To Close, Observe, or Reconstruct: The Third Way of Managing Dialysis Fistula Aneurysms in Kidney Transplant Recipients.

BACKGROUND: The management of patent dialysis fistulas in patients after kidney transplantation (KTx) is controversial-the options that are usually considered are the fistula's closure or observation. Many complications of dialysis fistulas occur in patients after KTx, and immunosuppression increases the risk of fistula aneurysms and hyperkinetic flow. This study aimed to evaluate the results of dialysis fistula aneurysm treatment in patients after KTx and to compare them to procedures performed in an end-stage renal disease (ESRD) dialyzed population. METHODS: We enrolled 83 renal transplant recipients and 123 ESRD patients with dialysis fistula aneurysms qualified for surgical revision to this single-center, prospective study. The results of the surgical treatment of dialysis fistula aneurysms were analyzed, and the primary, assisted primary and secondary patency rate, percentage and type of complications were also assessed. RESULTS: For the treatment of dialysis fistula aneurysms in transplant patients, we performed dialysis fistula excisions with fistula closure in 50 patients (60.2%), excision with primary fistula reconstruction (n = 10, 12.0%) or excision with PTFE bypasses (n = 23, 27.7%). Postoperative complications occurred in 11 patients (13.3%) during a follow-up (median follow-up, 36 months), mostly in distant periods (median time after correction procedure, 11.7 months). The most common complication was outflow stenosis, followed by hematoma, dialysis fistula thrombosis and the formation of a new aneurysm and postoperative bleeding, infection and lymphocele. The 12-month primary, primary assisted and secondary patency rates of fistulas corrected by aneurysm excision and primary reconstruction in the KTx group were all 100%; in the control ESRD group, the 12-month primary rate was 70%, and the primary assisted and secondary patency rates were 100%. The 12-month primary, primarily assisted and secondary patency rates after dialysis fistula aneurysm excision combined with PTFE bypass were better in the KTx group than in the control ESRD group (85% vs. 71.8%, 90% vs. 84.5% and 95% vs. 91.7%, respectively). Kaplan-Meier analysis showed a significant difference in primary patency (p = 0.018) and assisted primary (p = 0.018) rates and a strong tendency in secondary patency rates (p = 0.053) between the KTx and ESRD groups after dialysis fistula excisions combined with PTFE bypass. No statistically significant differences in patency rates between fistulas treated by primary reconstruction and reconstructed with PTFE bypass were observed in KTx patients. CONCLUSIONS: Reconstructions of dialysis fistula aneurysms give good long-term results, with a low risk of complications. The reconstruction of dialysis fistulas can be an effective treatment method. Thus, this is an attractive option in addition to fistula ligation or observation in patients after KTx. Reconstructions of dialysis fistula aneurysms enable the preservation of the dialysis fistula while reducing various complications.

Aneurysm Excision With Arteriovenous Anastomosis Proximalization for Dialysis Fistula Aneurysm Treatment.

INTRODUCTION: Dialysis fistula aneurysms are common complications, which require surgical revision in selective cases. The results of aneurysm excision with arteriovenous anastomosis proximalization for the treatment of dialysis fistula aneurysms have been described below. METHODS: Patients qualified for the reconstruction of a dialysis fistula aneurysm underwent a duplex ultrasound examination. The diameter, length of the aneurysm, relations with the artery, thrombus presence and blood flow were determined. In the case of favorable anatomical conditions, we performed aneurysm excision with arteriovenous anastomosis proximalization as the procedure of choice. Patients, dialysis access, operative data and the results obtained during a median follow-up of 41 months were then analyzed. FINDINGS: Since 2012, we have performed 20 aneurysm excision combined with primary anastomosis as dialysis fistula aneurysm treatment. In 18 patients, aneurysm excision was combined with simple re-anastomosis in the more proximal arterial segment. In 2 autogenous radio-cephalic forearm direct fistulas the aneurysm excision was combined with switching anastomosis type from side-to-end to end-to-end. The 12- and 24-month primary patency rates of corrected fistulas in the observed group were 94.7% and 82.4%, respectively. No early complications were noted. In 7 patients (35%) we observed late complications, which required reintervention or led to access failure. Dialysis fistula thrombosis as an indication for treatment was a significant risk factor for late re-occlusion. DISCUSSION: A simple primary reconstruction by arteriovenous anastomosis proximalization and aneurysm excision for the surgical correction of dialysis fistula aneurysms has potential benefits compared to established methods-aneurysmorraphy and aneurysm excision with a vascular prosthesis bypass. The obtained data showed the efficiency, safety and excellent long-term results of this procedure.

Hybrid procedures in the dialysis fistula aneurysm treatment.

OBJECTIVES: Dialysis fistula aneurysms are common complications which in selective cases require surgical revision. It is recommended to detect and treat outflow stenosis concurrent with a dialysis fistula aneurysm, but usually, the treatment is divided into two stages - the open and endovascular stages are performed separately. We describe the results of hybrid procedures composed of aneurysm resection and endovascular correction for outflow veins performed for a dialysis fistula aneurysm treatment. METHODS: From March 2012, we performed hybrid procedures in 28 patients to correct dialysis fistula aneurysms. Patients, dialysis access, operative data, and the results obtained during a median follow-up of 28.5 months were analyzed. RESULTS: For dialysis fistula aneurysm correction, we performed 27 bypasses and 1 aneurysmorraphy. For outflow vein stenosis correction, we performed standard balloon angioplasty, no stents or stentgraft were used. The average increase in minimal diameter after angioplasty was 135.5% (range 57-275%). The 12- and 24-month primary patency rates of corrected fistulas in the observed group were 92.3% and 80%, respectively. A significant difference in the one-year patency rates between the urgent and planned procedures was observed (81.2% vs. 100%, respectively). No early complications related to endovascular or open procedures were observed. Late complications were observed in seven patients (25%) - mainly thrombosis caused by the recurrence of outflow vein stenosis (six patients, 21.5%), infection, lymphocele, and hematoma (one case of each complication). CONCLUSIONS: A hybrid procedure for the surgical correction of dialysis fistula aneurysms with the simultaneous correction of outflow pathologies enables effective long-term treatment. The obtained data showed the efficiency and good results of this procedure. Procedures performed for urgent indications significantly increase the risk for later complications, especially fistula thrombosis and loss of dialysis access.

Ultrasound-guided angioplasty of dialysis fistulas in renal transplant patients.

INTRODUCTION: Percutaneous endovascular angioplasty has become the treatment of choice for dialysis fistula stenosis. The ultrasound-guided endovascular procedure is used in patients with severe renal impairment and advanced renal transplant failure, when the need for nephrotoxic contrast administration in standard angioplasty may worsen renal function. AIM: To evaluate endovascular angioplasty guided by ultrasound for dialysis fistula stenosis in renal transplant patients with severe graft insufficiency. MATERIAL AND METHODS: We compared ultrasound (US)-guided angioplasty, performed in patients after renal transplantation, with standard contrast angioplasty performed in dialysis patients. We treated 10 kidney allograft recipients (9 kidneys and 1 kidney-pancreas) with significantly compromised renal transplant function and significant stenosis in dialysis fistulas, as detected during US examination. Patients were qualified for percutaneous angioplasty under US guidance. The mean period from transplantation was 32.7 months (5-100 months). Results of their treatment were compared to the control group of 20 end-stage renal disease patients with dialysis fistula stenosis treated by angioplasty under standard contrast visualization. RESULTS: The immediate effectiveness of the angioplasty was 100% in both groups. No early complications of angioplasty or problems with the guidewire crossing the stenosis were observed. Twelve months of primary patency was observed in 80% and 45% in the US-guided and control groups, respectively. CONCLUSIONS: The US-guided endovascular procedure is an effective and safe method of treating dialysis fistula stenosis in patients with impaired renal transplant function.

Upper limb ischaemia after formation of dialysis fistula.

UNLABELLED: Limb ischaemia caused by formation of dialysis fistula is rare but serious complication. The severity of symptoms may vary but rest pains and necrotic lesions are observed in most advance cases. In these patients different invasive procedures for treatment are performed - from simplest dialysis fistula ligation to complicated vascular reconstructions. The aim of the study was to evaluate treatment results of upper limb ischaemia triggered by dialysis fistula. MATERIAL AND METHODS: We have analysed methods and results of treatment of 14 patients with symptomatic upper limb ischaemia caused by dialysis fistula treated in our department between 1st January, 2006 and 30th June, 2013. Treatment was subject to anatomical situation and clinical symptoms. In three patients the ligation of dialysis fistula was performed, four patients underwent inflow reconstruction - in one case by ligation of ligation of vein branch, in three patients by cephalic transfer of arterial anastomosis. In 2 patients hyperkinetic fistula aneurysm was excised and replaced by PTFE bypass, in three patients fistula reconstruction with DRIL method (distal revascularization - interval ligation) was performed, in one patient surgical operation of brachial artery stenosis was conducted. One patient underwent brachial artery angioplasty. RESULTS: Rest pains occurred in all patients (100%), regressive changes in 10 patients (71.4%). Eight patients (57.2%) had concomitant diabetes, seven (50%) ischaemic heart disease, five (35.5%) chronic lower limb ischemia and hyperparathyroidism was observed in fivepatients (35.5%). The imaging studies in all patients revealed pathological steal syndrome (stealing blood to the fistula), in majority concurrent with other pathologies - obstruction stenosis of peripheral artery, defects in blood out flow from the limb. As a result of the surgical treatment, symptoms of limb ischaemia subsided in all patients. CONCLUSIONS: Critical limb ischaemia caused by dialysis fistula is a dangerous complication. In most cases there are several causes of ischaemia. Treatment methods should be selected individually for each patient and clinical situation. Clinical symptoms should subside as a result of optimal choice of treatment and, if possible, maintaining of dialysis access.

Ultrasound-guided angioplasty of dialysis fistula - technique description.

Endovascular procedures are commonly used for treatment of vascular pathologies. These interventions are routinely performed under angiographic control. Angioplasty is increasingly more often used for correction of dialysis fistula - especially dilatation of stenosis. We describe the technique of dialysis fistula angioplasty under ultrasound control. Benefits of this procedure include lack of nephrotoxic contrast, what is especially important in chronic kidney disease patients in pre-dialysis period. Advantages of ultrasound guidance during dialysis fistula angioplasty lead to cause more and more frequent employment of this technique.