ASDIN 7th Annual Scientific Meeting

Transcription

1 Perigraft seroma has been a relatively rare complication of PTFE grafts, occurring in 1-4% of implants. A gelatin-coated PTFE graft has been marketed for dialysis access with claims of reduced suture line bleeding and graft weeping. We trialed this graft and found 11 significant seromas out of 30 implants: many more perigraft seromas than we expected. A fluid collection around the graft that: 1) Prevents palpation of the boundaries of the graft (i.e. causing difficulty with graft cannulation) 2) Required further surgery for correction The objective of this study was to summarize the results of one centers results with the gelatin-coated PTFE graft The study was retrospective in nature 3) Required explantation of the graft All patients underwent ultrasound vascular mapping to assess their options for an autogenous AVF Contrast venography was done in all patients with a history of prior central venous devices or sternotomy Commercially available gelatin-sealed grafts in 6mm and 4mm-7mm sizes were used Minimum i vein size of 3.0mm was used to receive the venous outflow If the inflow artery was < 4.0 mm the 4-7mm tapered gelatin-sealed graft was used If the inflow artery was >= 4.0 mm the 6mm gelatin-sealed graft was used 1

2 Brachial plexus block anesthesia Manufacturer s Instructions for Use followed carefully Sword and Sheath tunneller utilized Suturing done with 6-0 PTFE suture Intraoperative volume flows measured by duplex assessment Use atraumatic clamps without excessive force. Soak in saline no longer than 5 minutes and don t let it to dry out afterwards. Avoid excessive tension on prosthesis, moderate tension only. Use appropriate length of graft to avoid stress at anastomosis. Don t fill graft with blood before passing it through the tunnel. Pressure on graft may cause blood components to pass through graft causing seroma Never cut or open a graft to form a surgical patch. Don t remove outer eptfe wrap on wrapped grafts. Preclotting not necessary to prevent graft bleeding. Do not remove or cannulate the central spiral support portion. May damage graft. Externally supported grafts have less gelatin coverage under the support. When support is removed, the underlying graft can behave like unsealed eptfe. Never force saline or blood into the graft under pressure Distal (venous) clamp always removed first 30 procedures were performed on 28 patients.( 2 patients had 2 grafts implanted) We implanted 20, 6mm straight grafts and 10, 4-7mm tapered AV Grafts. 5 were placed in forearm and 25 in the Upper arm 11 seromas were detected in 30 sealed PTFE grafts 2

3 No seroma Seroma Total χ 2 (1) 100% 90% 80% Group A: 6mm Gelatin Sealed Graft Group B: 4-7mm Tapered Gelatin Sealed Graft (50.0%) (50.0%) 9 1 (90.0%) (10.0%) * 70% 60% 50% 40% 30% 20% 50% 50% 90% No Seroma Seroma Total 19 (63.3%) 11 (36.7%) 30 Note. The results were determined to be significant by both the Pearson chi-square test and Fisher s exact test. *p < % 0% Group A: 6mm Gelatin Sealed Graft Statistically significant with Fisher s Exact Test P= % Group B: 4-7mm Tapered Gelatin Sealed Graft Group Statistics Group N Mean (ml/min) Std. deviation Std. Error Mean 6mm mm Seroma N Mean Std Deviation Std Error Mean No Yes patients had grafts explanted 2 patients cannulation delayed 2 months 2 patients cannulation delayed 3 months 1 patients had cannulation delayed 4 months 3

4 4

5 Patient 02 OP Note Patient 02 Week 5 Patient 02 Week 5 Patient 02 Week 5 Patient 02 Week 5 5

6 eptfe is a linear thermoplastic polymer. Its porosity varies from microns. It is strongly hydrophobic although this can be altered by application of alcohols, oils, Betadine or pressure After chronic implantation an inflammatory reaction elicits tissue ingrowth; however, initially, the graft is dependent on its hydrophilic properties to prevent serum from ultrafiltrating through the walls. Super-hydrophobic lotus leaf Hydrophobic properties lost in a weeping graft With 11 clinically significant seromas out of 30 implants, the gelatin-sealed PTFE vascular prosthesis is not the ideal dialysis graft. Eric D. Ladenheim M.D. Nathan B. Chadwick PA-C Theresa M. Dunaway RN, BSN, CCRP Sid Agrawal M.D. Craig Lum D.O. 6