Use of short PTFE segments (⬍6 cm) compares
favorably with pure autologous repair in failing or
thrombosed native arteriovenous fistulas
George S. Georgiadis, MD,a Miltos K. Lazarides, MD,a Constantinos D. Lambidis, MD,a Stelios A.
Panagoutsos, MD,b Alkis G. Kostakis, MD,c Elias A. Bastounis, MD,c and Vassilios A. Vargemezis, MD,b
Alexandroupolis and Athens, Greece
Objective: The re-establishment of patency in a stenosed or thrombosed native arteriovenous fistula (AVF) is fundamental
to regaining adequate hemodialysis through the same cannulable vein. Many surgeons have been reluctant to use even
small segments of synthetic grafts in AVF revisions because of a perception that these would lead to poor results; however,
studies comparing various treatment options are scarce. This study compared the use of short (<6 cm) polytetrafluoroethylene (PTFE) segments with pure autologous repair in stenosed or thrombosed native fistulas.
Methods: The cumulative postintervention primary patency rates of two groups of hemodialysis patients receiving different
surgical revision operations of their vascular accesses were prospectively compared. Group I (n ⴝ 30) comprised patients
who presented with stenosed or thrombosed native fistulas and received short (2 to 6 cm) interposition PTFE grafts
placed after the stenosed or thrombosed outflow vein segment was resected. These short PTFE grafts were not used for
cannulation. Group II (n ⴝ 29) comprised patients who presented with dysfunctional or failed AVFs and underwent
various types of pure autogenous corrections. AVF dysfunction or thrombosis was detected with clinical examination and
color duplex ultrasound scanning. In all cases, on-table arteriography-fistulography was performed before surgical repair.
Access adequacy was assessed in all patients postoperatively after the first puncture and every month thereafter (mean
follow up 16.7 months).
Results: No statistically significant difference in patency was observed between the two groups. Postintervention
cumulative patencies were 100%, 88%, and 82% for group I and 90%, 82%, and 71% for group II at 6, 12, and 18 months,
respectively (P ⴝ .8).
Conclusions: Short (<6 cm) interposition PTFE segments used for the revision of failing or failed AVFs compare favorably
to purely native repair and do not alter the autologous behavior of the initial access. These short PTFE revisions resulted
in satisfactory midterm primary patency without further consumption of the venous capital by harvesting segments of
vein from other locations and without compromising more proximal access sites. This practice is recommended and is
justified as part of an aggressive access salvage policy addressed by many authors so far. ( J Vasc Surg 2005;41:76-81.)
The autogenous radial-cephalic direct wrist arteriovenous fistula (AVF) remains the most reliable access for
adequate hemodialysis.1 However, some patients with inadequate arm veins who are referred to vascular surgeons
receive other proximal native access choices such as a brachial-cephalic fistulas or brachial-basilic transpositions. All
of these autogenous accesses are prone to stenosis or
thrombosis of the cannulable segment of the outflow vein.
The surgical2-4 or endovascular5-11 correction of such failing or early failed native AVFs seems more attractive than
performing the next preference access, according to National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines, because revision operations preserve other access sites for future use.
From the Departments of Vascular Surgerya and Nephrology,b Demokritos
University, Alexandroupolis, Greece, and Surgical Sector, Athens University.c
Competition of interest: none.
Reprint requests: Miltos K. Lazarides, MD, Demokritos University, Marathonos 13 Str (N. Chili), 68 100 Alexandroupolis, Greece (e-mail:
[email protected])
0741-5214/$30.00
Copyright © 2005 by The Society for Vascular Surgery.
doi:10.1016/j.jvs.2004.10.034
76
Even small stenotic vein lesions contribute to low
blood-flow states and inadequate hemodialysis. If detected
early, however, they can be corrected surgically and access
patency can be maintained without extensively limiting the
cannulable vein length. Salvage procedures in autogenous
direct or transposed AVFs represent a challenging problem
for the vascular surgeon because any successful correction
enables nephrologists to deal with the same vascular access
and eliminates the need for central venous catheters.
The outcome of surgical interventions in direct or
transposed AVFs that presented with segmental stenosis,
segmental recent thrombosis, or other complications predisposing to failure is the primary focus of this study. Short
interposition PTFE grafts were used in a group of patients
to repair stenotic AVFs segments. The midterm patency of
these revised vascular accesses was compared with that of a
second group of patients with revised AVFs in which no
prosthetic material was used.
MATERIALS AND METHODS
From December 1999 through April 2004, all patients
admitted for surgical revision of autogenous forearm and
upper arm AVFs that were either stenosed, thrombosed, or
had other types of lesions, were prospectively observed.
JOURNAL OF VASCULAR SURGERY
Volume 41, Number 1
The study cohort were all patients who underwent surgical
revision of their failing or failed (thrombosed) accesses and
were either treated with interposition short-length (⬍6
cm) PTFE grafts (group I, n ⫽ 30) or without any prosthetic material (group II, n ⫽ 29).
The short-length PTFE segment was used to bridge
short stenotic/thrombotic lesions and not for cannulation.
This type of short-length PTFE revision comprised 24% of
126 surgically revised accesses in the same period. The
selection of the type of AVF revision was made case-by-case
at the judgment of the operating surgeon. Postrevision
need for central venous catheter insertion was not required
in either group.
Baseline data for both groups were recorded, including
patient demographics (age, gender, underlying renal disease, comorbid conditions) and AVF characteristics (autogenous access type and status prior to revision, previous
accesses, type of lesions detected).
Proximal or distal stenotic/thrombotic lesions were
detected preoperatively by color Doppler ultrasound scans.
Clinical criteria were also used, including poor thrill on
palpation, high venous pressures, and low blood-flow states
on hemodialysis for the failing access and thrill disappearance for the failed accesses. The DOQI suggestion of a 50%
or greater normal vessel lumen reduction of the draining
vein system on color duplex scanning was the main criterion for the decision of surgical repair on failing accesses.
Other conditions contributing to AVF malfunction (aneurysms, steal syndrome, low inflow or difficult cannulation)
were also evaluated by color Doppler ultrasound scanning.
A detailed image of the failing or failed AVF anatomy
was obtained by on-table arteriography-fistulography. Stenotic vein segments detected with fistulography were classified as type I and type II lesions. Type I lesions were
characterized as those located close to the AV anastomosis,
whereas type II lesions were those located between two
needling areas.2
All patients were operated on with local anesthesia, and
all failed accesses were operated on as soon as possible
(elapsed time to operation was 4 to 16 hours) to minimize
the upward extension of thrombus. Access adequacy was
assessed in all patients postoperatively after the first puncture and every month thereafter during follow-up.
The main outcome measure was the patency rate of the
corrected access (postintervention patency) and was presented according to recommended standards of reporting
dealing with arteriovenous hemodialysis accesses.12Any
AVF surgically corrected was considered successfully revised if sufficient hemodialysis throughout the remaining
usable vein was possible.
Follow-up was complete in all patients and ranged
between 2.5 and 52 months (mean, 16.7 months). Access
follow-up was considered censored if the patient died,
received a transplant with a patent access, or reached the
end of the study period with a patent access.
Observed baseline variables in the two patient groups
were compared. Continuous variables were assessed with
the Student t test (age), while categorical variables (gender,
Georgiadis et al 77
Table I. Patient demographic data
Patient demographics
Group I
(n ⫽ 30)
(%)
Group II
(n ⫽ 29)
(%)
P
Age (year)
⬍55
9 (30)
10 (34)
55-70
15 (50)
13 (45)
⬎70
6 (20)
6 (21)
Mean ⫾ 1 SD
58.17 ⫾ 15.15 57.14 ⫾ 15.66 .799*
Gender
Male/female
20/10 (67/33) 19/10 (65/35) .926†
Underlying renal disease
Diabetes mellitus
9 (30)
7 (24)
.412†
Hypertension
10 (33)
7 (24)
.436†
Glomerulonephritis
1 (3)
Polycystic kidneys
1 (3)
3 (10)
Nephrolithiasis
2 (7)
1 (3)
Comorbid conditions
Tobacco use
4 (13)
3 (10)
Coronary artery
5 (17)
9 (3)
disease
Chronic heart failure
1 (3)
3 (10)
Myocardial infarction
—
2 (7)
Aortic stenosis ⫹
1 (3)
—
atrial fibrillation
Peripheral vascular
6 (20)
5 (17)
disease
Stroke
1 (3)
1 (3)
Parathyroid gland
2 (7)
1 (3)
adenoma
Tuberculosis
1 (3)
—
*Student t test.
† 2
␹ test, two-tailed P values.
diabetes mellitus, hypertension, type of AVF before revision, AVF patency before revision, previous accesses, type
of lesion) were assessed with the ␹2 test or the Fisher exact
test, as appropriate. The cumulative patencies were assessed
by life tables and presented as Kaplan-Meier curves. Logrank testing was used to compare patencies between the
two groups. Data were analyzed using SPSS statistical
software (version 10.0; SPSS Science, Inc, Chicago, Ill)
with differences considered significant at the level of P ⱕ
.05.
RESULTS
Patient demographics and access characteristics of the
study cohort are listed in Tables I and II, respectively. All
but one of the failing AVFs was already patent longer than
1 year, whereas all failed AVFs were in use for more than 1.5
years.
In group I, 25 patients (83%) presented with patent
vascular accesses still supporting dialysis but having short
stenotic segments of the cannulable vein (failing accesses).
Fifteen (60%) of these 25 patients had a small, partially
thrombosed pseudoaneurysm included in the affected vein
segment. The types of stenotic lesions detected are listed in
Table II.
All accesses received short interposition PTFE grafts
(Baxter or Gore-Tex 6 mm) of 2 cm to 6 cm in length as
part of the outflow vein after resection of a section that was
JOURNAL OF VASCULAR SURGERY
January 2005
78 Georgiadis et al
Table II. Baseline access characteristics
Access characteristics
Group I
(PTFE)
(%)
Type of autogenous AVF before revision
Lower arm accesses
20 (67)
Upper arm accesses
10 (33)
Brachiocephalic access
6 (20.0)
Brachiobasilic access
4 (13)
AVF condition before revision
Failing
25 (83)
Failed
5 (17)
Previous accesses on ipsilateral arm
0-2
26 (87)
⬎2
4 (13)
Lesions detected
Type I stenosis
15 (50)
Type II stenosis
15 (50)
Steal syndrome
—
Difficult vein cannulation
—
segment
Low inflow state
—
Anastomotic aneurysm
—
Vein aneurysm rupture
—
Group II
(autologous)
(%)
P
.275*
23 (79)
6 (21)
3 (10)
3 (10)
.953*
24 (83)
5 (17)
1.00†
25 (86)
4 (14)
.691*
Kaplan-Maier postintervention primary patency curves. SE, standard error.
stenosed or thrombosed (or both). In 15 (50%) of group I
patients, interposition PTFE grafts were placed in the middle of the cannulable portion of the vein, in one revised
radiocephalic fistula a secondary cephalic vein branch was
anastomosed to the PTFE graft. The remaining 15 group I
patients with type-I lesions were treated with interposition
PTFE grafts anastomosed to a patent nonstenosed vein cuff
always present in these series 1 to 2 cm from the original
arteriovenous anastomosis. Surgical incisions were kept
short for conservation of the accessible cannulation vein.
Five patients (17%) were referred for hemodialysis 4 to 6
hours after the surgical intervention, while the remaining
patients (83%) were referred the day after the procedure.
Except for a small hematoma, no perioperative complications were observed.
In group II, 24 (83%) of the 29 patients had failing
accesses. One radiocephalic fistula presented with anastomotic aneurysm, 1 brachiocephalic fistula presented with a
ruptured vein aneurysm, 2 autogenous fistulas at the elbow
presented with clinically significant steal syndrome, and 2
others had difficult vein cannulation. Two additional radiocephalic fistulas presented with low inflow conditions. The
remaining 16 failing autogenous accesses (1 brachiocephalic, 15 radiocephalic fistulas) had stenosis of the outflow
vein at presentation. Five recently clotted radiocephalic
fistulas (thrombosis of a stenotic lesion) completed the
non-PTFE–revised group.
A new autogenous radiocephalic fistula to a more proximal forearm level was performed in 19 group II patients, a
radiocephalic fistula from an autogenous brachiobasilic fistula was performed in 1, an autogenous brachial-cephalic
forearm looped transposition was done in 2, an autogenous
ulnar-cephalic forearm looped transposition in 1, brachiobasilic transpositions were performed in 2, and vein tributaries ligated in 1 patient. Small segments of the cannulation vein were resected in 3 patients and the vein
anastomosed in an end-to-end fashion. In all patients,
immediate cannulation was achievable either in afferent or
efferent dilated vein segments from previous longstanding
forearm fistulas.
In group I, the usable vein ready for immediate cannulation was more than 14 cm in 16 (53%) patients and 7 to
14 cm long in the remaining 14 (47%) patients, whereas the
corresponding cannulation vein lengths for group II were
more than 14 cm in 23 (79%) patients and 7 to 14 cm in 6
(21%) patients. There was a trend (␹2 test, P ⫽ .06) for
group II patients to have a longer vein for cannulation after
revision.
There was no statistical difference between the two
groups regarding patient demographic data and baseline
access characteristics (Tables I and II). Postintervention
primary cumulative patency in group I was 100% at 6
months, 88% at 12 months, and 82% at 18 months, whereas
the corresponding patency for group II was 90% at 6
months, 82% at 12 months, and 71% at 18 months. No
statistical differences in postintervention patency rates were
observed between the two groups (Fig).
In group I, two patients required a second revision in
their failing accesses. During the follow-up, six (20%) accesses eventually thrombosed in group I and seven (24%) in
group II and had to be converted to other access configurations by the use of longer synthetic segments or more
proximal autogenous accesses. A radiocephalic fistula at the
wrist (group I) was abandoned because of venous hypertension after unsuccessful angioplasty for subclavian vein
stenosis. A patient with basilic vein transposition from
group II entered group I because of segmental basilic vein
replacement with a short PTFE graft. Seven (24%) of the 29
group II patients and 1 (3%) of the 30 group I patients died
during follow-up with patent accesses. A kidney transplant
was successful in another patient from group I. Forty-nine
16 (55)
5 (17)
2 (7)
2 (7)
2 (7)
1 (3)
1 (3)
PTFE, Polytetrafluoroethylene; AVF, arteriovenous fistula.
*␹2 test.
†
Fisher-exact test, two-tailed P values.
JOURNAL OF VASCULAR SURGERY
Volume 41, Number 1
Georgiadis et al 79
Table III. Post-intervention patency rates in revised native arteriovenous fistulas from the current literature
Authors
Access type
(n)
Treatment
Type of treatment
6 mo
12 mo
E: Declotting ⫹ PTA
S: More proximal anastomosis/short
prosthetic graft/patch/vein
transposition
PTA/PTA ⫹ stenting
79%
64%
67%
57%
74%
E: 80%
S: 80%
51%
35%
47%
E: 80%
S: 80%
37%
58%
44%
40%
56%
39%
26%
55%
97%
72%
26%
86%
68%
77%
Oakes et al 19974
LAF, f ⫹ t (22)
E⫹S
Turmel-Rodriguez et al 20006
E
Hingorani et al 20013
LAF, f (155)
UAF, f (65)
LAF, t (54)
LAF (18)
UAF (31) f ⫽ 45,
t⫽2
Manninen et al 200134
LAF, f ⫹ t (53)
E
Turmel-Rodriguez et al 20017
LAF, f (52)
LAF, t (17)
LAF, f (53)
LAF, f (32)
LAF, f (55)
UAF, f (45)
E
Clark et al 20029
Tessitore et al 200327
Bethard et al 200310
E⫹S
E
E
E
E: PTA alone/PTA ⫹ stenting
S: Vein patch/interposition graft/
AVF to a more proximal level/
extension bypass
PTA alone/PTA ⫹ stenting/PTA ⫹
brachytherapy/thrombolysis ⫹
PTA
PTA alone/PTA ⫹ stenting/
thromboaspiration ⫹ PTA
PTA alone/PTA ⫹ stenting
PTA alone
PTA alone/PTA ⫹ accessory vein
obliteration
24 mo
LAF, Lower arm fistula; UAF, upper arm fistula; E, endovascular; S, surgical; f, failing; t, thrombosed; PTA, balloon angioplasty; AVF, arteriovenous fistula.
(85%) of the remaining 58 patients are still on long-term
hemodialysis; of these, 36 receive dialysis through their
revised accesses on the same arm as their original AVF.
DISCUSSION
A native radiocephalic AVF remains the preferred option for every patient who undergoes dialysis.1,13-18 This
procedure still remains the initial access of choice 38 years
after the historic report by Brescia et al19 because it has the
lowest complication rate, including thrombosis, stenosis,
and infection, among all vascular access procedures.1,20,21
Alternative types of autogenous AVFs have also been described in all types of suboptimal outflow vein anatomy.
However, before proceeding to more proximal procedures,
access life can be extended by performing revisions either
by surgical3,4,22-26 or endovascular3,4,6,7-9,10,24,25,27
methods. Early detected and timely corrected vein lesions
may minimize the possibility of complicated operations,
patient morbidity, and more important, predict better patency rates.3,6,7,25,28 Stenosis or thrombosis may be present
in every segment of the cannulable outflow vein.6,7
Polo et al29 introduced the short interposition PTFE
graft procedure to overcome cases in which brachiocephalic
fistulae were not constructible at the elbow crease owing to
the absence of the median antecubital vein. The “brachialcephalic jump-graft fistula” resulted when short interposition grafts were placed between the brachial artery and the
cephalic vein at the upper arm.29 The method of repair used
in group I has the same concept. Rather than constructing
another autogenous fistula at a higher level in case of type I
or II lesions, a short PTFE graft was used to cover the
“gap” after the lesion was removed. The configuration that
was used in group I has also been reported by other authors
but was presented in small numbers as part of various
salvage procedure studies.3,4
Primary postintervention cumulative patency rates of
the revised accesses with PTFE were not different in a
statistically significant level compared with those of revised
AVFs without the use of PTFE. Infection rates also remained the same between the two groups, leading to the
conclusion that the use of a short interposition PTFE
segment of less than 6 cm in length does not change the
autogenous behavior of the vascular access. Group II,
which contained a wide range of lesions including steal,
aneurysms, and poor inflow, confounded the comparison
to some extent; however, the simple message that the use of
short PTFE interposition grafts is not deleterious in general
can be justified. Many surgeons have been reluctant to
perform similar revisions because of an erroneous perception that PTFE would lead to poor results.
Recent review of 34 studies in which dialysis accesses
patency was reported revealed that primary and secondary
patency for all autogenous AVFs was 72% and 86% at 6
months and 51% and 77% at 18 months, respectively.24 In
the present study, similar patencies are reported but for
revised accesses, competing with the “best possible evidence” from the literature. These results justify a very
strong revision policy instead of embarking to a new more
proximal access according to DOQI standards.1
The use of translocated autogenous grafts such as the
saphenous vein3 is also an option; however, harvesting the
long saphenous vein as a substitute for short lesions may
have drawbacks because the prolonged operative time is
not ideal for the aged population. In addition, outflow
veins in long-standing AVFs are much too dilated and thus
contribute to anastomotic mismatch if such a correction is
considered. One may overcome anastomotic mismatch by
using the superficial femoral vein; however, the magnitude
of the procedure and the significant complication rate when
the superficial femoral vein is used limits this graft for
JOURNAL OF VASCULAR SURGERY
January 2005
80 Georgiadis et al
exceptional cases.30 The use of a small PTFE segment
instead of vein has a theoretical advantage in that the
venous capital of the patient remains unharmed.
Based on earlier reports, Kumpe et al31 stated that only
a minority of thrombosed AVFs can be salvaged surgically.
For this reason, salvage procedures were not attempted on
thrombosed AVFs. Endovascular interventions have, however, revolutionized the treatment of failing or failed native
fistulas. Although some authors3,6,7,27 have reported excellent results with such methods, the optimal treatment of
failing or thrombosed native AVFs remains unresolved as
no randomized studies have compared the various surgical
and interventional methods. In a nonrandomized study,
Hingorani et al3 reported no statistical difference in patency
rates between surgical or endovascular methods in native
malfunctioning or occluded AVFs, but angioplasty was
reserved only for lesions of less than 1 cm and more
extended lesions were repaired surgically.
A meta-analysis of randomized controlled trials comparing open and endovascular treatment of thrombosed
prosthetic grafts found that the endovascular techniques
were inferior to surgery in terms of primary patency.32The
strength of these results has been criticized,33 however, and
their extrapolation to thrombosed native accesses is questionable as the stenotic lesions in prosthetic grafts have
different locations predominantly in the distal venous anastomosis.
Several other studies, mainly on failing native dysfunctional accesses, report a great variation of results and many
different rescue procedures that do not permit definitive
conclusions about the advantages of interventional or surgical treatment (Table III). Postintervention patency rates
differ greatly among units, a variation also mentioned by
Hodges et al.23 Differences in demographic data and poor
surveillance programs in the past can partly explain the
conflicting results with the present data since newer methods are able to predict more stenotic or thrombotic
events.6,28
It is obvious that the quality of evidence regarding the
management of failing or failed native AVFs is limited and
the clinical decision about which treatment is best for which
stenosis remains unclear. There is some agreement that
endovascular treatment for type I stenosis is not recommended, and even dedicated radiologists propose surgical
revision for this type of lesion.2,34 There is no optimal
treatment for type II stenosis, however. Minimal invasiveness and preservation of the full amount of access length
support the endovascular approach, whereas multiple lesions, previous failure, and lack of an available expert interventionalist are indications for surgical repair.
Regarding the type of surgical treatment, autogenous
revisions would be preferable, whereas short PTFE insertion would be preferred where the cannulable vein length is
limited. In this study, the use of a small piece of PTFE
resulted in satisfactory midterm primary patency without
further consumption of the venous capital by harvesting
segments of vein from other locations and without compromising more proximal access sites.
These data suggest that short (⬍6 cm) PTFE segments
used for revising failing or failed AVFs compare favorably to
purely native repair and do not alter the autologous behavior of the initial access. For this reason, this practice is
recommended and is justified as part of an aggressive access
salvage policy that has been addressed by many authors so
far.
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Submitted, Aug 28, 2004; accepted, Oct 21, 2004.