Rescue Therapy of Complicated A-V Fistula for Hemodialysis

ABSTRACT

Effectively functioning arterio-venous fistula (AVF) is so important as to be called a lifeline of the patient with end stage renal disease by maintaining hemodialysis. Not infrequent development of complications of AVF is a major cause of patient's admission and medical cost. Rescue therapy of complicated AVF had several advantages; delay or prevention of new AVF formation, prevention of temporary percutaneous central vein cannulation, and maintenance of psychologic stability. PURPOSE: In order to analyse the patterns of AVF complications and the short- and long-term results of rescue therapy, we made a clinical review retrospectively. PATIENTS & METHODS: We performed AVF in 1503 cases from Jan. 1986 to Dec. 1997. Among them, we performed 93 rescue therapies in 70 patients. Rescue therapy is defined to be a secondary procedure to correct complications while maintaining the primary anastomosis. Secondary procedures in immediate postoperative failure due to technical cause, such as improper selection of vein, were excluded. RESULTS: The most common indication of rescue therapy in 93 cases was thrombosis (78 cases, 83.9%), which is followed by aneurysm in 9 cases, venous hypertension in 2 cases, steal syndrome in 2 cases, high output cardiac failure in 1 case. Autogenous veins were used in initial operation in 55 cases and PTFEs in 38 cases. Early failure within 1 month after rescue therapy happened in 20 cases (21.5%). Complications occured in 4 cases, such as infection (2), brachial plexus injury (1), and arm edema. (1) Mean follow up duration was 3.9 months (1~123 months). Secondary patency rate after 3, 6, 12, 24 months were 70.3+/-3.97, 62.0+/-4.89, 50.6+/-5.85, 37.9+/-7.03% respectively. Secondary patency rate in successfully rescued patients excluding early failure within 1 month after rescue therapy were 91.5+/-3.11, 80.9+/-4.46, 68.9+/-6.15, 54.1+/-8.19%. CONCLUSIONS: Thrombosis or malfunction due to neointimal hyperplasia was the most common complication in AVF. Early and proper rescue therapy in complicated fistula could salvage the AVF. So careful and prompt evaluation of the inflow and outflow of the complicated fistula is necessary, and every effort to rescue the fistula should be made.