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Anastomotic Disruption after Endovascular AVF Creation
Channa Blakely, Prashanth Iyer, Vamsi K Potluri, Jennifer Worsham, Michael B Silva, Jr., Mellick T Sykes, Christine Shokrzadeh
UTMB, Galveston, TX
INTRODUCTION: Endovascular AVF (eAVF) creation is a proposed new method of establishing dialysis access in patients without open surgery. Early experience comes largely from outpatient interventional centers; patient follow up has been variable. We present a case of a total anastomotic disruption after outpatient eAVF creation requiring urgent surgical intervention to prevent limb loss.
METHODS: A 66-year-old blind patient on catheter hemodialysis had an eAVF creation at an outside facility. Pain and swelling developed immediately post-op, but communication problems with the outpatient center delayed evaluation for two days. He subsequently presented to our institution. Imaging revealed active extravasation and hematoma at the proximal forearm. Patient was taken urgently to the operating room where a large sub-fascial hematoma with actively bleeding injuries of the median cubital vein and proximal radial artery were identified and repaired.
Figure 1. Proximal radial artery injury (black arrow), vein repair with 6-0 prolene suture (white arrow)
RESULTS: Patient had immediate improvement in functional status of his left hand after surgery. He was discharged on post-op day two with plans for a future fistula creation.
CONCLUSIONS: As eAVF creations become more common, especially among interventionalists who are not surgically trained, standard protocols to mitigate complications will increase patient safety. We propose a protocol to monitor patients after eAVF creations. The protocol includes improved patient education and selection, duplex ultrasound training for more accurate reading post-op, longer recovery stays to assess for complications, and better post-op communication.
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