Development and Initial Evaluation of a Same-Day Discharge Percutaneous Endovascular Aneurysm Repair Pathway

Abstract

Background: Worldwide, the majority of kidney failure patients are treated by hemodialysis. The demand for vascular access surgery is increasing rapidly because of the continuing expansion of this population. A reliable access to the circulation for hemodialysis is essential. A proportion of hemodialysis patients exhaust all options for permanent arteriovenous (AV) access (fistula or graft) in both upper extremities. AV thigh grafts are a potential vascular access option in hemodialysis patients who have exhausted all upper limb sites. This paper reports our experience with vascular access in the thigh.Methods: We performed a retrospective review of the University Health Network's Division of Nephrology dialysis access database to identify all thigh AV access grafts placed between November 1995 and November 2015. Electronic medical records were then reviewed to determine demographic and clinical information. The charts were examined for subsequent surgical or endovascular procedures performed on the accesses. The patency of each thigh AV access was determined from the time of surgical creation placement, and the reason for failure was documented.Results: A total of 41 hemodialysis patients received 47 thigh AV accesses for hemodialysis vascular access during the study period. The average age of the cohort was 46 years (range, 13-79 years). The majority of the patients (53.6%; n ¼ 22) were female, and the majority of AV accesses (55.3%; n ¼ 26) were placed in the left leg. Three patients were lost to follow-up; but of the remaining 38 patients, the average patency for the grafts (n ¼ 44) was 1130.6 days (range, 0-4745 days). Thirty-six percent (n ¼ 17) of the grafts required surgical revision to eradicate infection or to maintain patency. Seventeen of 44 grafts (38.6%) served as definitive hemodialysis AV access during the patient's lifetime of dialysis. The majority failed because of infection 43.1% (n ¼ 19) or thrombosis 13.6% (n ¼ 6).Conclusions: AV thigh grafts are used infrequently, but they have a good patency. However, they require frequent revisions and have a high infection rate resulting in the ultimate loss of the access in 43.1% of cases. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.