Background
Venous scarring at the elbow is a common problem that can cause early and late forearm
arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort
to prolong the long-term patency of distal vascular accesses could benefit the patient's
survival, maximizing the use of restricted venous patrimony. This study aims to report
a single-center experience in the recovery of distal autologous AVF with venous outflow
obstruction at the elbow using different surgical techniques.
Methods
Retrospective observational study of all patients treated at a single vascular access
center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting
with outflow stenosis or occlusions at the elbow treated by open surgery, using 3
different surgical techniques. Demographics and clinically relevant data were collected.
Evaluated endpoints included primary, assisted primary, and secondary patency rates
at 1 and 2 years.
Results
Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with
a mean age of 64 ± 15 years. The majority (96%) had a radiocephalic fistula. The median
time from vascular access creation to intervention was 34.5 months (12–216 months).
A total of 24 procedures have been performed using 3 different surgical techniques
for bypassing the obstructed venous outflow at the elbow. Technical success was achieved
in 96% of the surgically treated patients. Primary and secondary patency rates at
1 year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2 years, with a
median follow-up of 19 months (6–92 months).
Conclusions
AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy
could lead to vascular access abandonment. Our study demonstrates multiple surgical
solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction
seems effective for distal vascular access preservation. Close surveillance is essential
for timely endovascular treatment of newly developed stenosis at the venous drainage.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Annals of Vascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Editor's choice - vascular access: 2018 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 757-818
- KDOQI clinical practice guideline for vascular access: 2019 update.Am J Kidney Dis. 2020; 75: S1-S164
- Stenosis complicating vascular access for hemodialysis: indications for treatment.J Vasc Access. 2014; 15: 76-82
- Vein preservation: an algorithmic approach to vascular access placement in patients with compromised renal function.J Assoc Vasc Access. 2007; 12: 89-91
- A patient with arteriovenous fistula of simultaneously performed anastoplasty for excessive blood flow and graft bypass to secure an outflow tract.J Vasc Access. 2019; 20: 80-83
- Managing thrombosis of arteriovenous fistula accompanied by aneurysm and single outflow of elbow perforating vein: a case report.BMC Nephrol. 2022; 23: 271
- Radiocephalic fistula recovery using the brachial vein and forearm basilic vein: a case series and literature review.Ther Apher Dial. 2018; 22: 570-574
- Radio-cephalic arteriovenous fistula recovered with drainage through the brachial vein.Hemodial Int. 2018; 22: E53-E56
- Radio-cephalic fistula recovered with drainage to forearm basilic vein.Hemodial Int. 2017; 21: E63-E65
- Radio-cephalic fistula recovered with drainage to median basilic vein by straightening of the forearm cephalic vein: a case report.Semin Dial. 2022; 35: 544-547
- Patterns of the superficial veins of the cubital fossa: a meta-analysis.Phlebology. 2017; 32: 403-414
- Recommended standards for reports dealing with arteriovenous hemodialysis accesses.J Vasc Surg. 2002; 35: 603-610
- Outcomes of vascular access for hemodialysis: a systematic review and meta-analysis.J Vasc Surg. 2016; 64: 236-243
- Percutaneous transluminal angioplasty of dysfunctional hemodialysis vascular access: can careful selection of patients improve the outcomes?.Indian J Nephrol. 2022; 32: 233-239
- Cubital vein transposition for a distal radiocephalic fistula complicated by outflow obstruction.J Vasc Access. 2020; 21: 520-523
Article info
Publication history
Published online: February 28, 2023
Accepted:
February 21,
2023
Received in revised form:
February 14,
2023
Received:
January 1,
2023
Publication stage
In Press Journal Pre-ProofFootnotes
Conflict of interest: None.
Funding Sources: None.
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
