Techniques for Insertion and Management of Complications

Abstract

In a series of 602 procedures, over 90% of primary forearm insertions of PTFE grafts between the radial artery and a cubital vein were possible. Thrombosis of the graft, which was invariably due to venous outflow obstruction, was the most common complication encountered. Revision of the venous anastomosis was not necessary in about one-third of the thrombosed grafts if a size 3 coronary dilator could be passed and the augmentation test was satisfactory. For revisions, creation of a new venous anastomosis using a jump graft was preferred over patch angioplasty or venous endarterectomy. Crossing the elbow for this purpose did not adversely affect graft patency. The incidence of aneurysm formation and infection was 16% and 35%, respectively. Infections involving the graft were managed by drainage, antibiotics, and bypass of the infected portion. Immediate bypass and delayed bypass were equally effective. About one-half of the infected grafts were salvaged by these techniques. The most common organism was Staphylococcus aureus. With a combination of the techniques outlined above, the service life of individual PTFE grafts can be extended. Two-year access patency in this series was 77%.

INFECTIOUS COMPLICATIONS OF ARTERIOVENOUS ePTFE GRAFTS FOR HEMODIALYSIS

“…The PGE has been evaluated in many single-centre studies and good results have been reported in 74-80% (ref. 37,53,81,82,89 ). Although, this approach is not generally accepted.…”

“…In patients with arteriovenous graft the incidence of infection is from 11 to 35% (ref. 13,[32][33][34][35] ), and infection complications associated with arteriovenous graft are approximately one third more than arteriovenous fistula 23 . Also later published studies have shown that the incidence of infection in arteriovenous graft is ten times more common than autologous fistula and significantly lower than central venous catheter 13,36 .…”

“…Risk factors result from graft localization -infection is more common in lower extremities 40,41 , insufficient antisepsis during surgical procedure 34 , technique of venipuncture with risk of hematoma creation or infection contamination 42 . Clearly, the longer the arteriovenous graft is used for hemodialysis the higher is the risk of graft infection emergence 33,36,43 . The incidence of arteriovenous graft infection is affected by a large number of factors such as: impaired immunosurveillance in hemodialysis patient caused by neutrophils dysfunction in uremia [44][45][46] , obesity, diabetes mellitus 47 , hypalbuminemia 36,48 , insufficient personal hygiene 49 .…”

Vascular access graft thrombosis by iatrogenic fistula

“…[9][10][11][12] In this case, traumatic fi stula between a vascular access graft and the adjacent basilic vein formed by repeated needling for maintenance HD likely was the predisposing factor in the graft thrombosis. Presently, and consistent with the typical scenario, blood fl ow in the venous limb of the graft was decreased due to steal through the traumatic fi stula.…”

“…The major predisposing factor for thrombosis of PTFE grafts is stenosis of the graft-venous anastomosis. [7][8][9] But, factors other than venous stenosis may also cause or contribute to graft thrombosis. Prosthetic arteriovenous graft thrombosis is multifactorial and includes stenosis of the graft-venous and graft-arterial anastomosis, excessive compression for hemostasis at the end of dialysis, complication of dialysis needle placement, hypotension, hypovolemia, and hypercoagulable states.…”