INTRODUCTION

Currently, over 325,000 patients are on dialysis in the United States, and more than 100,000 new patients begin dialysis each year.¹ Medicare spends over $18 billion dollars annually in the care of these patients; a large portion of the expenses is dedicated to dialysis access and its complications.² With these numbers, it is no surprise that vascular access is a prevalent part of many surgeons’ practices. With the ever-increasing numbers and cost of care of these patients, it is imperative that surgeons provide the most reliable dialysis access with the lowest possible risk of complications.

Autogenous arteriovenous accesses have consistently been shown to have excellent patency rates and low risk of complications when compared with prosthetic arteriovenous accesses. Two-year primary patency rates of autogenous access range between 34% to 69%, which is clearly superior to the 2-year primary patency rates of prosthetic access, which averages 25%.^3–6 Complications of infection, pseudoaneursyms, and seromas are rarely seen in autogenous access. With these benefits, the disadvantages of autogenous access, including a long maturation time, failure to mature, and acute thrombosis, are acceptable. In consideration of these data, the current Dialysis Outcomes Quality Initiative (DOQI) recommendation is to place autogenous access in at least 50% of all patients requiring long-term access.⁷

In order to place long-term autogenous access with the lowest risk of complications, preoperative evaluation is essential. A thorough patient history is taken, documenting the patient’s dominant extremity, recent history of peripheral intravenous lines, site of indwelling or previous central lines, all previous access procedures, any history of trauma or previous surgery to the extremity, and all comorbid conditions. On physical examination, the patient’s arm is evaluated for edema and varicosities. With an upper arm tourniquet in place, the arm is inspected for visible cephalic and basilic veins. Indications for preoperative venography are listed in Box 61-1; venography may be substituted with a venous duplex scan as long as the surgeon recognizes the limitations of evaluating the central venous system. To assess for adequate arterial inflow, a thorough pulse examination including Allen’s test is done. Abnormal pulses in the planned operative extremity are further evaluated with arteriogram.^7,8

Box 61-2 lists the multiple access configurations possible in the upper and lower extremities as well as the body wall.⁹ An autogenous access is always attempted before prosthetic access, including use of basilic vein transpositions. One-year primary patency rates of basilic vein transpositions range between 35% and 84% with an acceptably low complication rate and are, therefore, an excellent alternative to cephalic vein access.^6,10–13 Preference is given to the nondominant arm over the dominant arm, followed by distal location over proximal location. Controversy still exists whether a prosthetic forearm access should be placed before an upper arm autogenous access. The autogenous access will likely offer longer patency but eliminates the placement of subsequent forearm prosthetic access. Therefore, this decision remains surgeon and patient dependent. Lower extremity and body wall access are used only once both upper extremity uses have been exhausted.⁷

INDICATIONS

OPERATIVE STEPS

Autogenous Posterior Radial Branch–Cephalic Direct Wrist Access (Fig. 61-1)

Step 1 Cephalic vein exposure and evaluation

Step 2 Posterior radial branch artery exposure

Step 3 Radial artery–to–cephalic vein anastomosis

Step 4 Ligation of venous branches

Step 5 Wound closure

Figure 61-1 Autogenous posterior radial branch-cephalic direct wrist access.

(Adapted from Weiswasser JM, Sidawy AN. Strategies of arteriovenous dialysis access. In Rutherford RB (ed): Vascular Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1671.)

Autogenous Brachial-Basilic Upper Arm Transposition (Fig. 61-2)

Step 1 Basilic vein exposure and evaluation

Step 2 Basilic vein harvest with ligation of all side branches (see Fig. 61-2A)

Step 3 Brachial artery exposure (see Fig. 61-2B)

Step 4 Tunneling of basilic vein

Step 5 Brachial artery–to–basilic vein anastomosis (see Fig. 61-2C)

Step 6 Wound closure

Figure 61-2 Autogenous brachial-basilic upper arm transposition. A, Basilic vein harvest with ligation of all side branches. B, Brachial artery exposure. C, Brachial artery–to–basilic vein anastomosis.

Prosthetic Brachial-Antecubital Forearm Loop Access (Fig. 61-3)

Step 1 Antecubital vein exposure and evaluation

Step 2 Brachial artery exposure

Step 3 Tunneling of graft

Step 4 Arterial graft anastomosis

Step 5 Venous graft anastomosis

Step 6 Wound closure

Figure 61-3 Prosthetic brachial-antecubital forearm loop access.

(Reproduced with permission from Weiswasser JM, Sidawy AN. Strategies of arteriovenous dialysis access. In Rutherford RB (ed): Vascular Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1674.)

OPERATIVE PROCEDURE

Venous Exposure

Early Autogenous Arteriovenous Access Thrombosis

• Consequence

Access thrombosis and inability to dialyze. The major disadvantage of autogenous arteriovenous access is primary failure rates that range from 3% to 33%.^13–15 Early access thrombosis is due to technical failure and most commonly is associated with inadequate venous outflow, which may be secondary to inadequate caliber of the outflow vein or central venous stenosis. With the publication of the DOQI guidelines in 1997, surgeons have become more aggressive in attempting to place autogenous accesses, with use of smaller-caliber veins, possibly increasing early thrombosis rates.¹⁶ This is believed to be an acceptable risk for the potential benefits of autogenous access.⁷ Other less common causes include poor arterial inflow and anastomotic stenosis.

Grade 3 complication

• Repair

Thrombectomies and thrombolysis are rarely successful for autogenous accesses. If early thrombosis is secondary to small caliber of the outflow vein, the autogenous arteriovenous access is redone using a different vein (e.g., conversion of an autogenous radial-cephalic direct wrist access to an autogenous radial-basilic forearm transposition) or, if no vein is available, a prosthetic arteriovenous access. Central venous stenosis (Fig. 61-4) is treated with angioplasty and/or stenting or venous bypass (e.g., subclavian vein–to–internal jugular vein bypass [Fig. 61-5]), followed by a new autogenous or prosthetic arteriovenous access. An arterial inflow stenosis is treated with angioplasty and/or stenting or proximal arterial bypass to restore adequate arterial inflow followed by a new autogenous or prosthetic arteriovenous access. An alternative approach is to move the fistula either proximally or to another extremity where arterial inflow is adequate. Anastomotic stenosis is a primary technical failure and is redone with close attention to surgical technique.

Figure 61-4 Central venous stenosis. A, Upper extremity varicosities associated with central venous stenosis. B, Upper extremity edema associated with central venous stenosis. C, Venogram of the patient in Figure 61-4A demonstrates subclavian vein stenosis.

(A and C, Reproduced with permission from Adams ED, Sidawy AN. Nonthrombotic complications of arteriovenous access for hemodialysis. In Rutherford RB (ed): Vascular Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1700.)

Figure 61-5 Subclavian vein–to–internal jugular bypass. A, Subclavian vein–to–internal jugular bypass using a 6-mm expanded polytetrafluoroethylene (ePTFE) prosthetic graft. B, Postoperative venogram of subclavian vein–to–internal jugular bypass using a 6-mm ePTFE prosthetic graft.

(A, Reproduced with permission from Adams ED, Sidawy AN. Nonthrombotic complications of arteriovenous access for hemodialysis. In Rutherford RB (ed): Vascular Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1701.)

• Prevention

Preoperative evaluation with a thorough history and physical examination is imperative to place functional autogenous arteriovenous accesses. We perform a preoperative venous duplex scan on all patients with the indications listed in Box 61-1 and any patient whose superficial veins cannot be visualized on physical examination. The cephalic or basilic veins are used for autogenous access only if they are a minimum of 2.0 mm in diameter.¹⁷ Preoperative venography is completed in any patient with high clinical suspicion for central venous stenosis or with abnormal findings on venous duplex scan. Occurrence of central venous stenosis is decreased by keeping use of central venous lines to a minimum. If they are required, the internal jugular approach is preferable. Central venous stenosis is treated before placement of arteriovenous fistula with angioplasty and/or stenting or proximal venous bypass. Any patient with an abnormal pulse examination is further evaluated with upper extremity pulse volume recordings and segmental pressures. Any drop in pressure greater than 30 mm Hg is believed to be abnormal, and if possible, we place the arteriovenous access in an alternate extremity or proximal to the area of stenosis. If an arteriovenous access must be placed in an area of abnormal arterial inflow, the patient is further evaluated with arteriogram, and any stenosis is treated with angioplasty and/or stenting or arterial bypass. To avoid anastomotic stenosis, care must be taken intraoperatively to ensure patency of this small anastomosis.^7,8

Late Arteriovenous Access Thrombosis

• Consequence

Access thrombosis and inability to dialyze. Primary patency rates of autogenous accesses range between 43% and 84% at 1 year and 34% and 69% at 2 years and are superior to primary patency rates of prosthetic accesses of 41% to 54% at 1 year and 24% to 25% at 2 years.3–6,^{10,11,13–15} Late arteriovenous access thrombosis is most commonly due to intimal hyperplasia (Fig. 61-6A). In an autogenous access, this usually occurs just distal to the anastomosis; however, it may occur anywhere along the venous outflow tract. In a prosthetic access, intimal hyperplasia occurs at the graft–venous anastomosis. Central venous stenosis is a second common cause of late autogenous and prosthetic arteriovenous access failure.

Grade 2/3 complication

Figure 61-6 Later arteriovenous access thrombosis due to intimal hyperplasia. A, Cross-section of intimal hyperplasia at the prosthetic graft–venous anastomosis. B, Arterial plug seen with complete thrombus removal performed with a Fogarty catheter. C, Jump graft placed around the prosthetic graft–venous anastomosis to prevent future thrombosis.

• Repair

Thrombectomies and thrombolysis are rarely successful in autogenous fistulas. If late thrombosis is due to intimal hyperplasia in the outflow vein, the autogenous arteriovenous access is redone using a different outflow vein (e.g., converting an autogenous radial-cephalic direct wrist access to an autogenous radial-basilic forearm transposition) or using a proximal site of access (e.g., converting an autogenous radial-cephalic direct wrist access to an autogenous brachial-cephalic upper arm direct access). Central venous stenosis (see Fig. 61-4) is treated with angioplasty and/or stent placement or proximal venous bypass (e.g., subclavian–to–internal jugular bypass [see Fig. 61-5]), followed by placement of a new arteriovenous access.

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