Arteriovenous fistula failure due to two straight shunts formation at draining vein

Abstract

A 48-year-old asian man was admitted to hospital for the consideration of hemodialysis (HD). An adequate site was decided on for the AVF after Doppler ultrasonography examination of radial artery and cephalic vein. The AVF was formed under local anaesthetic at his right wrist. When seen at the clinic appointment one month later, the AVF was not working. The subsequent Doppler ultrasonography examination revealed two straight shunts at draining vein. The failure of AVF is due to impaired outflow following reduction of the resistance between draining vein and peripheral venous system. Key words: Arteriovenous fistula; Shunts; Hemodialysis; Ultrasonography; Draining vein.The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines for Vascular Access recommend increasing the proportion of arteriovenous fistula (AVF) among hemodialysis (HD) patients (Clinical practice guidelines for vascular access, 2006). Adherence to these recommendations has increased the prevalence of AVF at wrist in Chinese HD patients. A major hurdle to increasing further the proportion of AVF use is the high rate of primary AVF failures (AVF never usable for HD) (Allon et al., 2002). A case of AVF failure due to two straight shunts formation at draining vein is reported. Case reportThe patient was a 48-year-old asian man with a history of chronic renal failure. His medication included ferrous sulphate 300mg, three times daily; folacin 10mg, three times daily; rhEPO 3000u, two times weekly; nifedipine, 10mg, three times daily; and salt restriction. He was admitted to the hospital for consideration of HD with the IgA nephropathy as the primary disease. Doppler ultrasonography examination of radial artery and cephalic vein was performed before the operation. The cephalic vein was assessed as suitable ( Figure 1) with no shunts found. An adequate site was decided on for AVF.The AVF was formed under local anaesthetic at his right wrist. The radial artery and cephalic vein were exposed through longitudinal incision. The vein was freed by wide dissection and the collateral branch was ligated with microsurgical clips. A transverse section was made with ligature of the distal branch, followed by a longitudinal veinotomy of the posterior wall of the cephalic vein. The anterior wall of the artery was exposed without any dissection of its trunk. A longitudinal arteriotomy of 15mm in length was made. Then artery-to-vein, side-to-end anastomosis was performed. Attention was paid to avoid twisting the vein. When anastomosis was completed, the tourniquet was released. Additional sutures were added in the case of leak. Hand exercises, such as squeezing a rubber ball at frequent intervals, were recommended in the postoperative period.After the operation, the fistula functioned briefly. But when seen at the clinic appointment one month later, the AVF was not working. The thrill of AVF to auscultation and palpation disapeared. The subsequent ultrasonography examination revealed two straight shunts at draining vein (Figure ...