Asian Cardiovasc Thorac Ann 2003;11:171-173
© 2003 Asia Publishing EXchange Ltd
Fully Ringed Polytetrafluoroethylene Graft for Vascular Access in Hemodialysis
Chiung Lun Kao, MD,
Jen Ping Chang, MD
Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
For reprint information contact: Chiung Lun Kao, MD Tel: 886 5 362 1000 Fax: 886 5 362 3005 email: sa11421{at}adm.cgmh.org.tw Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Chiayi, 6 Sec. West, Chia Pu Road, Putzu City, Chiayi Hsien, Taiwan.
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ABSTRACT
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Polytetrafluoroethylene grafts have become the alternative to arteriovenous fistulas for hemodialysis access. The most frequent complication of prosthetic grafts is thrombotic occlusion, caused especially by hypotension after hemodialysis and excessive compression for hemostasis. We describe a technique using the ringed polytetrafluoroethylene graft for constructing an upper arm curved graft to overcome external compression. It yields favorable results.
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INTRODUCTION
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For patients with endstage renal disease requiring chronic hemodialysis, the autogenous Brescia-Cimino fistula is the first choice of arteriovenous access for hemodialysis. However, when a fistula cannot be created because of small veins or in the case of fistula failure, the expanded polytetrafluoroethylene (PTFE) graft, implanted as an arteriovenous conduit, is widely accepted as an alternative.1,2
Thrombosis of a prosthetic arteriovenous graft (PAVG) may occur because of one or more of 3 possible causes: poor inflow, poor outflow, and poor conduit.3 The third cause usually results from prosthetic breakdown after repeated punctures. External compression of the graft, especially in patients with low blood pressure after hemodialysis, may also cause thrombosis. Ringed grafts are frequently used in peripheral vascular reconstruction, as well as for vascular access when making a loop configuration or when crossing the antecubital fossa or the joints. We have used for years ringed grafts for routine PAVG placement. In this study, we describe the results of using ringed PTFE grafts to construct upper arm PAVGs.
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TECHNIQUE
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A fistula is created under local anesthesia, except in patients who are ventilator-dependent preoperatively, and an upper arm curved graft procedure is performed. A subcutaneous tunnel is created using a 6-mm tunneling device (Gore Tunneler; WL Gore, Flagstaff, AZ, USA), through which a 6-mm Gore-Tex PTFE graft with removable rings (WL Gore, Flagstaff, AZ, USA) is placed. The ends are prepared by removing 2 rings and cutting to a bevel shape, leaving about 6 mm between the edge and the first ring. End-to-side arterial and venous anastomoses are completed using 7/0 polypropylene suture (Ethicon, Somerville, NJ, USA) (Figure 1
). No systemic heparinization is used, but the lumen of the vessels is flushed with heparinized saline (50 U heparin in 1 mL normal saline). No parenteral antibiotic is given, but oral cefadroxil 500 mg is administered twice a day for 3 days. Anticoagulant therapy for maintaining graft patency is not given after the procedure. Hemodialysis through the implanted graft is begun no sooner than 3 weeks postoperatively.
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Figure 1. Two ringed Gore-Tex grafts placed in the left upper arm, one thrombotic and the other functioning. We usually place the second graft more proximally to the axilla. A = axilla, E = elbow.
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Between February 1999 and January 2000, we performed 154 upper arm PAVGs with 6-mm externally supported PTFE grafts. All the patients had no suitable vein to construct an autogenous fistula. A total of 124 patients received a first graft in the upper arm, while 27 patients received a second graft and 3 patients received a third graft in the same upper arm. There were 94 males and 60 females, aged 33 to 91 years (mean, 65 ± 11 years). These patients had been undergoing dialysis 2 or 3 times a week for an average of 33 months. The incidence of diabetes was 35% (54 patients), hypertension 42% (65), and smoking 26% (40).
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RESULTS
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The upper arm curved graft procedure was carried out without any significant complications in all 154 patients, with 95 of them operated on as outpatients. The mean operative time was 49 ± 14 minutes (range, 17 to 90 minutes). All the patients were started on hemodialysis via the new graft 3 weeks after the procedure. The patients were followed up for up to 28 months (mean, 14 months; median, 16 months). Four grafts were removed when they became infected after an average of 6.2 months of use. A 71-year-old man suffered from left arm swelling secondary to central vein stenosis 2 months after the operation. After failed percutaneous transluminal angioplasty to the stenosis, a right arm autogenous fistula was created and the left Gore-Tex graft closed. Significant steal occurred in an 81-year-old diabetic woman following graft placement. She was treated by division and reanastomosis of the graft using 7/0 PTFE suture to reduce the lumen, and she had been on maintenance hemodialysis through the graft for 12 months without recurrence of symptoms. Thrombosis was the main cause of graft loss (42 of 154 grafts or 27.3%). Thrombectomy to maintain graft patency was not performed. The primary patency rate from graft insertion to the occurrence of thrombosis, calculated by Kaplan-Meier analysis, was 89.2% at 6 months, 82.0% at 12 months, 68.6% at 18 months, and 54.2% at 24 months. The patency rate at 28 months estimated by life table analysis was 39.7% (Figure 2).
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Figure 2. Patency rate life table of the ringed graft showing primary patency rate of 39.7% at 28 months.
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DISCUSSION
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Despite a secondary patency rate of 80% at one year postoperatively, standard expanded PTFE grafts experience a significant rate of thrombotic occlusion, infection, and puncture complications. Thrombosis is the main cause of graft failure, the result of mishandling of the graft by dialysis personnel, hemostatic banding, unintentional obstruction while sleeping,4 or venous stenosis. Low blood pressure during dialysis also may compromise the graft secondary to thrombotic occlusion. Ringed grafts have been used in vascular access involving an axillary artery to jugular vein fistula5 or a fistula that crosses the joints6 because they are resistant to kinking. We use ringed grafts for vascular access to prevent thrombosis secondary to external compression. Maturation, puncture technique, and hemostasis of ringed grafts have to be considered. We usually cannulate the graft 3 weeks postoperatively to allow tissue ingrowth. There was no pseudoaneurysm or postdialysis subcutaneous hematoma formation during the follow-up period. Our dialysis team has not experienced any problem with puncture or hemostasis following decannulation, and excellent vascular access has been obtained. We are reluctant to perform thrombectomy or revision to maintain graft patency because of the unavailability of intraoperative angiography to evaluate the immediate result after thrombectomy and because the time to failure of new grafts is twice as long compared to revision of a previous access site.7 The primary patency rates of these grafts of 82.0% at 1 year and 54.2% at 2 years compare favorably with those of several recent studies evaluating PTFE grafts.1,2
A well-controlled randomized study is needed to confirm or refute the superiority of ringed grafts over nonringed grafts. Based on the results presented, we conclude that upper arm arteriovenous grafting with a ringed graft is a satisfactory procedure. It is particularly helpful for patients with low blood pressure after dialysis or who use the hemostatic device in a large-volume dialysis unit to compress the puncture hole.
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REFERENCES
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- Glickman MH, Stokes GK, Ross JR, Schuman ED, Sternbergh WC III, Lindberg JS, et al. Multicenter evaluation of a polyurethaneurea vascular access graft as compared with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications. J Vasc Surg
2001;34:465–72.[Medline]
- Cinat ME, Hopkins J, Wilson SE. A prospective evaluation of PTFE graft patency and surveillance techniques in hemodialysis access. Ann Vasc Surg
1999;13:191–8.[Medline]
- Douzdjian V, Abecassis MM. A new technique of prosthetic arteriovenous fistula construction that eliminates the need for temporary access. Am J Surg
1993;166:304–5.[Medline]
- Delorme JM, Guidoin R, Canizales S, Charara J, How T, Marois Y, et al. Vascular access for hemodialysis: pathologic features of surgically excised ePTFE grafts. Ann Vasc Surg
1992;6:517–24.[Medline]
- Agroyannis B, Mourikis D, Fourtounas C, Tzanatos H, Kopelias I, Chatzioannou A, et al. Ringed Gore-Tex for haemodialysis access. Nephrol Dial Transplant
1999;14:2520–1.[Free Full Text]
- Mukherjee D. Rescue of failed forearm arteriovenous access grafts using an externally supported polytetrafluoroethylene graft. Am J Surg
1993;166:306–7.[Medline]
- Brothers TE, Morgan M, Robison JG, Elliott BM, Baliga P, Cofer JB, et al. Failure of dialysis access: revise or replace? J Surg Res
1996;60:312–6.[Medline]
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ABSTRACT
INTRODUCTION
