Vascular complications of native arteriovenous fistulas for hemodialysis: Role of microsurgery

Abstract

This article describes the treatment of 56 early and late vascular complications of native arteriovenous fistula (AVF) in patients with end‐stage renal disease, between January 1987 and January 1999. Twenty‐six were arteriovenous aneurysms and 2 pseudoaneurysms; 25 were thromboses. We also observed two cases of periarteritis associated with systemic lupus erythematosus (SLE) and one complex iatrogenic lesion caused by an attempt at percutaneous restoration of potency. We applied microsurgical principles, instruments, and techniques. It was possible to restore a vascular access at the original site, using the same vessels in 45 cases (80.4%). In 10.7% of cases, we were able to rescue the original AVF by microsurgical revision. A new vascular access had to be created proximally in the same limb or in the contralateral forearm in 11 cases of aneurysms (19.6% of the total, 42% of the aneurysms). After a minimum follow‐up of 8 months, a total of four patients had to be reoperated for further complications (7.2%). Our data support the idea that microsurgical treatment of vascular complications of native AVF is highly successful compared with results obtained by conventional surgery and, in a defined subgroup of patients, permits salvage of the fistula. Si descrive il trattamento di 56 complicanze vascolari precoci e tardive di fistole arterovenose in pazienti uremici, fra il gennaio 1987 ed il gennaio 1999: ventisei aneurismi arterovenosi, 2 pseudoaneurismi e 25 trombosi. Abbiamo anche osservato due casi di periarterite associata a LES ed una complessa lesione iatrogena causata durante un tentativo di disostruzione percutanea. Abbiamo applicato i principi, gli strumenti e le tecniche della Microchirurgia. È stato possibile ripristinare un accesso nel sito originario, utilizzando gli stessi vasi, in 45 casi (80.4%). Nel 10.7% dei casi si è potuta recuperare la fistola originaria per mezzo di una revisione microchirurgica. In 11 casi di aneurisma (19.6% del totale, 42% degli aneurismi) è stato creato un nuovo accesso vascolare prossimalmente nello stesso lato o sull'altro avambraccio. Dopo un follow‐up minimo di 8 mesi, il 7.2% dei pazienti è stato rioperato per ulteriori complicanze. I nostri dati supportano l'idea che il trattamento microchirurgico delle complicanze vascolari delle fistole arterovenose sia estremamente efficace in confronto ai risultati della chirurgia convenzionale, consentendo in un sottogruppo di pazienti il salvataggio della fistola originaria. © 2000 Wiley‐Liss, Inc. MICROSURGERY 20:252–254 2000

Angiographic mapping of AV fistula related vascular complications in ESRD via multislice CT; adjuvant role in correlation with CDUS

“…The most common complications reported in our study were aneurysm (10 cases) and total thrombosis (7 cases) which is similar to the results of the study of Cavallaro et al (19).…”

Management of true aneurysms of hemodialysis access fistulas

“…3 One-third of all AVFs develop complications, including thrombosis (51.6%), stenosis (22.6%), aneurysm formation (6.7%), and infection (6.5%). 1 Complications of vascular access require hospitalization in 39% of patients with definitive loss of vascular access in 29%.…”

“…4 Risk factors for these complications include hypertension, hypotension, immunologic diseases, diabetes mellitus, arteriosclerosis, and factors related to inappropriate use of the AVF such as early puncture, repeated punctures in the same site, and external mechanical compression. 3 There is no definition for AVF true aneurysms. In previous reports, AVF true aneurysms were described by their large size and wall characteristics seen during excision and histologic analysis.…”

Surgical revision of complicated false and true vascular access–related aneurysms

“…Surgical correction of false aneurysms includes resection of the involved segment and new graft interposition, 4,7,9,37 aneurysm ligation followed by insertion of a bypass graft adjacent to the old one, 4,7,38 or primary repair (stump reanastomosis). 4,39 Other alternative treatment modalities include duplex US-guided percutaneous thrombin injection into the false aneurysm 21,40 or compression of the false aneurysm (also under US guidance). 41 Several endovascular reports published since 1992 have described the intragraft percutaneous deployment of covered stents as an alternative treatment for excluding AVArelated aneurysms while maintaining patency of a AVA (Appendix Table VII online only.…”