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The construction of arteriovenous fistula for hemodialysis in patients with chronic obstructive arterial disease in the upper limb

The construction of arteriovenous fistula for hemodialysis in patients with chronic obstructive arterial disease in the upper limb

J Vasc Access 2017; 18(2): 167 - 169

Article Type: TECHNIQUES IN VASCULAR ACCESS

DOI:10.5301/jva.5000624

Authors

Fábio Linardi, Jose A. Costa, Fernanda R. Angelieri, Maria G. Marabezzi, Jose L. Bevilacqua

Abstract

Objective

Describe the construction of arteriovenous fistula for hemodialysis in chronic renal patient on hemodialysis who presented chronic arterial obstruction in the upper limb.

Methods

A surgical procedure was performed on a patient with obstruction of the brachial artery in its proximal third. The procedure was carried out by the construction of a bypass with autologous vein between the proximal brachial and distal brachial arteries and the performing of an arteriovenous fistula with superficialized and anteriorized basilic vein, with anastomosis in the bypass at the same surgical procedure.

Results

There was good immediate result and arteriovenous fistula presented function for 43 months.

Conclusions

Even when faced with chronic obstructive arterial disease in the arm, there is the possibility of creating a new arteriovenous fistula for hemodialysis.

Article History

Disclosures

Financial support: No grants or funding have been received for this study.
Conflict of interest: None of the authors has financial interest related to this study to disclose.

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Introduction

Vascular access for hemodialysis has always been one of the great medical and surgical problems in the treatment of terminal chronic renal failure disease (1, 2).

At the present time it remains a major cause of hospitalization and is also one of the largest financial costs of dialysis treatment (2).

With increasing survival, in the elderly and patients with diabetes mellitus, the difficulty of obtaining an internal vascular access has become a major challenge for vascular surgeons (3).

For making a good arteriovenous fistula (AVF), we depend on good caliber veins, with long, shallow path and free healthy arterial stenosis or obstruction and a presenting wrist with good amplitude (2).

When we examine a patient with no brachial pulse, radial or ulnar palpable, we immediately migrate to the contralateral limb. However, there are occasions when the contralateral limb is also unable to perform the AVF due to venous or arterial deficiency (4, 5).

Case report

We report a 53-year-old male patient with renal disease secondary grade V chronic glomerulonephritis. He began hemodialysis on 07/10/85 and underwent kidney transplant on 03/12/86. He returned to dialysis treatment on 15/03/94 for graft loss due to chronic rejection. Regarding vascular access, the patient had undergone five previous surgeries, two of which had not immediately functioned and the other three had a patency of 20 months, 57 months and 69 months, respectively.

The last AVF performed was on 03/03/2000 and it evolved into a major aneurysm and presented thrombosis with consequent loss of its function on 15/09/2006. Dialysis treatment was maintained through a long-term catheter. The patient was referred for evaluation into the possibility of a new AVF. During clinical examination of the right upper limb, the absence of pulses in the brachial, radial and ulnar was noted. A requested angiographic study showed occlusion of the brachial artery in its proximal third with refilling of the distal portion of the brachial artery before the bifurcation (Figs. 1 and 2).

Brachial artery obstruction.

Brachial artery refilling.

Through venous clinical examination it was noted the presence of the vein basilica of good size and good length.

The surgical procedure

Patient underwent general anesthesia.

Marking the basilica vein in all its extension.

Dissections of the basilica vein throughout its length to the height of his mouth in the brachial vein (Fig. 3).

Removal of the distal half of the basilica vein and performed preparation thereof to be used as autologous replacement for the completion of the bypass.

Maintained the proximal half of the basilica vein in his bed and prepared to be used for the creation of the AVF.

Dissection of brachial artery in its proximal third and prepared to perform the proximal anastomosis of the bypass.

Dissection of brachial artery in its distal third and prepared to perform the distal anastomosis of the bypass.

Performed by the brachial-brachial pass to the vein segment basilica removed and prepared beforehand.

Performed anastomotic vein proximal basilica in the distal third of the bypass previously realized.

In all anastomoses Prolene 7-0 was used.

Room vein proximal basilica in the surgical bed (Fig. 4).

Closure in layers.

Basilic vein dissection.

Basilic vein accommodation.

The postoperative period passed without any complications and evolved into the presence of distal pulses and good thrill in the basilica vein path (Fig. 5).

Final aspect – 30th postoperative.

Discussion

Vascular access for hemodialysis remains a major challenge in the maintenance of patients with chronic renal failure on dialysis (2). Currently, this challenge is greater due to increased patient survival and, therefore, increased time on dialysis, increased percentage of elderly patients starting hemodialysis and a greater presence of diabetes mellitus in this population (3).

These factors themselves make it difficult to perform a good AVF due to exhaustion and weakness of the superficial veins, mainly due to the increased prevalence of chronic arterial disease obstructive (2, 5).

The occlusive arterial disease of the upper limbs has a low prevalence compared to the disease of the lower limbs. The important network side, lower muscle mass and less use of the arms relative to the lower body, make the ischemic conditions more tolerable and usually asymptomatic. Atherosclerosis is the major cause of obstructive disease in the upper limbs and it is necessary to control their risk factors in these patients. It is estimated that bypasses of the upper limb due to ischemia account for only 4% of all vascular surgical procedures (6-7-8). Due to the shortage of surgical access opportunities for dialysis in this patient, having held several previous accesses and the absence of distal pulse, the denial of patient fabricate AVF in thigh, enabled the author to rethink a way of obtaining good access. It was then decided to carry out a brachyfacial-brachial bypass followed by the preparation of an AVF through this arterial bypass. No similar case has been found in the literature.

Conclusion

In patients with chronic arterial disease in upper limbs is feasible to perform AVF through a by-pass followed by the confection of the access.

Disclosures

Financial support: No grants or funding have been received for this study.
Conflict of interest: None of the authors has financial interest related to this study to disclose.
References
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  • 2. Rodríguez JA López J Clèries M Vela E Vascular access for haemodialysis—an epidemiological study of the Catalan Renal Registry. Nephrol Dial Transplant 1999 14 7 1651 1657
  • 3. Konner K Primary vascular access in diabetic patients: an audit. Nephrol Dial Transplant 2000 15 9 1317 1325
  • 4. Kaufman JL The decline of the autogenous hemodialysis access site. Semin Dial 1995 8 2 59 61
  • 5. Greenfield LJ Rajagopalan S Olin JW Upper extremity arterial disease. Cardiol Clin 2002 20 4 623 631
  • 6. Gracz KC Ing TS Soung LS Armbruster KF Seim SK Merkel FK Proximal forearm fistula for maintenance hemodialysis. Kidney Int 1977 11 1 71 75
  • 7. Fujitani RM Mills JL Fujitani RM Mills JL Acute and chronic upper extremity ischemia. I. Large vessel arterial occlusive disease. Ann Vasc Surg 1993 7 1 106 112
  • 8. Bender MH Bruyninckx CM Gerlag PG The brachiocephalic elbow fistula: a useful alternative angioaccess for permanent hemodialysis. J Vasc Surg 1994 20 5 808 813

Authors

Affiliations

  • Department of Surgery at the Faculty of Medical and Health Sciences, Pontifícia Universidade Católica de São Paulo, Sorocaba, São Paulo - Brazil
  • Hemodialysis Institute of Sorocaba, Sorocaba, São Paulo - Brazil

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