Upper extremity vascular access for continuous arteriovenous hemofiltration and dialysis after cardiac operations

Upper Extremity Vascular Access for Continuous Arteriovenous Hemofiltration and Dialysis After Cardiac Operations Jerome B. Riebman, MD, Glenn W. Laub, MD, Albert H. Olivencia-Yurvati, DO, and Lynn B. McGrath, MD Division of Thoracic and Cardiovascular Surger,., Departnlent ot Surgery, Deborah tteart and Lung Center, Browns Mills; and the University of Medicine and Dentistry of Ne~ Jersey, Robert Wood Iohnson School of Medicine, New Brunswick, New Jersey

Background. There is increasing interest in the use of c o n t i n u o u s arteriovenous hemofiltration/dialysis for treatment of profound renal failure after cardiovascular operations. Vascular access for this is usually accomplished by percutaneous cannulation of the femoral artery and vein, with the inherent risks of vascular trauma, patient immobilization, hemorrhage, or infectious complications. Methods. Fifteen (0.369;) of 4,166 patients receiving cardiovascular surgical procedures sustained postoperative renal failure requiring treatment with continuous arteriovenous hemofiltration/dialysis. Each patient had creation of acute arteriovenous forearm access using a modified Allen-Brown shunt. Shunts were monitored c o n t i n u o u s l y for hemorrhage, malfunction, infection, and thrombus, and were explanted when no longer required.

Results. Sixteen shunts were implanted in 15 patients over the 41-month period. All shunts functioned satisfactorily, with the duration of implantation ranging from 1 to 64 days. There were no infectious or hemorrhagic complications. Conclusions. The acute creation of a simple forearm s h u n t for postoperative continuous arteriovenous hemofiltration/dialysis is preferred over femoral arterial and venous c a n n u l a t i o n because it can be constructed rapidly and easily in the operating room or at the bedside, has a low complication rate, is available for immediate use, may be left in place indefinitely, does not interfere with patient mobilization or ambulation, and is easily removed.

he occurrence of acute renal failure after cardiovascular surgical procedures is an u n c o m m o n complication that may be associated with decreased survival [1 I. Early, aggressive therapy may improve the prognosis of postoperative oliguric renal failure and frequently requires the use of ultrafiltration, hemofiltration, or hemodialysis at the bedside in the intensive care unit [2, 31. The techniques available include peritoneal dialysis, hemodialysis, and continuous arteriovenous (or venovenous) hemofiltration or hemodialvsis. There has been an increasing interest in using continuous arteriovenous hemofiltration/dialvsis (CAVH/D~ for patients in this setting in preference to peritoneal dialysis or conventional hemodialysis [4]. For some patients, ( A V I I / D is the only option if contraindications exist tot peritoneal dialysis or hemodialysis. Vascular access for acute CAVH/D is tlSklally obtained by percutaneous cannulation of the femoral artery and vein, which can be performed at the bedside. However, this requires inlmobilization of the patient and may be conlplicated by bleeding or infection at the access sites, especially in these critically ill patients ~ h o may

have concomitant sepsis, thrombocytopenia, coagulopathy, or multiorgan failure [5]. In an effort to develop a protocol for postoperative CAVH/D that provides effective and safe access with fewer complications, we adopted a technique involving the acute creation of a simple forearm s h u n t for CAVH/D in patients suffering from oliguric renal failure after cardiovascular surgical procedures. This s h u n t can be constructed rapidly and easily in the operating room or at the bedside, has a low complication rate, is available for imnlediate use, may be left in place indefinitely, does not interfere with patient mobilization or ambulation, and is

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Material and Methods

Patients Between Janua D' 1, 1991 and May 31, 1994, 4,166 patients u n d e r ~ e n t cardiovascular surgical procedures at Deborah tteart and Lung Center. Of this group, 15 patients (0.36,,,) sustaining postoperative renal failure (oliguric or anuric) were treated with acute CAVH/D, after failure of medical therapy, for control of metabolic toxicity, acidbase regulation, or fluid balance. Conventional hemodialvsis was not used for these patients because of their unstable h e m o d y n a m i c status or a contraindication to 0003-4975/95159.50 SSDI 0003-4975(95)00523-N

Ann Thorac Surg 1995;60:1072-5

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Tabh, 1. Results o f Contimlous Arteriovcnous H e m q f i l t r a t i o n / l ) i a h l s i s Patient No.

Age (y)

Sex

Surgical Procedure

1 2

70 67

F M

Pericardectonw, AAA repair CAB(; , 3

3 4 5

57 59 57

M F [:

CABG - 4 Mitral valve replacement Repair tetralog} of Fallot

6 7

74 57

M

CABG

2

F

CAB(;

I

8 9 10 11 12

66 66 53 61 61

M M F F F

CAB(; 3 CABG 2 CABG 2 CABG, 2 Pericardial ~xindm~

13 14 15

74 78 68

M M M

CABG - 3 Reuperatix e CAB(; 1 Reoperati~e CABG ~ ,~, "~ right CFA

AAA

abdominal

aortic anuur\~m;

(_ \ B ( ;

coronary

Shunt Electively Explanted

Hospital Survivor

17 18

No Yes

No Yes

1 I IS ~0 S 25

No No Yes Yes No Yes

No No Yes

II 13 12 64

No No Yes No No

No No Yes No No

20 ~ 30

No No Yes

No No No

Duratiuo of Shunt Implantation (d)

arter\

b~pa,,s grafting;

(EA

: carotid

No Yes

endartereclom~

Shunt-Related Complications None Thrombosis × 1 Thrombectomy restored function None None None None Thrombosis × 2 Thrombectomy × 2 restored function None None None None Thrombosis x 2 Thrornbectomy × 2 restored function None None None

F :: f e m a l e ;

M = male.

s y s t e m i c a n t i c o a g u l a t i o n , l ' e r i t o n e a l dialysis w a s n o t u s e d b e c a u s e of a b d o m i n a l p a t h o l o g y or p r e v i o u s abd o m i n a l o p e r a t i o n , or it h a d b e e n tried a n d w a s ineffective. T h e r e w e r e 8 m a l e a n d 7 f e m a l e p a t i e n t s r a n g i n g in age f r o m 53 to 78 y e a r s ( m e a n age, 64.6 years). T h e p r i m a r y surgical p r o c e d u r e s are listed in T a b l e l. Thirt e e n of t h e p a t i e n t s u n d e m ' e n t p r o c e d u r e s u s i n g c a r d i o pulmonary bypass. Before t h e i n s t i t u t i o n of C A V H / D , each p a t i e n t h a d surgical c r e a t i o n of a f o r e a r m s h u n t in t h e o p e r a t i n g r o o m (n 10) or at the b e d s i d e in t h e surgical i n t e n s i v e care u n i t (n 5). W e p e r f o r m e d C A V H / D u s i n g a Diafilter 20S H e m o f i l t e r ( A m i c o n , Beverly, MA) with c o n t i n u o u s l o w - d o s e h e p a r i n i z a t i o n i n t r o d u c e d into t h e circuit on the arterial s i d e of the filter+ W o u n d care c o n s i s t e d of r o u t i n e b u l k y g a u z e d r e s s i n g s . The s h u n t s w e r e m o n i t o r e d c o n t i n u o u s l y for h e m o r r h a g e , m a l f u n c tion, p r e s e n c e of infection, or t h r o m b o s i s . W h e n no l o n g e r n e e d e d , the s h u n t s w e r e e x p l a n t e d .

Sure, ical T e c h n i q u e W i t h a s e p t i c surgical t e c h n i q u e , w e c r e a t e d a f o r e a r m arteriovenous external loop s h u n t using a modified Allen-Brown shunt (Neostar Medical Technologies, N o r t h B r u n s w i c k , NJ) (Fig 1). This s h u n t , d e s i g n e d for l o n g - t e r m h e m o d i a l y s i s a c c e s s , is i d e a l for a c u t e C A V H / D . T h e arterial a n d v e n o u s l i m b s c o n s i s t of a s h o r t s e c t i o n of 4 - r a m u l t r a - l i g h t w e i g h t k n i t t e d D a c r o n graft

FiS, 1. Forearm location (!( the arteriovenous loop shunt created using a modified Allen-Brown shunt. The shunt limbs are connected usin£, a T-shalwd connector incorpon#in g a port for heparin or salira' flushink~.

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RIEBMAN FT AI UPPER FXIREMITY \ A S C L I \ R A t ( k S S

()

)

Ann Thorac Surg 1995;60:1072-5

PTFEVesselTip

+ cut here

'

~

~

Allen-BrownShuntLimb

0 Fig 2. Modification of one limb ({¢ t/Ic AIIcl~ Brown >hun! in In'el mration for venous cannulation, (PTFE t~ohttctraflttorocthyh,nc.)

Recovery of renal function (or the institution of intermittent hemodialysis or peritoneal dialysis) permitting elective removal of the shunt was associated with survival in all but I patient (4 of 5, 80%). There were no hemorrhagic or infectious complications related to the shunts. The presence of a coagulopathy resulted in some p o s t o p e r a tive bleeding at the surgical sites; however, this was a minor problem, easily controlled with local compression and without sequelae in all cases. Three patients (20%) experienced thrombosis of their shunts requiring surgical t h r o m b e c t o m y to restore function, with 2 of these patients requiring t h r o m b e c t o m y twice. There were no complications related to shunt removal.

Comment (DuPont, Wilmington, DE) material molded to a straight length of silicone r u b b e r tubing. A Dacron velour sleeve covers a s e g m e n t of the tubing distal to the graft, creating a barrier for infection and providing stabilization by acting as a matrix for tissue ingrowth. Before implantation, the graft material on the end of one of the shunt limbs was preclotted and cut on a bevel, keeping the graft length as short as possible. The brachial artery and the antecubital vein were identified as far cephalad on the forearm as possible, and the one preclotted shunt limb was a n a s t o m o s e d to the artery in an end-to-side fashion using 7-0 p o l y p r o p y l e n e suture. The other shunt limb was modified for simplified venous connection by transecting the silicone tubing above the Dacron cuff and fitting the end with a vascular polytetrafluoroethylene cannula tip (Neostar Medical Technologies) (Fig 2). Venous access was accomplished by directly cannulating the vein through a venotomy and ligating the distal vein. After assessing the flow, we t u n n e l e d the silicone rubber tubings subcutaneously to skin exit sites further distal on the forearm, making sure that the Dacron velour cuff on the arterial limb tubing r e m a i n e d below the skin level. Air ~,as removed from the shunt limbs, and they were joined with a polytetrafluoroethylene connector with a side port, through which a heparin solution was infused constantly at a low flow rate using an infusion pump. The shunt was used immediately for CAVH/D. W h e n no longer required, the shunts were explanted by transecting and oversewing the cuff of graft material on the artery and decannulating and ligating the vein.

Results The results regarding shunt implantation, duration, clinical outcome, and complications are s u m m a r i z e d in Table 1. All shunts functioned satisfactorily after implantation. Sixteen shunts were i m p l a n t e d in the 15 patients; 1 patient experienced an i m p r o v e m e n t of renal function a n d had the shunt removed, but later in his hospital course required a second shunt for another period of CAVH/D. The duration of shunt implantation (time from implantation until death or surgical removal) ranged from less than I day to 64 days, with a mean of 19.3 davs.

Early intervention in oliguric renal failure after cardiac surgery may reduce the high mortality rate associated with this complication ]2, 3]. The aggressive use of hemodialysis and hemofiltration postoperatively in these patients has gained w i d e s p r e a d acceptance [1-3]. Conventional hemodialysis, though effective, can be p r o b lernatic in patients who are h e m o d y n a m i c a l l y unstable or who have a contraindication to systemic anticoagulation therapy. This technique also has logistic limitations in that it requires expensive e q u i p m e n t and trained technicians to perform dialysis at the b e d s i d e in the intensive care unit. The effectiveness a n d patient tolerance of peritoneal dialysis are less predictable than those for hemodialysis, and the former may require a longer treatment interval to generate an effect. Although it is easily instituted at the bedside and m a n a g e d b y the intensive care unit staff, peritoneal dialysis m a y be contraindicated in patients with a b d o m i n a l p a t h o l o g y or previous a b d o m i n a l surgery [3]. There has been an increasing interest in the use of CAVH/D for acute renal failure after cardiac operations based on its d e m o n s t r a t e d safety and efficacy in other critically ill patients [4, 6-8]. Vascular access is usually accomplished by p e r c u t a n e o u s cannulation of the femoral artery and vein with dialysis catheters. Although this technique provides rapid, functional access for most patients, vascular complications are not infrequent a n d include p s e u d o a n e u r y s m formation, femoral arteriovenous fistula, and traumatic vessel injury resulting in limb ischemia or femoral artery or vein thrombosis [5, 8]. In addition, the critically ill nature of these patients m a y lead to coagulation abnormalities and immunologic dystunctinn, potentiating the d e v e l o p m e n t of related complications such as h e m o r r h a g e or infection at the access site. In obese patients, the femoral access site i m p e d e s the early detection of complications that may arise in the thigh, groin, or retroperitoneal areas. The presence of cannulas in the femoral vessels precludes mobilization of the patient, such as sitting out of bed, physical therapy, or ambulation, thus increasing the risks associated with long-term immobilization and preventing the potential recovery benefits associated with positional changes a n d activity. Because of the inherent risks, femoral cannulas are usually removed w h e n the CAVH/D is stopped, a n d

Ann Thorac Sur,~ 1995;60:1072 5

p a t i e n t s r e q u i r i n g reinstitution of t h e r a p y m u s t be recannulated. C o n t i n u o u s v e n o v e n o u s h e m o d i a l y s i s a n d ultrafiltration has b e e n p r o p o s e d as a potentially safer m e t h o d for v a s c u l a r access as c o m p a r e d with f e m o r a l arterial and v e n o u s c a n n u l a t i o n . H o w e v e r , limitations of this m e t h o d i n c l u d e the l a r g e - b o r e d o u b l e l u m e n v e n o u s c a t h e t e r f r e q u e n t l y r e q u i r e d and the necessity for a m e c h a n i c a l peristaltic p u m p , e q u i p p e d with p r e s s u r e m o n i t o r i n g d e v i c e s and an air trap with a l a r m circuitry, to p r o v i d e the driving force for blood flow [9[. In contrast, the acute creation of a f o r e a r m arterial loop s h u n t p r o v i d e s excellent v a s c u l a r access for C A V H / D in p a t i e n t s r e q u i r i n g renal r e p l a c e m e n t t h e r a p y after card i o v a s c u l a r surgery. The limited surgical p r o c e d u r e req u i r e d for s h u n t i m p l a n t a t i o n allows the e m e r g e n t perf o r m a n c e of the p r o c e d u r e in the o p e r a t i n g r o o m or at the b e d s i d e , and the s h u n t is available i m m e d i a t e l y for C A V H / D . The u p p e r e x t r e m i t y location of the s h u n t is s i m p l e for the staff to access and m a n a g e , p e r m i t s easy s u r v e i l l a n c e of the s h u n t a n d insertion sites for c o m p l i cations, and causes m i n i m a l d i s c o m f o r t to the patient. In our experience, there h a v e b e e n no v a s c u l a r c o m p l i c a tions and no s h u n t - r e l a t e d c o m p l i c a t i o n s o t h e r than the occasional patient r e q u i r i n g t h r u m b e c t o m y for m a i n t e n a n c e of s h u n t function. The f o r e a r m location of the s h u n t creates no restriction in sitting the patient up, m o v i n g the p a t i e n t out of bed, or p r o v i d i n g physical therapy. Patients with i m p r o v e m e n t in renal functi~m m a y h a v e the s h u n t limbs c o n n e c t e d with a straight p o l y t e t r a f l u o r o e t h y l e n e connector, a l l o w i n g a m b u l a t i o n and r e e s t a b l i s h m e n t of C A V H / D if r e q u i r e d . After recovery of a c c e p t a b l e renal function (or c o n v e r s i o n to con-

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v e n t i o n a l h e m o d i a l y s i s or p e r i t o n e a l dialysis), the s h u n t can be easily e x p l a n t e d . A l t h o u g h f e m o r a l c a n n u l a t i o n m a y p r o v i d e functional access for p e r f o r m a n c e of C A V H / D after c a r d i o v a s c u l a r operations, u p p e r e x t r e m i t y v a s c u l a r access w i t h a forearm s h u n t confers substantial a d d i t i o n a l a d v a n t a g e s a n d is the p r e f e r r e d a p p r o a c h .

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7. Magilligan DJ Jr. Indications for ultrafiltration in the cardiac surgical patient. J Thorac Cardiovasc Surg 1985;89:183-9. 8. Tominaga GT, lngegno MD, Scannell G, Pahl MV, Waxman K. Continuous arteriovenous hemodiafiltration in postoperative and traumatic renal failure. Am J Surg 1993;166:612-6. 9. Bellomo R, Parkin G, Love J, Boyce N. A prospective comparative study of continuous arteriovenous hemodiafiltration and continuous venovenous hemodiafiltration in critically ill patients. Am J Kidney Dis 1993;21:400-4.