- Email: [email protected]
Simultaneous Iliac Vein Bovine Pericardial Patch Venoplasty and Creation of PTFE Lower Limb Arteriovenous Fistula Graft for Rescue Vascular Access
Case Report Simultaneous Iliac Vein Bovine Pericardial Patch Venoplasty and Creation of PTFE Lower Limb Arteriovenous Fistula Graft for Rescue Vascular Access Lewis Meecham,1 Owain Fisher,1 George Kirby,1 Richard Evans,1 Pauline Buxton,1 Jocelyn Legge,2 Sriram Rajagopalan,1 John Asquith,3 and Arun Pherwani,1 Stoke-on-Trent, United Kingdom
Background: We present a case of external iliac vein patch venoplasty to accommodate rescue vascular access via a polytetrafluoroethylene loop arteriovenous fistula graft (AVG) for a patient with multiple central venous stenoses. Methods: A 35-year-old female with anti-glomerular basement membrane antibody disease required rescue vascular access for hemodialysis. Repeated occlusion and/or thrombosis of long-term central venous access cannulae, to facilitate dialysis, had caused stenosis of brachiocephalic veins: right external iliac vein and occlusion of the left common iliac vein. A previous right brachiobasilic fistula had occluded within 1 year. No other upper limb options for arteriovenous fistula (AVF) were available. A right external iliac vein bovine patch angioplasty concurrently with a polytetrafluoroethylene AV graft between common femoral artery and common femoral vein was performed to restore venous patency and allow rescue dialysis access. Results: At 3-year follow-up, the fistula remains widely patent with 2 L/min flow rates and no recurrent stenosis to the treated iliac vein. She has not required any further surgical or interventional radiological procedures to maintain fistula or central venous patency. Central venous stenosis or occlusion is common for patients requiring dialysis, especially those with multiple previous long-term central venous cannulations. If restriction of outflow is present, AVF may fail. Venous patch angioplasty in these cases is a successful technique, allowing AVF formation and long-term patency. Conclusion: Central venous stenosis can be treated successfully with patch venoplasty to accommodate AVF/AVG formation for rescue vascular access; this is a potentially lifesaving intervention for patients requiring dialysis.
1
Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK. 2 Department of Renal Medicine, Royal Stoke University Hospital, Stoke-on-Trent, UK. 3 Department of Interventional Radiology, Royal Stoke University Hospital, Stoke-on-Trent, UK.
Correspondence to: Owain Fisher, MBBCH, Department of Vascular Surgery, Royal Stoke University Hospital, Newcastle Road, Stoke-OnTrent ST4 6QG, UK; E-mail: [email protected] Ann Vasc Surg 2016; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2016.03.018 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: December 15, 2015; manuscript accepted: March 12, 2016; published online: - - -
The incidence of central venous occlusive disease (CVOD) in hemodialysis patients is reportedly as high as 29%1 and remains a significant problem in their long-term management. Trauma, neoplasia, indwelling catheters, external compression, and high flow arteriovenous fistulae are implicated in the cause of CVOD.2 It accounts for 20e30% of hospitalizations of patients undergoing hemodialysis.3 CVOD may present either through malfunctioning or loss of preexisting vascular access or as venous hypertension of the affected limb.4 The mainstay of treatment is endoluminal; however, if this is 1
2 Case Report
unsuccessful surgical intervention should be considered.5 We present a case where a patient with central venous stenosis and no viable upper limb options for vascular access with previous lower limb deep venous thrombosis (DVT) and the use of indwelling central lines causing iliac venous stenosis underwent surgical external iliac vein (EIV) patch venoplasty with bovine pericardium and simultaneous lower limb arteriovenous polytetrafluoroethylene (PTFE) graft fistula (AVG). On inspection of the literature, there is very little on such venous reconstruction to accommodate rescue vascular access.
CASE REPORT A 35-year-old female smoker with anti-glomerular basement membrane antibody disease required rescue vascular access for hemodialysis. Multiple previous tunneled central venous access catheters had occluded; therefore, prophylactic anticoagulation with warfarin was instituted to try to prevent this although evidence for prophylactic anticoagulation is weak.6 This had resulted in stenosis of brachiocephalic veins: right internal jugular, right external iliac vein (EIV), and occlusion of the left common iliac vein along with bilateral lower limb DVT. A previous transposed right brachiobasilic fistula had occluded within a year due to venous stenosis despite repeated interventions. She has also suffered systemic sepsis due to infected lines. No other upper limb options for arteriovenous fistula (AVF) were available and lower limb superficial femoral vein (SFV) transposed fistulae were contraindicated due to both SFV DVT and proximal iliac narrowing and occlusion. Urgent transplantation was proposed but turned down due to extensive cervical intra-epithelial neoplasia with widespread field change in the perineum. She also had a trial of peritoneal dialysis but this had failed due to extensive intra-abdominal surgery and adhesions. Given the desperate nature of her vascular access, it was decided that a lower limb graft fistula was the most feasible option and due to previous DVT and pro-coagulant state a PTFE graft would be the most suitable conduit combined with venous reconstruction for proximal iliac venous stenosis. An Hemodialysis Reliable Outflow (HeROÒ) graft would have been a novel approach for rescue access; however, experience in using HeRO within the unit was limited and given the time critical nature of the patient’s condition it was not considered. The right EIV was exposed via a Rutherford Morrison incision and retroperitoneal dissection. Control was obtained proximally at the common and internal iliac veins and inflow control via the confluence of the common femoral vein (CFV) via a longitudinal incision in the groin. The stenosed venous segment was incised from the common femoral below the inguinal ligament through the length of the EIV above the ligament, and a long segment
Annals of Vascular Surgery
bovine biologic pericardial patch (XenosureÒ; Le Maitre Vascular, Inc.) was used to surgically angioplasty the vein and restore the venous lumen. The inguinal ligament was not divided with both the patch and sutures passed beneath the ligament to retain continuity. A 6-mm PTFE (IMPRAÒ; Bard Peripheral Vascular, Inc.) graft was then anastomosed to the superficial femoral artery in a superficial anterior thigh loop with the venous anastomosis performed on to the bovine patch at the CFV. An immediate strong thrill was palpable indicating good performance of the AV fistula and reconstituted venous drainage (Fig. 1). At 3-year follow-up, the fistula remains widely patent with flow rates of 2 L/min and no recurrent stenosis in the treated iliac vein. The patient is undergoing successful dialysis thrice weekly and has not required any further surgical or interventional radiological procedures to maintain AVG or central venous patency and remains free from sepsis and without venous hypertension.
DISCUSSION With the insertion of more central venous lines to provide temporary vascular access, the incidence of CVOD is increasing.3 This is increasingly burdensome as patients receiving hemodialysis are living longer.7 Conventionally, CVOD is treated in the first instance with endovenous methods; surgery is only considered when these have failed.8 Endovascular intervention for hemodialysisrelated CVOD is the mainstay of treatment. Options include percutaneous angioplasty (PTA) alone, PTA with bare metal stent insertion, and covered stent or stent graft insertion. PTA for CVOD is widely employed with good immediate technical success; unfortunately, long-term patency (primary or secondary) is poor9 even with the use of modern venous stents. When these have failed there are a number of surgical options. These must be tailored to the individual patient, considering whether they have preexisting patent vascular access or require new AVF formation. These options are invasive and carry a high element of risk particularly in patients with renal failure who are physiologically challenged. Many open surgical procedures have been described in the literature. These range from anatomical venous bypass in the upper and lower limb (axillosubclavian; axillo-axillo cross over; axillo-right atrium; femoro-iliac; femoro-IVC, and fem-fem cross over) to extra-anatomical upper to lower limb bypass (axillo-femoral, axillo-iliac) and finally arterial loop in the axillary artery to provide access.5,8,10,11 Although at the time a lack of experience in using a HeRO graft precluded its use in this patient. It does offer a solution for patients with
Vol.
-,
No.
-, -
2016
Case Report 3
patient, the potential for death from lack of suitable access for dialysis, with the surgical impact, is less than other bypass measures. Central venous stenosis can, as demonstrated here, be treated successfully with a novel approach of bovine pericardial patch venoplasty to accommodate AVF formation for rescue vascular access; this is a lifesaving intervention for the renal patients in extreme conditions requiring vascular access. REFERENCES
Fig. 1. Computed tomography three-dimensional reconstruction showing thigh loop graft in situ.
challenging access needs12 and certainly could be considered as an option in this patient should the need arise to consider further intervention to restore vascular access. Upper limb proximal venous reconstruction is extremely difficult due to the virtual mandatory thoracotomy for access. The iliac veins when stenosed lend themselves to venous re-construction as they may be approached via a retroperitoneal or transperitoneal approach. The preferred conduit both for venoplasty and for the access is autologous vein as it has the best long-term patency but as this at a premium in renal patients, biologic bovine pericardium is a suitable alternative.13 Surgical patch angioplasty with bovine pericardium is an immediately effective treatment strategy for CVOD, as shown in our case. It is robust and demonstrates longevity. The morbidity associated with surgery is far less than that associated with permanent loss of vascular access for dialysis patients and in the most extreme cases such is with our
1. Anaya-Ayala JE, Smolock CJ, Colvard BD, et al. Efficacy of covered stent placement for central venous occlusive disease in haemodialysis patients. J Vasc Surg 2011;54:754e9. 2. Glanz S, Gordon DH, Lipkowitz GS, et al. Axillary and subclavian vein stenosis: percutaneous angioplasty. Radiology 1998;168:371e3. 3. Agarwal AK, Patel BM, Haddad NJ. Central vein stenosis: a nephrologist’s perspective. Semin Dial 2007;20:53e62. 4. Campistol JM, Abad C, Torras A, et al. Salvage of upper arm access graft in the presence of symptomatic subclavian vein thrombosis. Nephron 1989;51:551e2. 5. Hamish M, Shalhoub J, Rodd CD, et al. Axillo-iliac conduit for haemodialysis vascular access. Eur J Vasc Endovasc Surg 2006;31:530e4. 6. Geerts W. Central venous catheter-related thrombosis. Hematology Am Soc Hematol Educ Program 2014;2014: 306e11. 7. Hill CJ, Fogarty DG. Changing trends in end-stage renal disease due to diabetes in the United kingdom. J Ren Care 2012;38 Suppl 1:12e22. 8. Anaya-Anaya JE, Bellows PH, Ismail N, et al. Surgical management of hemodialysis-related central venous occlusive disease: a treatment algorithm. Ann Vasc Surg 2011;25: 108e19. 9. Kim YC, Won JY, Choi SY. Percutaneous treatment of central venous stenosis in hemodialysis patients: long-term outcomes. Cardiovasc Intervent Radiol 2009;32:271e8. 10. Cimochowski GE, Harter HR, Rutherford WE, et al. Axillary artery to iliac vein vascular access using an external supported prosthetic graft: a new approach for dialysis access. J Vasc Surg 2004;40:379e80. 11. Doty DB, Doty JR, Jones KW. Bypass of superior vena cava. Fifteen years’ experience with spiral vein graft for obstruction of superior vena cava caused by benign disease. J Thorac Cardiovasc Surg 1990;99:889e96. 12. Wallace J, Chaer R, Dillavou E. Report on the Hemodialysis Reliable Outflow (HeRO) experience in dialysis patients with central venous occlusions. J Vasc Surg 2013;58:742e7. 13. Del Campo C, Fonseca A. Replacement of the left common iliac vein with a custom-made bovine pericardium tubular graft. Tex Heart Inst J 2001;28:39e41.
Background: We present a case of external iliac vein patch venoplasty to accommodate rescue vascular access via a polytetrafluoroethylene loop arteriovenous fistula graft (AVG) for a patient with multiple central venous stenoses. Methods: A 35-year-old female with anti-glomerular basement membrane antibody disease required rescue vascular access for hemodialysis. Repeated occlusion and/or thrombosis of long-term central venous access cannulae, to facilitate dialysis, had caused stenosis of brachiocephalic veins: right external iliac vein and occlusion of the left common iliac vein. A previous right brachiobasilic fistula had occluded within 1 year. No other upper limb options for arteriovenous fistula (AVF) were available. A right external iliac vein bovine patch angioplasty concurrently with a polytetrafluoroethylene AV graft between common femoral artery and common femoral vein was performed to restore venous patency and allow rescue dialysis access. Results: At 3-year follow-up, the fistula remains widely patent with 2 L/min flow rates and no recurrent stenosis to the treated iliac vein. She has not required any further surgical or interventional radiological procedures to maintain fistula or central venous patency. Central venous stenosis or occlusion is common for patients requiring dialysis, especially those with multiple previous long-term central venous cannulations. If restriction of outflow is present, AVF may fail. Venous patch angioplasty in these cases is a successful technique, allowing AVF formation and long-term patency. Conclusion: Central venous stenosis can be treated successfully with patch venoplasty to accommodate AVF/AVG formation for rescue vascular access; this is a potentially lifesaving intervention for patients requiring dialysis.
1
Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK. 2 Department of Renal Medicine, Royal Stoke University Hospital, Stoke-on-Trent, UK. 3 Department of Interventional Radiology, Royal Stoke University Hospital, Stoke-on-Trent, UK.
Correspondence to: Owain Fisher, MBBCH, Department of Vascular Surgery, Royal Stoke University Hospital, Newcastle Road, Stoke-OnTrent ST4 6QG, UK; E-mail: [email protected] Ann Vasc Surg 2016; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2016.03.018 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: December 15, 2015; manuscript accepted: March 12, 2016; published online: - - -
The incidence of central venous occlusive disease (CVOD) in hemodialysis patients is reportedly as high as 29%1 and remains a significant problem in their long-term management. Trauma, neoplasia, indwelling catheters, external compression, and high flow arteriovenous fistulae are implicated in the cause of CVOD.2 It accounts for 20e30% of hospitalizations of patients undergoing hemodialysis.3 CVOD may present either through malfunctioning or loss of preexisting vascular access or as venous hypertension of the affected limb.4 The mainstay of treatment is endoluminal; however, if this is 1
2 Case Report
unsuccessful surgical intervention should be considered.5 We present a case where a patient with central venous stenosis and no viable upper limb options for vascular access with previous lower limb deep venous thrombosis (DVT) and the use of indwelling central lines causing iliac venous stenosis underwent surgical external iliac vein (EIV) patch venoplasty with bovine pericardium and simultaneous lower limb arteriovenous polytetrafluoroethylene (PTFE) graft fistula (AVG). On inspection of the literature, there is very little on such venous reconstruction to accommodate rescue vascular access.
CASE REPORT A 35-year-old female smoker with anti-glomerular basement membrane antibody disease required rescue vascular access for hemodialysis. Multiple previous tunneled central venous access catheters had occluded; therefore, prophylactic anticoagulation with warfarin was instituted to try to prevent this although evidence for prophylactic anticoagulation is weak.6 This had resulted in stenosis of brachiocephalic veins: right internal jugular, right external iliac vein (EIV), and occlusion of the left common iliac vein along with bilateral lower limb DVT. A previous transposed right brachiobasilic fistula had occluded within a year due to venous stenosis despite repeated interventions. She has also suffered systemic sepsis due to infected lines. No other upper limb options for arteriovenous fistula (AVF) were available and lower limb superficial femoral vein (SFV) transposed fistulae were contraindicated due to both SFV DVT and proximal iliac narrowing and occlusion. Urgent transplantation was proposed but turned down due to extensive cervical intra-epithelial neoplasia with widespread field change in the perineum. She also had a trial of peritoneal dialysis but this had failed due to extensive intra-abdominal surgery and adhesions. Given the desperate nature of her vascular access, it was decided that a lower limb graft fistula was the most feasible option and due to previous DVT and pro-coagulant state a PTFE graft would be the most suitable conduit combined with venous reconstruction for proximal iliac venous stenosis. An Hemodialysis Reliable Outflow (HeROÒ) graft would have been a novel approach for rescue access; however, experience in using HeRO within the unit was limited and given the time critical nature of the patient’s condition it was not considered. The right EIV was exposed via a Rutherford Morrison incision and retroperitoneal dissection. Control was obtained proximally at the common and internal iliac veins and inflow control via the confluence of the common femoral vein (CFV) via a longitudinal incision in the groin. The stenosed venous segment was incised from the common femoral below the inguinal ligament through the length of the EIV above the ligament, and a long segment
Annals of Vascular Surgery
bovine biologic pericardial patch (XenosureÒ; Le Maitre Vascular, Inc.) was used to surgically angioplasty the vein and restore the venous lumen. The inguinal ligament was not divided with both the patch and sutures passed beneath the ligament to retain continuity. A 6-mm PTFE (IMPRAÒ; Bard Peripheral Vascular, Inc.) graft was then anastomosed to the superficial femoral artery in a superficial anterior thigh loop with the venous anastomosis performed on to the bovine patch at the CFV. An immediate strong thrill was palpable indicating good performance of the AV fistula and reconstituted venous drainage (Fig. 1). At 3-year follow-up, the fistula remains widely patent with flow rates of 2 L/min and no recurrent stenosis in the treated iliac vein. The patient is undergoing successful dialysis thrice weekly and has not required any further surgical or interventional radiological procedures to maintain AVG or central venous patency and remains free from sepsis and without venous hypertension.
DISCUSSION With the insertion of more central venous lines to provide temporary vascular access, the incidence of CVOD is increasing.3 This is increasingly burdensome as patients receiving hemodialysis are living longer.7 Conventionally, CVOD is treated in the first instance with endovenous methods; surgery is only considered when these have failed.8 Endovascular intervention for hemodialysisrelated CVOD is the mainstay of treatment. Options include percutaneous angioplasty (PTA) alone, PTA with bare metal stent insertion, and covered stent or stent graft insertion. PTA for CVOD is widely employed with good immediate technical success; unfortunately, long-term patency (primary or secondary) is poor9 even with the use of modern venous stents. When these have failed there are a number of surgical options. These must be tailored to the individual patient, considering whether they have preexisting patent vascular access or require new AVF formation. These options are invasive and carry a high element of risk particularly in patients with renal failure who are physiologically challenged. Many open surgical procedures have been described in the literature. These range from anatomical venous bypass in the upper and lower limb (axillosubclavian; axillo-axillo cross over; axillo-right atrium; femoro-iliac; femoro-IVC, and fem-fem cross over) to extra-anatomical upper to lower limb bypass (axillo-femoral, axillo-iliac) and finally arterial loop in the axillary artery to provide access.5,8,10,11 Although at the time a lack of experience in using a HeRO graft precluded its use in this patient. It does offer a solution for patients with
Vol.
-,
No.
-, -
2016
Case Report 3
patient, the potential for death from lack of suitable access for dialysis, with the surgical impact, is less than other bypass measures. Central venous stenosis can, as demonstrated here, be treated successfully with a novel approach of bovine pericardial patch venoplasty to accommodate AVF formation for rescue vascular access; this is a lifesaving intervention for the renal patients in extreme conditions requiring vascular access. REFERENCES
Fig. 1. Computed tomography three-dimensional reconstruction showing thigh loop graft in situ.
challenging access needs12 and certainly could be considered as an option in this patient should the need arise to consider further intervention to restore vascular access. Upper limb proximal venous reconstruction is extremely difficult due to the virtual mandatory thoracotomy for access. The iliac veins when stenosed lend themselves to venous re-construction as they may be approached via a retroperitoneal or transperitoneal approach. The preferred conduit both for venoplasty and for the access is autologous vein as it has the best long-term patency but as this at a premium in renal patients, biologic bovine pericardium is a suitable alternative.13 Surgical patch angioplasty with bovine pericardium is an immediately effective treatment strategy for CVOD, as shown in our case. It is robust and demonstrates longevity. The morbidity associated with surgery is far less than that associated with permanent loss of vascular access for dialysis patients and in the most extreme cases such is with our
1. Anaya-Ayala JE, Smolock CJ, Colvard BD, et al. Efficacy of covered stent placement for central venous occlusive disease in haemodialysis patients. J Vasc Surg 2011;54:754e9. 2. Glanz S, Gordon DH, Lipkowitz GS, et al. Axillary and subclavian vein stenosis: percutaneous angioplasty. Radiology 1998;168:371e3. 3. Agarwal AK, Patel BM, Haddad NJ. Central vein stenosis: a nephrologist’s perspective. Semin Dial 2007;20:53e62. 4. Campistol JM, Abad C, Torras A, et al. Salvage of upper arm access graft in the presence of symptomatic subclavian vein thrombosis. Nephron 1989;51:551e2. 5. Hamish M, Shalhoub J, Rodd CD, et al. Axillo-iliac conduit for haemodialysis vascular access. Eur J Vasc Endovasc Surg 2006;31:530e4. 6. Geerts W. Central venous catheter-related thrombosis. Hematology Am Soc Hematol Educ Program 2014;2014: 306e11. 7. Hill CJ, Fogarty DG. Changing trends in end-stage renal disease due to diabetes in the United kingdom. J Ren Care 2012;38 Suppl 1:12e22. 8. Anaya-Anaya JE, Bellows PH, Ismail N, et al. Surgical management of hemodialysis-related central venous occlusive disease: a treatment algorithm. Ann Vasc Surg 2011;25: 108e19. 9. Kim YC, Won JY, Choi SY. Percutaneous treatment of central venous stenosis in hemodialysis patients: long-term outcomes. Cardiovasc Intervent Radiol 2009;32:271e8. 10. Cimochowski GE, Harter HR, Rutherford WE, et al. Axillary artery to iliac vein vascular access using an external supported prosthetic graft: a new approach for dialysis access. J Vasc Surg 2004;40:379e80. 11. Doty DB, Doty JR, Jones KW. Bypass of superior vena cava. Fifteen years’ experience with spiral vein graft for obstruction of superior vena cava caused by benign disease. J Thorac Cardiovasc Surg 1990;99:889e96. 12. Wallace J, Chaer R, Dillavou E. Report on the Hemodialysis Reliable Outflow (HeRO) experience in dialysis patients with central venous occlusions. J Vasc Surg 2013;58:742e7. 13. Del Campo C, Fonseca A. Replacement of the left common iliac vein with a custom-made bovine pericardium tubular graft. Tex Heart Inst J 2001;28:39e41.