Axillary to common iliac arteriovenous graft for hemodialysis access: Case report and review of 揺xotic?axillary-based grafts
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《血管的通路杂志》
Departments of Surgery and Pathology, Duke University Medical Center, Durham NC - USA
ABSTRACT
A 58-year-old Caucasian male with end-stage renal disease and peripheral arterial disease was referred to us for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. Magnetic resonance venography (MRV) of his chest revealed extensive bilateral venous occlusions due to numerous past hemodialysis access catheters. The patient was scheduled for right lower extremity arteriovenous graft placement, but intraoperatively was found to have severe peripheral arterial disease and a thromboendarterectomy was performed instead. Lower body venous imaging demonstrated patent iliac veins. Based on these anatomic considerations a right axillary artery to right common iliac vein polytetrafluoroethylene (PTFE) graft was placed. The graft required revision twice ?once for graft ultrafiltration at the arterial end of the graft and once for needle stick infection ?but continues to serve as sufficient access after 15
months. Grafts based off the axillary artery have become increasingly popular in recent years and several venous outflow options have been considered, each with distinct advantages.
The common iliac vein offers a central location with high flow rate and low probability of infection. Axillary artery to iliac vein arteriovenous grafting may have a place in the vascular surgeon抯 armamentarium for complex vascular access cases.
Key Words: Axilloiliac arteriovenous graft, Axillary artery to iliac vein graft, Hemodialysis access, Vascular access
CASE REPORT
A 58-year-old Caucasian male with end-stage renal disease secondary to hypertension, coronary artery disease, and peripheral arterial disease was referred to us by his nephrologist for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. He also had undergone peritoneal dialysis in the past, but a history of diverticulitis and abdominal surgery limited its efficacy. Physical examination revealed a left internal jugular PermCath in place. He had prominent midline abdominal scars and a scar in the left groin from a previous graft. Pulses were palpable in both of his groins. Collateral veins were visible on his right chest consisten with occlusion of the right central vein. He had faintly palpable dorsalis pedis and posterior tibial pulses. Outside imaging revealed tight, but not complete occlusion of both subclavian veins bilaterally and arterial anatomy adequate to support inflow of a lower extremity vascular access graft.
Magnetic resonance venography (MRV) of his chest and pelvis to evaluate the patency of his venous system revealed central occlusion of the left subclavian vein at the mid clavicle and numerous chest collaterals draining into the azygos vein. An occlusion above the PermCath was noted in the left jugular vein. The right jugular vein was patent high within the neck but occluded at the base of the neck. A prominent right external jugular vein drained into the right subclavian vein, which is patent throughout its course. There is long segment narrowing involving the right brachiocephalic vein to the junction of the superior vena cava. Inferior vena cava, bilateral iliac and femoral veins were normal (Fig. 1).
The patient was scheduled for right lower extremity arteriovenous graft placement after preoperative arteriography. Arteriogram showed diffuse 60%
stenosis of the right common iliac artery and moderate bilateral common femoral disease. The iliac artery was stented and the femoral arteries were felt to be suitable for an attempt at graft placement. Intraoperatively,
the superficial and common femoral arteries were found to have very weak pulses and contained calcified plaque. An intraoperative arteriogram
confirmed extensive atherosclerotic disease.
Since there was a risk of significant steal arterial compromise with graft placement, the procedure was aborted. A right common femoral artery
thromboendarterectomy was performed with a Dacron patch to improve the blood flow to the right lower extremity.
With the severe aortoiliac occlusive disease and an MRV showing limited vessels to target for graft outflow, he underwent a right axillary artery to right
common iliac vein polytetrafluoroethylene (PTFE) graft as an extreme measure to establish a vascular access graft. A transverse incision was made below the right clavicle and the axillary artery was identified.
An oblique incision was made in the right lower abdomen and the right common iliac vein was identified. A 6 mm PTFE graft of appropriate length was tunneled through the right side of the abdominal and chest walls and anastomosed to the right common iliac vein. The distal end of the graft
was anastomosed to the right axillary artery after proximal and distal clamping of the axillary artery. Once both anastomoses were completed, all clamps were removed and Doppler ultrasound confirmed good flow through the graft. The patient tolerated the procedure well and was discharged soon afterwards. The graft was evaluated radiographically by injection of contrast and found to be widely patent with good flow (Fig. 2).
Two weeks later he presented with swelling over the proximal incision on his right anterior chest. Weeping at the axillary anastomosis was identified and
bypassed with a 6 mm polyurethane (VectraTM) graft. The seroma resolved and he was successfully dialyzed the next day through the graft. Four
months later a needle stick abscess was identified and the patient was taken to the operating room for revision with resection of the infected portion and
bypass with polyurethane (VectraTM) conduit. In the ten months since his last revision, the patient has been doing quite well and continues to dialyze
with this graft, which is accessed through the chest wall. There is excellent flow with an audible bruit and a palpable thrill throughout the entire length
of the graft.
DISCUSSION
The population of patients dependent on dialysis is continually expanding. In 2002 512,574 persons were living with end-stage renal disease (1). This
number is sure to expand as diabetes and HIV nephropathy take their toll. With increases in the numbers of dialysis patients and concomitant increases
in patient longevity comes a need for new dialysis access procedures to provide these patients with safe and effective access for longer durations.
A standard guideline for dialysis access has been published as part of the Dialysis Outcomes Quality Initiative (DOQI) (2). Those guidelines advocate
use of the upper extremity with a preference for autologous fistula formation, particularly a radialcephalic wrist fistula. If wrist or elbow (brachialcephalic)
fistula creation is not possible, a fistula created with basilic vein transposition or a graft is indicated. Graft placement in the arm is generally preferred, with the thigh as an alternate but less ideal site because of a high risk of infection. With more patients surviving for longer periods of time, it is increasingly common to encounter patients who have exhausted all of these standard options for dialysis access. Additionally, with the often inappropriate
long-term use of catheters, central venous stenosis is frequently encountered.
Grafts based off of the axillary artery are becoming an increasingly popular choice. An axillary artery to contralateral axillary vein graft was first described
by Garcia-Rinaldi and Von Koch in 1978 (3). This form of graft, sometimes referred to as a 搉ecklace,?has become common in instances where venous thrombosis, severe steal syndrome, or extremely small brachial artery size prevents use of the upper extremity. In the largest series published,
grafts from the axillary artery to axillary or jugular vein have a 77% survival at 3 years (4). In instances where the contralateral axillary vein or
jugular vein is not a suitable anatomic target, other venous outflow is an option. In 1987 Cimochowski et al reported a series of eight patients who underwent axillary artery to iliac vein grafting (5). They reported six of eight patients had functioning grafts at twelve months. The remaining two patients had died with functioning grafts prior to the twelve month follow-up. One of the deaths was attributed to a postoperative myocardial infarction. One patient had experienced a graft occlusion due to debris and had another axillary artery to iliac vein graft placed on the contralateral side. Two patients
developed proximal iliac vein strictures and leg swelling due to retrograde flow down into the femoral vein. These patients underwent femoralfemoral
venous grafting which decompressed the affected femoral vein and the swelling subsequently resolved. Since their report, there has been no
further mention of the technique in the literature. There have been other methods proposed by groups interested in creating grafts originating off
the axillary artery and terminating on novel veins. Two cases of axillofemoral grafting were reported in 1991 and another in 1994, each with satisfactory
results (6, 7). More recently an axillorenal graft was reported with suitable long-term function (8). The authors noted several advantages including the low likelihood of prior renal vein cannulation and low flow resistance due to the proximity of the inferior vena cava. However, the sharper angle of curvature over the costal margin may compromise suboptimally placed grafts. Another group reported an axillary artery to popliteal vein graft in two patients
(9). This graft showed good postoperative function, but drawbacks include increased risk of kinking and possibly decreased flow rates due to the peripheral position of the venous outflow. Arterioarterial prosthetic loop grafts off of the axillary artery have recently been reported (10, 11). While the gold standards for vascular access continue to be located in the upper extremity, the increasing importance of exotic arteriovenous grafting should not be underestimated. While most of these exotic grafts have been based off the axillary artery, the options for venous outflow are numerous and the correct choice will be based on a number of patient-specific factors. We postulate that the common iliac veins will serve as superior outflow targets because of their large caliber and central location that permit high flow rates and their superior location that is high enough and deep enough to reduce infection risk but low enough to reduce kinking on the costal margin. This historic procedure described nearly twenty years ago, but not revisited since, should be considered among the vascular surgeon抯 last viable options to establish vascular access.
REFERENCES
1. US Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2004.
2. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Vascular Access, 2000. Am J Kidney Dis 2001; 37 (suppl. 1): S137-81.
3. Garcia-Rinaldi R, Von Koch L. The axillary artery to axillary vein bovine graft for circulatory access: surgical considerations. Am J Surg 1978; 135: 265-8.
4. McCann RL. Vascular access for the 慸ifficult?patient. In: Conlon PJ, Nicholson ML, Schwab SJ, eds. Hemodialysis Vascular Access: Practice and Problems. New York: Oxford UP, 2000; 141-56.
5. Cimochowski GE, Harter HR, Rutherford WE, Blondin J, Sartain JA. Axillary artery to iliac vein vascular access using an externally supported prosthetic graft. A new procedure for the recalcitrant secondary access patient. ASAIO Trans 1987; 33: 123-8.
6. Rueckmann I, Berry C, Ouriel K, Hoffart N. The synthetic axillofemoral graft for hemodialysis access. ANNA J 1991; 18: 567-71.
7. Lumsden AB, MacDonald MJ, Allen RC, Dodson TF. Hemodialysis access in the pediatric patient population. Am J Surg 1994; 168: 197-201.
8. Karp SJ, Hawxby A, Burdick JF. Axillorenal arteriovenous graft: a new approach for dialysis access. J Vasc Surg 2004; 40: 379-80.
9. Calder FR, Chemla ES, Anderson L, Chang RW. The axillary artery-popliteal vein extended polytetrafluoroethylene graft: a new technique for the complicated dialysis access patient. Nephrol Dial Transplant. 2004; 19: 998-1000.
10. Zanow J, Kruger U, Petzold M, Petzold K, Miller H, Scholz H. Arterioarterial prosthetic loop: a new approach for hemodialysis access. J Vasc Surg 2005; 41: 1007-12.
11. Bunger CM, Kroger J, Kock L, Henning A, Klar E, Schareck W. Axillary-axillary interarterial chest loop conduit as an alternative for chronic hemodialysis access. J Vasc Surg 2005; 42: 290-5.(D.C. Evans, E.C. Upton1, )
ABSTRACT
A 58-year-old Caucasian male with end-stage renal disease and peripheral arterial disease was referred to us for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. Magnetic resonance venography (MRV) of his chest revealed extensive bilateral venous occlusions due to numerous past hemodialysis access catheters. The patient was scheduled for right lower extremity arteriovenous graft placement, but intraoperatively was found to have severe peripheral arterial disease and a thromboendarterectomy was performed instead. Lower body venous imaging demonstrated patent iliac veins. Based on these anatomic considerations a right axillary artery to right common iliac vein polytetrafluoroethylene (PTFE) graft was placed. The graft required revision twice ?once for graft ultrafiltration at the arterial end of the graft and once for needle stick infection ?but continues to serve as sufficient access after 15
months. Grafts based off the axillary artery have become increasingly popular in recent years and several venous outflow options have been considered, each with distinct advantages.
The common iliac vein offers a central location with high flow rate and low probability of infection. Axillary artery to iliac vein arteriovenous grafting may have a place in the vascular surgeon抯 armamentarium for complex vascular access cases.
Key Words: Axilloiliac arteriovenous graft, Axillary artery to iliac vein graft, Hemodialysis access, Vascular access
CASE REPORT
A 58-year-old Caucasian male with end-stage renal disease secondary to hypertension, coronary artery disease, and peripheral arterial disease was referred to us by his nephrologist for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. He also had undergone peritoneal dialysis in the past, but a history of diverticulitis and abdominal surgery limited its efficacy. Physical examination revealed a left internal jugular PermCath in place. He had prominent midline abdominal scars and a scar in the left groin from a previous graft. Pulses were palpable in both of his groins. Collateral veins were visible on his right chest consisten with occlusion of the right central vein. He had faintly palpable dorsalis pedis and posterior tibial pulses. Outside imaging revealed tight, but not complete occlusion of both subclavian veins bilaterally and arterial anatomy adequate to support inflow of a lower extremity vascular access graft.
Magnetic resonance venography (MRV) of his chest and pelvis to evaluate the patency of his venous system revealed central occlusion of the left subclavian vein at the mid clavicle and numerous chest collaterals draining into the azygos vein. An occlusion above the PermCath was noted in the left jugular vein. The right jugular vein was patent high within the neck but occluded at the base of the neck. A prominent right external jugular vein drained into the right subclavian vein, which is patent throughout its course. There is long segment narrowing involving the right brachiocephalic vein to the junction of the superior vena cava. Inferior vena cava, bilateral iliac and femoral veins were normal (Fig. 1).
The patient was scheduled for right lower extremity arteriovenous graft placement after preoperative arteriography. Arteriogram showed diffuse 60%
stenosis of the right common iliac artery and moderate bilateral common femoral disease. The iliac artery was stented and the femoral arteries were felt to be suitable for an attempt at graft placement. Intraoperatively,
the superficial and common femoral arteries were found to have very weak pulses and contained calcified plaque. An intraoperative arteriogram
confirmed extensive atherosclerotic disease.
Since there was a risk of significant steal arterial compromise with graft placement, the procedure was aborted. A right common femoral artery
thromboendarterectomy was performed with a Dacron patch to improve the blood flow to the right lower extremity.
With the severe aortoiliac occlusive disease and an MRV showing limited vessels to target for graft outflow, he underwent a right axillary artery to right
common iliac vein polytetrafluoroethylene (PTFE) graft as an extreme measure to establish a vascular access graft. A transverse incision was made below the right clavicle and the axillary artery was identified.
An oblique incision was made in the right lower abdomen and the right common iliac vein was identified. A 6 mm PTFE graft of appropriate length was tunneled through the right side of the abdominal and chest walls and anastomosed to the right common iliac vein. The distal end of the graft
was anastomosed to the right axillary artery after proximal and distal clamping of the axillary artery. Once both anastomoses were completed, all clamps were removed and Doppler ultrasound confirmed good flow through the graft. The patient tolerated the procedure well and was discharged soon afterwards. The graft was evaluated radiographically by injection of contrast and found to be widely patent with good flow (Fig. 2).
Two weeks later he presented with swelling over the proximal incision on his right anterior chest. Weeping at the axillary anastomosis was identified and
bypassed with a 6 mm polyurethane (VectraTM) graft. The seroma resolved and he was successfully dialyzed the next day through the graft. Four
months later a needle stick abscess was identified and the patient was taken to the operating room for revision with resection of the infected portion and
bypass with polyurethane (VectraTM) conduit. In the ten months since his last revision, the patient has been doing quite well and continues to dialyze
with this graft, which is accessed through the chest wall. There is excellent flow with an audible bruit and a palpable thrill throughout the entire length
of the graft.
DISCUSSION
The population of patients dependent on dialysis is continually expanding. In 2002 512,574 persons were living with end-stage renal disease (1). This
number is sure to expand as diabetes and HIV nephropathy take their toll. With increases in the numbers of dialysis patients and concomitant increases
in patient longevity comes a need for new dialysis access procedures to provide these patients with safe and effective access for longer durations.
A standard guideline for dialysis access has been published as part of the Dialysis Outcomes Quality Initiative (DOQI) (2). Those guidelines advocate
use of the upper extremity with a preference for autologous fistula formation, particularly a radialcephalic wrist fistula. If wrist or elbow (brachialcephalic)
fistula creation is not possible, a fistula created with basilic vein transposition or a graft is indicated. Graft placement in the arm is generally preferred, with the thigh as an alternate but less ideal site because of a high risk of infection. With more patients surviving for longer periods of time, it is increasingly common to encounter patients who have exhausted all of these standard options for dialysis access. Additionally, with the often inappropriate
long-term use of catheters, central venous stenosis is frequently encountered.
Grafts based off of the axillary artery are becoming an increasingly popular choice. An axillary artery to contralateral axillary vein graft was first described
by Garcia-Rinaldi and Von Koch in 1978 (3). This form of graft, sometimes referred to as a 搉ecklace,?has become common in instances where venous thrombosis, severe steal syndrome, or extremely small brachial artery size prevents use of the upper extremity. In the largest series published,
grafts from the axillary artery to axillary or jugular vein have a 77% survival at 3 years (4). In instances where the contralateral axillary vein or
jugular vein is not a suitable anatomic target, other venous outflow is an option. In 1987 Cimochowski et al reported a series of eight patients who underwent axillary artery to iliac vein grafting (5). They reported six of eight patients had functioning grafts at twelve months. The remaining two patients had died with functioning grafts prior to the twelve month follow-up. One of the deaths was attributed to a postoperative myocardial infarction. One patient had experienced a graft occlusion due to debris and had another axillary artery to iliac vein graft placed on the contralateral side. Two patients
developed proximal iliac vein strictures and leg swelling due to retrograde flow down into the femoral vein. These patients underwent femoralfemoral
venous grafting which decompressed the affected femoral vein and the swelling subsequently resolved. Since their report, there has been no
further mention of the technique in the literature. There have been other methods proposed by groups interested in creating grafts originating off
the axillary artery and terminating on novel veins. Two cases of axillofemoral grafting were reported in 1991 and another in 1994, each with satisfactory
results (6, 7). More recently an axillorenal graft was reported with suitable long-term function (8). The authors noted several advantages including the low likelihood of prior renal vein cannulation and low flow resistance due to the proximity of the inferior vena cava. However, the sharper angle of curvature over the costal margin may compromise suboptimally placed grafts. Another group reported an axillary artery to popliteal vein graft in two patients
(9). This graft showed good postoperative function, but drawbacks include increased risk of kinking and possibly decreased flow rates due to the peripheral position of the venous outflow. Arterioarterial prosthetic loop grafts off of the axillary artery have recently been reported (10, 11). While the gold standards for vascular access continue to be located in the upper extremity, the increasing importance of exotic arteriovenous grafting should not be underestimated. While most of these exotic grafts have been based off the axillary artery, the options for venous outflow are numerous and the correct choice will be based on a number of patient-specific factors. We postulate that the common iliac veins will serve as superior outflow targets because of their large caliber and central location that permit high flow rates and their superior location that is high enough and deep enough to reduce infection risk but low enough to reduce kinking on the costal margin. This historic procedure described nearly twenty years ago, but not revisited since, should be considered among the vascular surgeon抯 last viable options to establish vascular access.
REFERENCES
1. US Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2004.
2. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Vascular Access, 2000. Am J Kidney Dis 2001; 37 (suppl. 1): S137-81.
3. Garcia-Rinaldi R, Von Koch L. The axillary artery to axillary vein bovine graft for circulatory access: surgical considerations. Am J Surg 1978; 135: 265-8.
4. McCann RL. Vascular access for the 慸ifficult?patient. In: Conlon PJ, Nicholson ML, Schwab SJ, eds. Hemodialysis Vascular Access: Practice and Problems. New York: Oxford UP, 2000; 141-56.
5. Cimochowski GE, Harter HR, Rutherford WE, Blondin J, Sartain JA. Axillary artery to iliac vein vascular access using an externally supported prosthetic graft. A new procedure for the recalcitrant secondary access patient. ASAIO Trans 1987; 33: 123-8.
6. Rueckmann I, Berry C, Ouriel K, Hoffart N. The synthetic axillofemoral graft for hemodialysis access. ANNA J 1991; 18: 567-71.
7. Lumsden AB, MacDonald MJ, Allen RC, Dodson TF. Hemodialysis access in the pediatric patient population. Am J Surg 1994; 168: 197-201.
8. Karp SJ, Hawxby A, Burdick JF. Axillorenal arteriovenous graft: a new approach for dialysis access. J Vasc Surg 2004; 40: 379-80.
9. Calder FR, Chemla ES, Anderson L, Chang RW. The axillary artery-popliteal vein extended polytetrafluoroethylene graft: a new technique for the complicated dialysis access patient. Nephrol Dial Transplant. 2004; 19: 998-1000.
10. Zanow J, Kruger U, Petzold M, Petzold K, Miller H, Scholz H. Arterioarterial prosthetic loop: a new approach for hemodialysis access. J Vasc Surg 2005; 41: 1007-12.
11. Bunger CM, Kroger J, Kock L, Henning A, Klar E, Schareck W. Axillary-axillary interarterial chest loop conduit as an alternative for chronic hemodialysis access. J Vasc Surg 2005; 42: 290-5.(D.C. Evans, E.C. Upton1, )