Axillary arteriovenous fistula for hemodialysis: case report

Na confecção de fístula arteriovenosa (FAV) para hemodiálise, condutos venosos autógenos demonstram performance superior quando comparados com material protético em relação à perviedade primária ou secundária. A prótese de politetrafluoroetileno (PTFE) é reservada para casos de falência de material autógeno e é geralmente utilizada em fístulas em membros superiores. Descrevemos o caso de uma paciente de 52 anos que, após falência de acessos para hemodiálise e impossibilidade de realização de diálise peritoneal em razão de peritonite bacteriana, foi submetida à confecção de FAV entre a artéria axilar direita e a veia cava inferior com prótese de PTFE de 6 mm. O acesso foi utilizado para hemodiálise 1 mês após sua criação e permanece pérvio após 24 meses. Até o momento, não houve complicações infecciosas, sinais de insuficiência cardíaca ou síndrome de roubo em membro superior direito.

With regards to the creation of an arteriovenous fistula (AV fistula) for hemodialysis, autogenous venous grafts clearly show high performance when compared with prosthetic material in terms of primary or secondary patency. Polytetrafluoroethylene (PTFE) grafts for the reconstruction of AV fistulae must be restricted to cases of failure of the autogenous material, which is generally used in upper limb fistulae. We describe a case of a 52-year-old patient, who, after access failure for hemodialysis and the impossibility of performing peritoneal dialysis due to bacterial peritonitis, underwent the reconstruction of an AV fistula between the right axillary artery and the cava vein using a 6-mm PTFE prosthesis. One month after surgery, this AV fistula started to be used for hemodialysis. The AV fistula remains patent 24 months after its creation. No infectious complications, cardiac insufficiency symptoms, or steal syndromes of right upper limb were detected.

Usefulness of PTFE Graft in Above-Knee Femoropopliteal Artery Bypass

PURPOSE: Which graft material is appropriate for the above-knee femoropopliteal (AK fem-pop) bypass has been a controversy. We were to evaluate the usefulness of PTFE graft in AK fem-pop bypass by comparing the results of autogenous vein graft in below-knee femoropopliteal bypass. METHODS: This was a retrospective study of data for Fem-Pop bypass from August 1999 to August 2008. The median follow-up was 59.9+/-27.3 months. The demographic data, patency rate, secondary procedures, and amputation rate were compared, and statistical comparison was performed by Kaplan-Meier method, Log-rank test, and Chi-square test. RESULTS: Seventy-three bypasses were performed in 63 patients: PTFE graft in 48 cases (Group A), autogenous vein in 25 cases (Group B). Sixty-one patients (96.81%) were men. The mean age was 67.3+/-8.0 years. The indication for surgery was intermittent claudication in 27 cases (37.0%), critical limb in 46 cases (63.0%). The 6-yr primary patency rates were 28.1%; 60.3%, the 6-yr secondary patency rates were 37.2+/-8.4%, 67.0+/-14.7% in Group A and Group B, respectively (P<0.05). The number of secondary procedures was 31 and 3, respectively (P<0.05). Major amputation at later periods was not needed in Group B, but there were 9 cases in group A (P<0.05). CONCLUSION: PTFE graft for above-knee femoropopliteal bypass shows poor long-term patency with a large number of secondary procedures and a higher amputation rate than vein graft in BK Fem-Pop bypass. PTFE graft should be limited to patients with high operative risk, or poor venous graft.

Surgical Treatment of Infected Prosthetic Dialysis Arteriovenous Graft

PURPOSE: Hemoaccess using a polytetraflouroethylene (PTFE) graft is widely performed when primary arteriovenous access is unavailable. An infection of a PTFE graft is a common complication and a major cause of hemoaccess failure. This study reviewed the infected case of PTFE grafts in our hospital, and evaluated the incidence, surgical treatment, progress and outcome. METHODS: From March 2000 to February 2005, among 1,067 patients who received PTFE graft surgery in Soonchunhyang University Hospital, 58 patients were treated graft infection. These patients were managed by a total graft excision (TGE), a subtotal graft excision (SEG), and a partial graft excision (PEG) with a bypass graft. Usually, SGE is defined as the removal of all of the graft except for 2~3 mm from the arterial anastomosis. However, in our cases, SGE was performed with 1~1.5 cm of the arterial remnants, according to the operative risk, and either the surgical technique or the patient's medical condition. All the records were reviewed retrospectively. RESULTS: The mean age of the patients was 55 years, and 36 patients had a history of diabetes. The PTFE graft placed in the brachiobrachial position of the upper arm was encountered most frequently (72%). 23 graft infections located within the body of the graft, 20 of these were documented to be at a recent puncture site for hemodialysis access. The most common presentation (29%) was purulent discharge. Among the 58 patients treated for a graft infection, 40 patients received SGE, PGE was replaced by a new graft in 15 patients, TGE was performed in 2 patients, and incision and drainage was performed in 1 patient. After surgery, all the patients were treated with antibiotics. The bacterial cultures were positive in 38 cases. Of the 38 culture positive wounds, the most common organism was Staphylococcus aureus (33 cases). 15 cases developed infectious complications: pneumonia, systemic sepsis, duodenal ulcer with or without bleeding, and septic arthritis. The overall mortality was 8% (5 patients). Among the SGE patients, 11 patients evolved an infection of the remnant prosthesis, and a surgical procedure was required. CONCLUSION: Infections are one of a serious complications of PTFE graft that can progress more graft failure or death. There are many treatment options. These include 1) Incision and drainage, 2) TGE, 3) SGE and 4) PGE. TGE should be performed if the graft is not well incorporated or the entire graft was infected. In our experience with infected peripheral bypass grafts, a subtotal graft excision was used if the arterial anastomosis was intact and encased in scar tissue. A risky dissection of an artery encased in scar tissue was avoided by oversewing 1~1.5 cm rather than a 2~3 mm cuff of the remainder of the graft.

A Case of Perigraft Seroma in Chronic Hemodialysis Patient / 대한신장학회잡지

Perigraft seroma is uncommon complication of polytetrafluoroethylene(PTFE) grafts applied as an arteriovenous shunt for hemodialysis. It is a collection of clear, sterile fluid confined to nonsecretory fibrous pseudomembrane, most commonly localized around the middle and distal portion of graft. The possible etiologic factors of perigraft seroma include poor graft incorporation, mechanical graft damage caused by alcohol and povidone-iodine, intraoperative streching of the graft, variations in quality control at the time of manufacture and contributing factors such as anemia and coagulopathy in uremia. The best strategy for management of perigraft seroma is not clear. spiration or drainage alone is not effective, and some authors advocate graft removal. We report a case of perigraft seroma around arterial end of PTFE graft along with a brief review of the literatures.

Clinical Analysis of PTFE Graft Arteriovenous Fistula: The long-term patency rate and factors affecting the patency rate

Expanded polytetrafluoroethylene(PTFE) graft fistulas are widely used as secondary vascular access for patients receiving long-term hemodialysis. It is well known also that several factors should be considered in order to maintain PTFE graft fistula adequately. To elucidate these factors, we reviewed 71 cases of PTFE graft arteriovenous fistula that performed at Hallym University Hospitals from March 1991 to December 1995 and analysed it for regard to age, serum creatinine level, diabetes mellitus, hypertension, diameter of graft and operation site and method. The resultes were as follows: 1) The mean duration of patency of PTFE graft fistula was 10month and the 6 month, 12 month and 24 month patency rate was 64.9%, 39.4% and 36.1% respectively. 2) The complication rate was 45%. 3) Of these factors, diabetes mellitus was the only factor that decreased the patency rate(P<0.05).