG was cannulated and used 6 hr following implantation with a successful and complete HD run. The patient was resumed on his anticoagulation therapy, and an appropriate therapeutic international normalized ratio was achieved. Three days after surgery the patient was discharged from the hospital with routine HD scheduled. At 6-month follow-up no postoperative steal syndrome or other vascular complications were noted, with continued use of the AVG.
138 Case reports
Annals of Vascular Surgery
though, is technically more challenging to implant than PTFE grafts due to the material it is made of, and the manufacturer’s technical instructions should be followed closely in order to prevent failure of the graft.10 Another option considered in this patient was percutaneous cannulation of the renal vein or inferior vena cava and dialysis catheter placement with interventional radiological guidance.14 However, permanent AVG implantation was chosen due to the young age of the patient and the dismal previous results with dialysis catheters in this patient. Yet a third choice evaluated in this patient, with his multiple vascular problems, was peritoneal dialysis (PD). The absence of surgical interventions to the peritoneal cavity made him an excellent candidate for PD.15,16 Unfortunately, PD is not available for incarcerated patients in Louisiana. The femororenal AVG described did require the patient to have an extended hospital stay, in contrast to the routine outpatient access surgery; and the Vectra graft at this time is more costly than PTFE grafts. However, the patient is alive and continues to use the femororenal AVG for HD with excellent flow rates, and this case should be kept in mind as an option for selected patients. Fig. 2. A Left common femoral artery to Vectra graft anastomosis; Vectra graft subcutaneously looped in the proximal thigh; Vectra graft anastomosed to ringed ePTFE graft and tunneled through inguinal approach into the abdomen. B In an end-to-side fashion to the left renal artery.
DISCUSSION The renal vein as a possibility for outflow in HD has been reported in the literature as an axillorenal AVG.11 Renal veins have also been proposed for use in a swine model for AVG.12 The present case represents the first femororenal AVG reported in the literature. Furthermore, the previously reported axillorenal AVG case underwent multiple thrombectomies and revisions secondary to the difficult anatomy and placement of the graft, contrary to this case.11 Regardless of the choice for vascular access, the most important consideration in planning placement of vascular access should be adequate venous outflow because this is where the majority of problems occur.13 This case also illustrates the adverse consequence on the venous circulation of requiring multiple dialysis catheters. Use of the Vectra graft is advantageous as it allowed for immediate and permanent HD. This graft,
REFERENCES 1. US Renal Data System. The 2005 USRDS annual data report: pre´cis, www.usrds.org/2005/pdf/0B_precis_05.pdf. (accessed August 25, 2006, p 20). 2. Mange KC, Joffe MM, Feldman HI. Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. N Engl J Med 2001;344: 726-731. 3. Laskow DA, Ashan N. Dialysis access failure: an indication for immediate kidney transplantation. Semin Dial 2002;15: 1-2. 4. Little MA, O’Riordan A, Lucey B, et al. A prospective study of complications associated with cuffed, tunneled, hemodialysis catheters. Nephrol Dial Transplant 2001;16:2194-2200. 5. El Minshawy O, Abd El Aziz T, Abd El Ghani H. Evaluation of vascular access complications in acute and chronic hemodialysis. J Vasc Access 2004;5:76-82. 6. Chemla ES, Morsy M, Anderson L, Makanjuola D. Complex bypasses and fistulas for difficult hemodialysis access: a prospective, single-center experience. Semin Dial 2006;19: 246-250. 7. Evans DC, Upton EC, Lawson JH. Axillary to common iliac arteriovenous graft for hemodialysis access: case report and review of ‘‘exotic’’ axillary-based grafts. J Vasc Access 2005; 6:192-195. 8. El-Sabrout RA, Duncan JM. Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment access. J Vasc Surg 1999;29:472-478. 9. National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for
Vol. 22, No. 1, 2008
vascular access, 2000. Am J Kidney Dis 2001;37(Suppl. 1): S137. 10. Glickman MH, Stokes GK, Ross JR, et al. Multicenter evaluation of a polyurethaneurea vascular access graft as compared with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications. J Vasc Surg 2001; 34:465-473. 11. Karp SJ, Hawxby A, Burdick JF. Axillorenal arteriovenous graft: a new approach for dialysis access. J Vasc Surg 2004; 40:379-380. 12. Wallace MJ, Thomas JW, Ahrar K, Wright KC. Transrenal arteriovenous dialysis graft creation: survival and patency in a swine model. Radiology 2003;227:501-509.
Case reports 139
13. Chen JC, Kamal DM, Jastrzebski J, Taylor DC. Venovenostomy for outflow venous obstruction in patients with upper extremity autogenous hemodialysis arteriovenous access. Ann Vasc Surg 2005;19:629-635. 14. Rajan DK, Croteau DL, Sturza SG, Harvill ML, Mehall CJ. Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access. Radiographics 1998;18:1155-1170. 15. Teitelbaum I, Burkart J. Peritoneal dialysis. Am J Kidney Dis 2003;42:1082-1096. 16. Collins AJ, Hao W, Xia H, et al. Mortality risks of peritoneal dialysis and hemodialysis. Am J Kidney Dis 1999;34: 1065-1074.
There has been a significant increase in the number of patients with end-stage renal disease. The limited number of kidney transplants necessitates that most patients become dependent upon chronic dialysis. Due to the numerous complications associated with temporary access catheters, permanent arteriovenous access is more beneficial for long-term vascular access. However, with the restricted availability of sites for permanent vascular access, it is important to have a variety of possibilities. In this case report, we present an alternative choice for an arteriovenous graft, left common femoral artery to left renal vein, in a patient with limited vascular access options.
Numerous diseases cause renal insufficiency, and dialysis has been used as a life-saving therapy in the setting of both acute and chronic renal failure for decades. Currently, approximately 325,000 patients undergo dialysis in the United States and the prevalence of end-stage renal disease (ESRD) is increasing annually. Hypertension and diabetes account for greater than 50% of new ESRD patients.1 Due to the very limited availability of kidney transplants, the number of patients requiring dialysis is likely to increase.2 Hemodialysis (HD) requires vascular access, and each vascular access site has a limited time of usage. When a particular site fails, a new site has to be established, thus decreasing the total number of possibilities for future access. It has been reported that as many as 2% of deaths in the dialysis patient population occur secondary to the lack of vascular access.3
Presented at the Annual Meeting of the Gulf Coast Vascular Society, New Orleans, LA, October 7, 2006. Section of Vascular Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA. Correspondence to: Azeem Khan, MD, 820 Sherwood Forest Blvd., Baton Rouge, LA 70815-5262, USA, E-mail: [email protected] Ann Vasc Surg 2008; 22: 136-139 DOI: 10.1016/j.avsg.2007.07.030 Ó Annals of Vascular Surgery Inc. Published online: January 10, 2008
136
Immediate HD access is usually created by the insertion of various types of dialysis catheters but is often fraught with complications including central vein thrombosis, infection, and failure to function.4,5 A more desirable access option is to create permanent HD access using autologous vein to make arteriovenous fistulas (AVFs) or arteriovenous grafts (AVGs) with synthetic materials. The classically described venous sites for AVF include cephalic, basilic, saphenous, and femoral veins. Alternative venous sites for access with AVG, which have been described previously, include the axillary, femoral, iliac, and jugular veins and the right atrium.6-8 A drawback of permanent access is the inability to immediately use HD. According to Dialysis Outcome Quality Initiative (DOQI) guidelines, AVFs require a waiting period of approximately 2-3 months to allow for maturation of the fistula. The most commonly used synthetic material for AVG is polytetrafluoroethylene (PTFE). PTFE AVGs require a waiting period of approximately 3-4 weeks to allow the body to form a fibrous coating around the AVG in order to prevent postaccess hemorrhage and thrombosis.9 A new prosthetic access graft composed of polyurethaneurea (Thoralon, created by Bard Peripheral Vascular, Tempe, AZ) is now available, which can be accessed within 24 hr of placement, contrary to the traditionally used PTFE grafts.10
Vol. 22, No. 1, 2008
Case reports 137
This case report describes an additional immediate access technique for permanent access in a patient with limited HD access possibilities.
CASE REPORT A 43-year-old male presented with a thrombosed right common femoral artery to right common femoral vein AVG and without HD for 3 days. The patient had a medical history significant for ESRD, chronic HD for 9 years, hypertension, and hepatitis C. Even though an extensive previously conducted laboratory investigation revealed no evidence of a hypercoagulable state, multiple venous occlusions were present, including the central brachiocephalic vein, superior vena cava, most of the inferior vena cava, and right renal vein. There was patency, however, of the left renal vein and marginal patency of the distal infrarenal inferior vena cava, as demonstrated by venography (Fig. 1). Surgical history included multiple permanent AVF, AVG, and temporary vascular catheters in the bilateral neck and upper and lower extremities. Medications included coumadin (for which the last dose had been 2 days prior to presentation), omeprazole, neurontin, and multivitamins. The patient was incarcerated and a one pack per day smoker for over 25 years. Numerous attempts at placement of a temporary percutaneous catheter in both the neck and groin were unsuccessful. Emergent thrombectomy of the right femoral AVG was done, followed by an AVG revision, which involved a bovine patch angioplasty of the previous arterial anastomosis. Shortly after the surgery, HD was initiated, but it was aborted secondary to poor venous outflow. Low-flow HD was attempted the next day but was also inadequate. At this juncture, it was decided to take the patient to the operating room for creation of a new AVF with the placement of a Bard Vectra Thoralon Vascular Access Graft (diameter 6.0 mm, length 50 cm, cat. 10002-6050-001) in the proximal left thigh, the only extremity without a previous permanent HD access in place. This graft was chosen due to its unique characteristics of rapid hemostasis and early access, 24 hr after implantation.10 Through a standard vertical groin incision the common femoral artery was exposed and an end-to-side arterial anastomosis was created at the left common femoral artery (Fig. 2B). The Vectra graft was then superficially tunneled as a loop in the proximal thigh and anastomosed end-to-end to a ringed expanded PTFE (ePTFE) graft (diameter 6.0 mm, length 80 cm, cat. F8006TW; Bard Peripheral Vascular) at the superior level of the inguinal incision. The ringed ePTFE graft was then tunneled retroperitoneally through the inguinal canal to the left renal vein. A midline abdominal incision was required to expose the left renal vein. At operation the infrarenal vena cava was thickened due to postphlebitic changes. An end-to-side venous anastomosis was created between the PTFE graft and the left renal vein (Fig. 2A).
Fig. 1. Venography demonstrating total occlusion of both the superior (A) and inferior (B) vena cava. The inferior approach was through a severely diseased left iliac system, revealing patency of the left renal vein.
The AVG was cannulated and used 6 hr following implantation with a successful and complete HD run. The patient was resumed on his anticoagulation therapy, and an appropriate therapeutic international normalized ratio was achieved. Three days after surgery the patient was discharged from the hospital with routine HD scheduled. At 6-month follow-up no postoperative steal syndrome or other vascular complications were noted, with continued use of the AVG.
138 Case reports
Annals of Vascular Surgery
though, is technically more challenging to implant than PTFE grafts due to the material it is made of, and the manufacturer’s technical instructions should be followed closely in order to prevent failure of the graft.10 Another option considered in this patient was percutaneous cannulation of the renal vein or inferior vena cava and dialysis catheter placement with interventional radiological guidance.14 However, permanent AVG implantation was chosen due to the young age of the patient and the dismal previous results with dialysis catheters in this patient. Yet a third choice evaluated in this patient, with his multiple vascular problems, was peritoneal dialysis (PD). The absence of surgical interventions to the peritoneal cavity made him an excellent candidate for PD.15,16 Unfortunately, PD is not available for incarcerated patients in Louisiana. The femororenal AVG described did require the patient to have an extended hospital stay, in contrast to the routine outpatient access surgery; and the Vectra graft at this time is more costly than PTFE grafts. However, the patient is alive and continues to use the femororenal AVG for HD with excellent flow rates, and this case should be kept in mind as an option for selected patients. Fig. 2. A Left common femoral artery to Vectra graft anastomosis; Vectra graft subcutaneously looped in the proximal thigh; Vectra graft anastomosed to ringed ePTFE graft and tunneled through inguinal approach into the abdomen. B In an end-to-side fashion to the left renal artery.
DISCUSSION The renal vein as a possibility for outflow in HD has been reported in the literature as an axillorenal AVG.11 Renal veins have also been proposed for use in a swine model for AVG.12 The present case represents the first femororenal AVG reported in the literature. Furthermore, the previously reported axillorenal AVG case underwent multiple thrombectomies and revisions secondary to the difficult anatomy and placement of the graft, contrary to this case.11 Regardless of the choice for vascular access, the most important consideration in planning placement of vascular access should be adequate venous outflow because this is where the majority of problems occur.13 This case also illustrates the adverse consequence on the venous circulation of requiring multiple dialysis catheters. Use of the Vectra graft is advantageous as it allowed for immediate and permanent HD. This graft,
REFERENCES 1. US Renal Data System. The 2005 USRDS annual data report: pre´cis, www.usrds.org/2005/pdf/0B_precis_05.pdf. (accessed August 25, 2006, p 20). 2. Mange KC, Joffe MM, Feldman HI. Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. N Engl J Med 2001;344: 726-731. 3. Laskow DA, Ashan N. Dialysis access failure: an indication for immediate kidney transplantation. Semin Dial 2002;15: 1-2. 4. Little MA, O’Riordan A, Lucey B, et al. A prospective study of complications associated with cuffed, tunneled, hemodialysis catheters. Nephrol Dial Transplant 2001;16:2194-2200. 5. El Minshawy O, Abd El Aziz T, Abd El Ghani H. Evaluation of vascular access complications in acute and chronic hemodialysis. J Vasc Access 2004;5:76-82. 6. Chemla ES, Morsy M, Anderson L, Makanjuola D. Complex bypasses and fistulas for difficult hemodialysis access: a prospective, single-center experience. Semin Dial 2006;19: 246-250. 7. Evans DC, Upton EC, Lawson JH. Axillary to common iliac arteriovenous graft for hemodialysis access: case report and review of ‘‘exotic’’ axillary-based grafts. J Vasc Access 2005; 6:192-195. 8. El-Sabrout RA, Duncan JM. Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment access. J Vasc Surg 1999;29:472-478. 9. National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for
Vol. 22, No. 1, 2008
vascular access, 2000. Am J Kidney Dis 2001;37(Suppl. 1): S137. 10. Glickman MH, Stokes GK, Ross JR, et al. Multicenter evaluation of a polyurethaneurea vascular access graft as compared with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications. J Vasc Surg 2001; 34:465-473. 11. Karp SJ, Hawxby A, Burdick JF. Axillorenal arteriovenous graft: a new approach for dialysis access. J Vasc Surg 2004; 40:379-380. 12. Wallace MJ, Thomas JW, Ahrar K, Wright KC. Transrenal arteriovenous dialysis graft creation: survival and patency in a swine model. Radiology 2003;227:501-509.
Case reports 139
13. Chen JC, Kamal DM, Jastrzebski J, Taylor DC. Venovenostomy for outflow venous obstruction in patients with upper extremity autogenous hemodialysis arteriovenous access. Ann Vasc Surg 2005;19:629-635. 14. Rajan DK, Croteau DL, Sturza SG, Harvill ML, Mehall CJ. Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access. Radiographics 1998;18:1155-1170. 15. Teitelbaum I, Burkart J. Peritoneal dialysis. Am J Kidney Dis 2003;42:1082-1096. 16. Collins AJ, Hao W, Xia H, et al. Mortality risks of peritoneal dialysis and hemodialysis. Am J Kidney Dis 1999;34: 1065-1074.