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Axillary - renal arteriovenous graft: a viable option for dialysis access in patients with central venous occlusion

Anton Dias Perera, H. Edward Garrett, Jr.
University of Tennessee, Memphis, TN

INTRODUCTION:
Hemodialysis cases can be difficult in patients who have had multiple central venous catheters complicated by superior and inferior vena caval occlusion. One option in dealing with this problem is a left axillary artery to left renal vein prosthetic graft. The 2nd and 3rd case reports of the procedure are described.
CASE REPORT 1:
A 43-old African-American man with end-stage renal disease (ESRD) presented with chronic occlusion of superior and inferior vena cava. A duplicated inferior vena cava and a right sided aortic arch with an aberrant left subclavian artery were also noted. Both iliac veins were chronically stenosed following multiple, indwelling catheters and deep venous thrombosis. A trans-hepatic, tunneled dialysis catheter used for access had become dislodged. An attempt to replace the catheter was abandoned after an inadvertent liver injury. He was not a candidate for kidney transplant because of hypercoagulable syndrome. Peritoneal dialysis was discontinued following peritonitis and multiple intra-abdominal complications. Emergent dialysis access was obtained through a left-sided trans-femoral tunneled dialysis catheter which was placed following percutaneous dilatation of a stenotic iliac vein. Retro-hepatic occlusion of inferior vena cava was confirmed by venogram. Venous drainage to the right atrium was through a complex collateral system formed by the hepatic veins. Following successful dialysis using the catheter, a left-axillary artery-to left renal vein arterio-venous (AV) prosthetic graft was placed using a 6 mm externally supported PTFE graft for long-term access. This was successfully cannulated for hemodialysis with a flow rate of 300 mL/min. An inferior vena cava-to-right atrial bypass was performed 3 months later to treat retro-heptic caval occlusion. Graft remained patent for 8 months when the patient died from un-related cause.
CASE REPORT 2:
A 40-year-old man with ESRD presented with chronic occlusion of superior vena cava, and stenoses of both iliac veins. Multiple access grafts in both upper-extremities had failed. The existing femoral catheter required multiple changes due to poor flow rates. Peritoneal dialysis was not considered because of history portal hypertension and ascites. A left axillary artery-to- left renal vein AV graft was placed for long term access. At six-month follow-up, the graft remains patent.
DSICUSSION:
Creation of dialysis access in patients with central venous occlusions is challenging. There is paucity of data on alternative and complex access procedures. Their long -term patency rates are unknown. However, without these alternative procedures, most dialysis-dependent patients face certain death. There are several published reports of complex access grafts created in similar circumstances. They include external iliac artery to iliac vein graft, arterial-to-arterial grafts and brachia/axillary artery to right atrial grafts. Renal vein has been previously used as an outflow vessel in previous reports and there is one published report of axillary artery to renal vein graft configuration. This case report illustrates the feasibility of this procedure when confronted with a life-threatening situation in a dialysis-dependent patient with complex central venous occlusions.


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