A New Technique to Superficialize Arteriovenous Fistulas Too Deep for Reliable Cannulation

Transcription

1 A New Technique to Superficialize Arteriovenous Fistulas Too Deep for Reliable Cannulation Danielle Fontenot, MD, MS Adam Tanious, MD, MMSc, Yusuf Chauhan, BS Alicia Stafford, BS, Karl A. Illig, MD University of South Florida Tampa, FL April 26, 2018

2 Disclosures One patient excluded since original abstract submitted due to variation in technique

3 Introduction Approximately 30% of autogenous cephalic vein arteriovenous fistulae are too deep for reliable cannulation despite adequate hemodynamics Tortuous outflow segment Small vein diameter DEPTH Inkollu et al. Successful use of minimal incision superficialization technique for arteriovenous fistula maturation. JVS. 2016;63(4): doi: /j.jvs Bronder et al. Fistula elevation procedure: Experience with 295 consecutive cases during a 7-year period. JVS. 2008;48(2): doi: /j.jvs Maliska et al. When Arteriovenous Fistulas Are Too Deep: Options in Obese Individuals. JVS. 2016;63(3):845. doi: /j.jvs

4 Introduction Rule of 6 s Depth 6 mm below the skin surface Minimum vein diameter of 6 mm Blood flow > 600 ml/min 6 weeks from surgical creation Studies suggest a depth 5 mm is best for reliable cannulation Inkollu et al. Successful use of minimal incision superficialization technique for arteriovenous fistula maturation. JVS. 2016;63(4): doi: /j.jvs Shenoy S. Innovative Surgical Approaches to Maximize Arteriovenous Fistula Creation. Seminars in Vascular Surgery. 2007;20(3): doi: /j.semvascsurg

5 Introduction Over 37% of U.S. adults are obese Obese individuals are more likely to require a superficialization procedure BMI of patients requiring a single stage procedure was 29.5 kg/m 2 BMI of patients requiring superficialization was kg/m 2 Inkollu et al. Successful use of minimal incision superficialization technique for arteriovenous fistula maturation. JVS. 2016;63(4): doi: /j.jvs Overweight & Obesity Statistics. National Institute of Diabetes and Digestive and Kidney Diseases. Published August 1, Accessed November 10, Allon M, Ornt DB, Schwab SJ, et al. Factors associated with the prevalence of arteriovenous fistulas in hemodialysis patients in the HEMO Study. Kidney International. 2000;58(5): doi: /j x.

6 Introduction Previously described methods: Tunnel Transposition Direct elevation transposition Minimal Incision Superficialization Technique (MIST) V-Wing Lipectomy Liposuction

7 Technique Mark path of fistula with ultrasound 3-4 transverse skin incisions 6 cm apart

8 Technique Create epidermal/dermal flap Avoid cautery Leave AVF undisturbed

9 Technique Circumferentially dissect AVF and ligate branches

10 Technique Mobilize and elevate vein above adipose tissue

11 Technique Close adipose tissue beneath vein with absorbable suture Close skin with running subcuticular or simple, interrupted nylon stitch

12 Results N = 12 patients from March 2016 May % brachio-cephalic fistulas 62% obese Average BMI kg/m 2 Average time to use days Two fistulas accessed in less than 7 days Fistula Characteristics N Percent Laterality Right Arm Left Arm Location Upper arm Forearm Inflow Artery Brachial Radial Outflow Vein Cephalic Basilic Anesthetic General 2 25 Local 6 75

13 Table 4: Fistula Depth N Mean Std Dev Min-Max Average Pre-op Depth mm +/- 2.3 mm ( mm) Average Post-op Depth 5 5 mm +/- 3 mm ( mm) Average Depth Change mm +/- 1.7 mm (0 4.8 mm)

14 Results Technical success: 100% Cannulation rate: 7 of 9 patients (77.8%) Excluding: Two patients lost to follow up and one patient not yet on dialysis One thrombosis prior to cannulation One refused due to pain

15 Advantages of procedure Transverse incisions with potential for improved healing No cannulation through scar tissue No lateral manipulation of outflow vein No revision of anastomosis

16 Conclusions Our method of superficialization appears to be safe, effective and comparable to techniques previously described

17