Axillary-Axillary Bovine Arteriovenous Fistula for Hemodialysis Maj Larry G. Manning, MC, USAF; Lt Col David J. Mozersky, MC, USAF; Maj Harry M. Murray, MC, USAF; Col Clyde O. Hagood, MC. USAF A preliminary evaluation of bovine carotid artery heterografts as axillary-axillary arteriovenous fistulas suggests that this graft may be an easily constructed and easily utilized portal for hemodialysis cannulation. At present, this fistula should be reserved for use when all other commonly employed peripheral sites and methods of constructing arteriovenous fistulas have been exhausted.
long-term hemodialysis Chronicproblem therapeutic modality providing
has become a com¬ in most large medical cen¬ of access to the circulation for ters. The this purpose is one that has challenged the ingenuity of many workers. At Wilford Hall USAF Medical Center we have recently treated two patients in whom all commonly used sites for creating arteriovenous anastomoses had been exhausted, and in whom continued hemodialysis by any of the usual portals was not possible. An axillary-axillary arterio¬ venous fistula using a bovine carotid arterial heterograft was created in these patients that provided excellent ac¬ cess to the circulation. The purpose of the present report is to describe the operative technique and to demonstrate the efficacy of the procedure. mon
SUBJECTS Two anephric patients in whom the peripheral vessels of the up¬ per and lower extremities had been previously used for either ex¬ ternal arteriovenous shunts or the creation of internal arterio¬ venous fistulas were referred to our Vascular Surgery Unit for the purpose of providing access for hemodialysis. In addition to the fact that the usual peripheral sites were no longer available, both patients had had extensive surgery on more
proximal vessels. One patient had had an aortobifemoral bypass, two attempts at revascularizing his kidneys that consumed his saphenoui veins, an occlusion of the brachial artery on one side that resulted from a previous arteriogram, and multiple venipunc¬ tures that had obliterated the superficial veins in the other arm. The other patient had had a total of 12 previous access proce¬ dures, superficial and deep thrombophlebitis in one leg, and a prior attempt to employ a femoral-saphenous bovine carotid arte-
Accepted for publication July 23, 1974. From the General Surgery Service, Department of Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, Tex. Reprint requests to General Surgery Service, Wilford Hall USAF Medical Center, Lackland Air Force Base, TX 78236 (Dr. Manning).
riovenous fistula in the other. This latter operation failed and had to be removed due to infection of the graft. A recently constructed side-to-side internal arteriovenous fistula in her right wrist was functioning but failed to produce dilation of any veins suitable for dialysis. At the time of our evaluation, she was being inadequately maintained on peritoneal dialysis. Because of the great difficulties encountered in both patients in the past, it was necessary to consider a unique alternative tech¬ nique. We believed that a subcutaneous axillary-axillary arterio¬ venous fistula using a bovine carotid heterograft might provide an effective, though rather unorthodox, portal of entry for hemodial¬
ysis.
OPERATIVE
TECHNIQUE
The operative procedure was identical in both patients. The first portions of the axillary vessels were exposed bilaterally through small incisions in the anterior chest wall. Seven-centime¬ ter transverse incisions were made on a line extending from the angle of Louis to the coracoid process. The sternal and clavicular heads of the pectoralis major were split and retracted. The clavipectoral fascia was then incised, giving access to the apex of the axilla. The first portions of the axillary vein and artery were then dissected and prepared for anastomosis. A presternal subcutane¬ ous tunnel was fashioned so that its diameter was slightly larger than that of the bovine heterograft. For the purposes of con¬ sistency, the left axillary artery and right axillary vein were used for anastomoses in both patients. A bovine heterograft 8 mm in diameter was then tailored and sutured end to side to the left ax¬ illary artery with 5-0 synthetic vascular suture. The graft was threaded across the sternum through the subcutaneous tunnel and then anastomosed to the right axillary vein. A small ellipse of vein was excised to facilitate the anastomosis. The graft was flushed with arterial blood to avoid kinking and angulation prior to com¬ pletion of the venous anastomosis. When the axillary vein anasto¬ mosis was completed, a prompt thrill was noted in the graft. After hemostasia had been obtained, the subcutaneous tissue and skin were closed. No attempt was made to close the deeper muscular layers. No drains were left in the anastomotic incisions.
POSTOPERATIVE COURSE Three
days postgrafting,
the first cannulations
were
performed in the anterior sternal region without diffi¬ culty. The procedure for cannulation and dialysis was car¬ ried out through a single needle technique in the standard fashion. Adequate blood flow rates were routinely achieved.
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Both patients' grafts have been used for hemodialysis three times weekly for three months. No difficulty with cannulation has been experienced and, as noted by others,1 the ease with which graft puncture is accomplished is su¬ perior to that encountered with the routine internal arte¬ riovenous fistula. The first patient operated on experi¬ enced mild hematoma formation at the cannulation site during the first week of usage. This complication was be¬ lieved to result from too extensive a dissection during the creation of the subcutaneous sternal tunnel. No further difficulties have been encountered. Although the systolic pressure in the left arms of both patients decreased approximately 40 mm Hg postopera¬ tively, close patient follow-up to date has revealed no clin¬ ical evidence of chronic arterial insufficiency in either up¬ per extremity. Initial mild edema was noted in the right upper extremities of both patients following the operative procedure. This was adequately controlled with elevation and elastic support. Both patients had a mild increase in their pulse rate postoperatively; however, there has been no overt evidence of undesirable cardiac effect from the fistulas. In neither patient has the pulse rate risen over 85 beats per minute. The hemodynamic characteristics of the fistulas, including pressure-flow relationships and altered systemic and/or cardiac effects, are presently being inves¬ tigated in these patients and will be the subject of a later
report.
COMMENT
The use of surgically created internal arteriovenous fis¬ tulas for hemodialysis was initially described by Brescia and co-workers.2 Cerili i and Limbert" have reported a high patency rate and low complication rate for internal fis¬ tulas. However, due to technical and other factors, these fistulas occasionally fail. Other portals of entry into the circulation for dialysis purposes must then be established. Numerous ingenious techniques have previously been de¬ vised for this purpose. When the forearm system of veins becomes inadequate or a suitable vein, such as the cephalic or saphenous, is not available for use, one must consider other grafting mate¬ rials. The silicone Dacron mandril1 has been used in sev¬ eral patients for this purpose. Its disadvantage is that it requires a minimum of six weeks for harvesting, and many of these patients cannot wait for that length of time. Chinitz and his co-workers1 reported the use of bo¬ vine heterograft as a prosthesis for creating arterio¬ venous fistulas in the arm or thigh with good results. Since these areas were no longer available in our patients, other possible access sites for constructing an arteriovenous fis-
tula A
were
considered.
well-functioning internal arteriovenous fistula should provide long-lasting easy access to the circulation. It should not limit the patient either during dialysis or dur¬ ing the pursuit of normal daily activities between dialysis. The hemodynamic effects of the fistula, moreover, should provide no local or systemic circulatory problems. Our experience with axillary-axillary Dacron bypass grafts in patients with symptomatic subclavian and in¬ nominate occlusions suggested the feasibility of using the easily approached first portion of the axillary vessels. The experience of Chinitz et al1 has further indicated that the bovine carotid heterograft is a durable and useful mate¬ rial for hemodialysis. The presternal location is appealing because cannulation of the bovine heterograft conduit leaves both arms and legs free during hemodialysis. More¬ over, our past experience has indicated that arterial sub¬ stitutes in this area are relatively free from the effects of local trauma and are tolerated extremely well by the pa¬ tients. The hemodynamic effects will be more clearly de¬ fined in a future publication; however, neither the local circulatory effects nor the increase in cardiac performance provided by these grafts have thus far proved trouble¬ some. If problems should occur at a later time, the super¬ ficial presternal location of the graft would be easily ac¬ cessible to surgical interruption or partial occlusion. The work of Osier and Szilagyi and his associates" has sug¬ gested, however, that sizable arteriovenous fistulas may be tolerated extremely well for long periods of time. It will be necessary to gain further experience and longer follow-up in patients with axillary-axillary fistulas before definite conclusions can be drawn. Our early obser¬ vations, however, would suggest that axillary-axillary ar¬ teriovenous fistulas may provide excellent access to the circulation in selected patients. References 1. Chinitz JL, Yokoyama T, Bower R, et al: Self-sealing prosthesis for arteriovenous fistula in man. Trans Am Soc Artif Intern Organs 18:452-455, 1972. 2. Brescia MJ, Cimino JE, Appel K, et al: Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 275:1089-1092, 1966. 3. Cerilli J, Limbert JG: Technique and results of the construction of arteriovenous fistulas for hemodialysis. Surg Gynecol Obstet 137:922-924, 1973. 4. Beemer RK, Hayes JF: Hemodialysis using a mandril-grown graft. Trans Am Soc Artif Intern Organs 19:43-44, 1973. 5. Osler W: An arterio-venous aneurysm of the axillary vessels of 30 years' duration. Lancet 2:1248-1249, 1913. 6. Szilagyi DE, Elliott JP, DeRusso FJ, et al: Peripheral congenital arteriovenous fistulas. Surgery 57:61-81, 1965.
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