NDT Advance Access originally published online on November 30, 2006
Nephrology Dialysis Transplantation 2007 22(3):970-971; doi:10.1093/ndt/gfl648
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Right superficial femoral artery to superior vena cava graft using a polytetrafluroethylene graft: a new technique in a complicated dialysis access patient
Email: eric.chemla{at}nhs.netSir,
The expansion of haemodialysis includes older patients with comorbidities, poor quality vessels, unsuitable for transplantation or peritoneal dialysis. Vascular access complications account for 20% of hospital admissions [1]. With exhausted sites in upper extremities, unusual sites for arteriovenous grafts formation are used [2]. The present case illustrates management of severe access difficulties with the first femoral artery to right atrium bypass graft for dialysis access.
A 44-year-old gentleman with end-stage renal failure had poor compliance, severe learning and behavioural difficulties, and failure of peritoneal dialysis and renal transplantation. Brachiocephalic arteriovenous fistulae, brachioaxillary arteriovenous fistulae, right brachial artery to left internal jugular vein bypass graft and finally right axillary artery to common iliac vein bypass graft had all previously failed. Central venous catheters were complicated by infection and thrombosis. He was referred for severe access difficulties.
Venography demonstrated bilateral axillary vein, superior vena cava (SVC), inferior vena cava (IVC) and femoral vein to iliac vein, thrombosis. A right superficial femoral artery to patent portion of the SVC at the junction with the azygos vein bypass graft was formed. The right atrium and SVC were dissected through a median sternotomy and pericardial incision. Common, superficial and profunda femoral arteries were dissected through a right femoral triangle incision. A subcutaneous tunnel was formed along the lateral aspect of the abdomen and chest wall for the 80 cm, 6 mm Intering PTFE GoreTex® graft. The top anastomosis was constructed end-to-side with the superficial femoral artery just after the profunda. The bottom anastomosis was formed just above the right atrium on the last centimetre of the SVC, after the connection of the azygos vein. The thorax was closed with steel wire. Post-operative care was in intensive care unit with dialysis using a femoral artery catheter. A fistulogram confirmed patency and ultrasound dilution monitoring with the Transonic® device (Ithaca, NY, USA) was carried out bimonthly. The graft was successfully needled after 2 weeks, and the patient resumed his previous life. At 5 months, the inflow was <600 ml but the patient refused intervention.
We assumed that the azygos vein was patent, allowing the anastomosis to be made on the last centimetre of the SVC just above the right atrium, which reduced the risk of atrial or ventricular arrhythmias. Using the superficial femoral artery just after the profunda, rather than the common femoral artery for the top end anastomosis, reduced the risk of steal syndrome. Bimonthly access monitoring, with early referral for fistulogram is vital [3].
This illustrates an alternative dialysis access procedure in extreme circumstances. Right atrial bypass grafting was successful for central venous obstruction associated with upper extremity graft malfunction or thrombosis [4]. In different circumstances, radiological intervention may have prevented thrombosis. Complex mental health issues and long-standing difficulties in compliance ultimately led to graft failure.
Conflict of interest statement. None declared.
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Department of Renal Transplantation,
St George's Hospital,
London, UK
References
- Feldman HI, Kobrin S, Wasserstein A. (1996) Hemodialysis vascular access morbidity (editorial review). J Am Soc Nephrol 7:523–535.[Abstract]
- Hazinedaro
lu SM, Karakayah F, Tüzüner A, et al. (2004) Exotic arteriovenous fistulas for hemodialysis. Transplant Proc 36:59–64.[CrossRef][Web of Science][Medline] - Safa AA, Valji K, Roberts AC, Ziegler TW, Hye RJ, Oglevie SB. (1996) Detection and treatment of dysfunctional hemodialysis access grafts: effect of a surveillance program on graft patency and the incidence of thrombosis. Radiology 178:653–657.
- El-Sabrout RA and Duncan JM. (1999) Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option. J Vasc Surg 29:472–478.[CrossRef][Web of Science][Medline]
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