Long-term Outcomes of Arteriovenous Thigh Grafts in Hemodialysis Patients

Ong, Song; Barker-Finkel, Jill; Allon, Michael

doi:10.2215/cjn.09240912

Cited by 36 publications

(46 citation statements)

References 16 publications

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“…Lower limb AV grafts are increasingly used as alternative/salvage vascular access in patients unsuitable for formation of vascular access in the upper limb. The outcomes of lower limb AVG are not significantly inferior to upper limb vascular access and are considered superior to tunneled central venous dialysis catheters …”

Section: Discussionmentioning

confidence: 99%

Lower limb gigantism, lymphedema, and painful varicosities following a thigh vascular access graft

Thompson

Thiyagarajan

Akoh

2014

Hemodialysis International

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Prosthetic arteriovenous grafts (AVGs) are associated with greater morbidity than autogenous arteriovenous fistulas (AVFs), but their use is indicated when AVF formation is not possible. This report adds to the literature a case of lower limb gigantism, painful varicosities, and lymphedema following long-term use of AVG in the upper thigh. The patient's past medical history included renal transplantation on the same side well before the AVG was inserted and right leg deep vein thrombosis. Suspicion of AVG thrombosis was excluded by Doppler ultrasound, which demonstrated an access flow of 1700 mL/min. A computed tomography (CT) scan of the abdomen and pelvis did not identify the cause of her symptoms. Whereas functional incompetence of the iliac vein valve might be responsible for the varicosities, the extent of hypertrophy in this case raises the suspicion of lymphatic blockage possibly secondary to groin dissection undertaken at the time of graft insertion, in addition to the previous dissection at the time of transplantation. This case highlights the need for minimal groin dissection during AVG insertion, particularly in patients with a history of previous abdominopelvic surgery.

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Section: Discussionmentioning

confidence: 99%

Lower limb gigantism, lymphedema, and painful varicosities following a thigh vascular access graft

Thompson

Thiyagarajan

Akoh

2014

Hemodialysis International

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“…Alternatively, the surgeon can create an AVG in the thigh. A recent observational study compared the longterm access outcomes in a large cohort of hemodialysis patients with tunneled internal jugular CVCs versus thigh AVGs (40). Infection-free survival at 1 year was 79% for thigh AVGs versus 21% for CVCs.…”

Section: Once All Upper-extremity Options For Permanent Vascular Accementioning

confidence: 99%

A Patient with Recurrent Arteriovenous Graft Thrombosis

Allon¹

2015

Clinical Journal of the American Society of Nephrology

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Arteriovenous grafts (AVGs) are prone to frequent thrombosis that is superimposed on underlying hemodynamically significant stenosis, most commonly at the graft-vein anastomosis. There has been great interest in detecting AVG stenosis in a timely fashion and performing preemptive angioplasty, in the belief that this will prevent AVG thrombosis. Three surveillance methods (static dialysis venous pressure, flow monitoring, and duplex ultrasound) can detect AVG stenosis. Whereas observational studies have reported that surveillance with preemptive angioplasty substantially reduces AVG thrombosis, randomized clinical trials have failed to confirm such a benefit. There is a high frequency of early AVG restenosis after angioplasty caused by aggressive neointimal hyperplasia resulting from vascular injury. Stent grafts prevent AVG restenosis better than balloon angioplasty, but they do not prevent AVG thrombosis. Several pharmacologic interventions to prevent AVG failure have been evaluated in randomized clinical trials. Anticoagulation or aspirin plus clopidogrel do not prevent AVG thrombosis, but increase hemorrhagic events. Treatment of hyperhomocysteinemia does not prevent AVG thrombosis. Dipyridamole plus aspirin modestly decreases AVG stenosis or thrombosis. Fish oil substantially decreases the frequency of AVG stenosis and thrombosis. In patients who have exhausted all options for vascular access in the upper extremities, thigh AVGs are a superior option to tunneled internal jugular vein central vein catheters (CVCs). An immediate-use AVG is a reasonable option in patients with recurrent CVC dysfunction or infection. Tunneled femoral CVCs have much worse survival than internal jugular CVCs.Clin J Am Soc Nephrol 10: 2255-2262, 2015. doi: 10.2215/CJN.00190115 Patient PresentationThe following vignette illustrates the numerous challenges in optimizing arteriovenous graft (AVG) patency in hemodialysis patients. A 28-year-old woman initiated peritoneal dialysis when she developed ESRD because of focal glomerular sclerosis. She was hospitalized with an intracerebral bleed caused by a ruptured aneurysm 1.5 years later. A ventricular-peritoneal shunt was placed to treat hydrocephalus, and she was anticoagulated with warfarin to keep the shunt patent. Because of residual left-sided weakness and inadequate family support, she was no longer able to perform peritoneal dialysis. A tunneled central vein catheter (CVC) was placed in the right internal jugular vein, and she was switched to maintenance hemodialysis. A left forearm arteriovenous fistula (AVF) clotted 2 weeks after its creation. A subsequent looped left upper-arm AVG was successfully cannulated 5 weeks after its creation. It clotted four times during the ensuing 6 months and was treated each time by an interventional radiologist or nephrologist, who performed percutaneous thrombectomy, in conjunction with angioplasty of a venous anastomotic stenosis. The patient resumed hemodialysis with an internal jugular CVC when the AVG failed. A right radiocephalic AV...

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“…Thigh grafts provide a superior alternative to catheters in patients who have exhausted all arteriovenous fistulas and graft upper extremity vascular access sites 9 . Earlier studies raised concerns about increased rates of infection and limb ischemia associated with thigh grafts compared to upper extremity grafts 10 – 13 .…”

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confidence: 99%