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| Journal of Vascular Access 2005; 6: 34 - 37 |
| A successful struggle to prolong arteriovenous fistula patency: A case report |
C.C. Gil1, F.V. Azevedo2, M.A. Ferreira3
1Hemodial, Vila Franca de Xira Hemodialysis Center - Portugal and Vascular Intervention Unit, Curry Cabral Hospital, Lisbon - Portugal
2F.M.C. Lumiar Hemodialysis Center - Portugal
3Vascular Intervention Unit, Curry Cabral Hospital, Lisbon - Portugal
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ABSTRACT
An adequate vascular access (VA) significantly determines the morbidity and mortality of chronic renal failure (CRF) patients on maintenance hemodialysis (HD). VA patency depends on the early identification of complications and its management by the nephrologists and vascular surgeon. Venous stenosis accounts for the majority of thromboses, but its early detection followed by either percutaneous angioplasty (PTA) and/or surgical correction will improve fistula patency. We present the clinical case report of a 90-year-old patient with recurrent central venous stenosis after PTA that was corrected with bypass surgery. Two years after surgery the original fistula is still used showing no signs of access dysfunction.
(The Journal of Vascular Access 2005; 6: 34-7)
Key Words. central venous stenosis, Percutaneous angioplasty, Central venous bypass with polytetrafluoroethylene
INTRODUCTION
VA conservation is a very important aspect for the chronic renal failure (CRF) patient. The multidisciplinary approach to problems related with VA increases the number of options towards its preservation (1).
CLINICAL CASE REPORT
We present the clinical case of a 90-year-old female patient, on hemodialysis (HD) >4 yrs. Nephroangiosclerosis was the most probable cause of CRF.
The patient initially had a temporary catheter in the right internal jugular vein. Approximately 1 month after beginning HD, a left brachio-cephalic fistula was ready for use. Eighteen months later, severe edema of the left upper limb, breast and hemiface appeared. Angiography was subsequently performed and revealed innominate vein stenosis >90% (Fig. 1a). Percutaneous angioplasty (PTA) of the lesion with a high-pressure balloon, 16 mm ¥ 4 cm (Figs. 1b, c) was performed with excellent clinical results, leading to the disappearance of the central venous hypertension signs.
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FIG. 1
a) Innominate vein stenosis; b) Angioplasty of the lesion with high-pressure balloon – 16 mm ×4 cm; c) Post angioplasty. |
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Central venous stenosis recurred twice after the intervention described above. The first at 6 months (Fig. 2) was resolved with PTA (16 mm ¥ 4 cm); therefore, relieving the central venous pressure (Fig. 3).
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FIG. 2
Central venous hypertension signs: edema of the left upper limb, breast and hemiface. |
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In addition, the patient was recovering from a right hemi-colectomy due to colonic ischemia. The second recurrence was 13 months later, this time PTA was impossible due to problems in overcoming the lesion with a guidewire (Fig. 4).
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FIG. 4
Angioplasty was not possible due to guide wire not overcoming
stenosis. |
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In an effort to maintain the same VA, the patient underwent bypass surgery, between the left subclavian vein and the right cephalic vein before its confluence with the right subclavian vein (Fig. 5).
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FIG. 5
PTFE graft between the left subclavian vein and right cephalic vein before its c o n f l u e n c e with the right s u b c l a v i a n vein. |
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Surgery was performed at an outpatient clinic and under local anesthesia. A 6 mm diameter polytetrafluoroethylene graft was used for the bypass. The fistula was punctured for the next dialysis session as usual, and no complications related to the surgery were registered.
Two years following the intervention, the original fistula has been maintained with no central venous hypertension recurrence or other signs of access dysfunction.
DISCUSSION
The case presented illustrates the desired multidisciplinary approach, combining endovascular intervention and surgery as means of prolonging VA patency (1, 2). Bypass surgery was chosen to solve the extreme limb edema caused by complete central venous stenosis; therefore, permitting the VA to be used on the same day and maintaining the usual puncture zones.
Another solution, not presented here, would be to close the fistula and insert a central venous catheter (CVC). This could be temporary while waiting for a new VA at the other limb or, permanently, in case one decides not to construct a new definite access.
In spite of the patient’s advanced age, the surgical intervention described performed with local anesthesia was accessible, avoiding the necessity of a CVC and the problems resulting from it.
Placing a stent in the innominate vein was never considered due to the following reasons: it could make the insertion of a central venous catheter at the right jugular vein impossible (3), put at risk the construction of a vascular access on the right upper limb, and at the same time, would not prevent a vascular restenosis and could even complicate future dilatations. It is curious that the patient never had a left jugular or subclavian vein catheter, a well-known cause of this form of venous stenosis.
We are aware that bypass surgery with a graft can lead to new venous stenosis juxta-grafts, but the solution to these problems must be individualized to each patient. In this elderly dialyzed patient, the solution presented seemed to be the best one and the original fistula has been maintained for >18 months, without incident.
Address for correspondence:
Célia Maria Colaço Gil
Rua António Sérgio, nº 23 - 5º A
2600 Vila Franca de Xira
Portugal
celia.gil@clix.pt
REFERENCES
1. Turmel-Rodrigues L, Pengloan J, Bourquelot P. Interventional radiology in haemodialysis fistulae and grafts: multidisciplinary approach. Cardiovasc Intervent Radiol 2002; 25: 3-16.
2. Coulson AS. Left axillary artery to right atrial shunt for dialysis access in patients with central venous stenosis. Dial Transplant 2003; 32: 333-8.
3. Bhatia DS, Mooney SR, Ochsner JL, et al. Comparison of surgical bypass and percutaneous balloon dilatation with primary stent placement in the treatment of central venous obstruction in the dialysis patient: One-year follow-up. Ann Vasc Surg 1996; 10: 452-5.
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C.C. Gil
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