RETROGRADE ANTECUBITAL ARTERIOVENOUS FISTULA FOR CHRONIC HEMODIALYSIS R. ADAR, M.D., F.I.C.A., E. ANTEBI, M.D., A. IAINA, M.D., F.I.C.A.

AND

M. MOZES, M.D.,

A small proportion of patients requiring repeated access to the circulation for chronic hemodialysis do not have adequate vasculature at the wrist. These are usually patients who have had multiple previous external or internal shunts performed, in whom the veins or the arteries or both are thrombosed or

Fic. 1

ligated. The use of saphenous vein autografts can solve many of these difficult problems. 1, However, some patients do not have a suitable segment of autogenous vein available for transplantation. An alternative solution to this difficult

problem

is the construction of

Department of General and Vascular Surgery, and Department of Medical Center and Tel-Aviv University Medical School. 160

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a

Nephrology, Chaim Sheba

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retrograde end to side antecubital arteriovenous fistula (AVF). The procedure can be performed under local anesthesia. An antecubital vein is mobilised and transected. The proximal vein is ligated and the distal end is anastomosed to the side of the brachial artery with a continuous 6-0 Tycron suture. Over the following 6-12 weeks the arterial pressure causes dilation of the vein and renders the valves incompetent. This process progressively develops more tributaries and increases flow in the draining veins. Between March 1971 and June 1974 four patients had a retrograde antecubital AVF constructed. One patient died of unrelated causes shortly after operation and one patient is too recent. The other two have undergone regular hemodialysis with this fistula for 18 and 26 months respectively. Hemodialysis was started 8 and 12 weeks after construction of the fistula, an external shunt being used during the time required for adequate arterialisation of the veins. Both patients experienced some swelling of the hand, but this was transient. No signs of arterial insufficiency or congestive heart failure were evident. The arterialised veins are seen in Figure 1. COMMENT

The standard wrist fistula and the autogenous saphenous vein graft fistula that can be used early after surgery are preferable whenever feasible. When these alternatives are not available we believe that the retrograde antecubital AVF, if technically feasible, should be preferred over the use of allografts or synthetic grafts, especially if some alternative can be used for the short period needed for adequate arterialisation of’ the veins. Haimov et al.~ found that the side to side antecubital AVF was problematic. The rapid cephalad flow caused distal arterial insufficiency and slowed down the retrograde arterialisation of the distal veins. Swelling of the forearm was also a continuous problem in one of their two cases. The experience of Graben et a1.3 was however similar to ours finding the retrograde end to side antecubital AVF a satisfactory procedure in suitable patients. R. Adar, M.D. Chaim Sheba Medical Center Tel-Aviv University Tel-Aviv, Israel REFERENCES 1.

Adar, R., Siegal, A., Bogokowsky, H. E. and Mozes, M.: The

of arteriovenous autografts 136: 941, 1973. 2. Haimov, M., Burrows, L., Baer, A., Neff, M. and Slifkin, R.: Alternatives for vascular access for hemodialysis: Experience with autogenous saphenous vein autografts and bovine heterografts. Surgery 75: 447, 1974. 3. Graben, N., Cremer, W., and Heimsoth, V. H.: A retrograde arteriovenous forearm fistula. Proc. Europ. Dial. Trnspl. Assoc. 10: 528, 1973.

and allograft fistulas for chronic

use

hemodialysis. Surg. Gynec. & Obst.,

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Retrograde antecubital arteriovenous fistula for chronic hemodialysis.

RETROGRADE ANTECUBITAL ARTERIOVENOUS FISTULA FOR CHRONIC HEMODIALYSIS R. ADAR, M.D., F.I.C.A., E. ANTEBI, M.D., A. IAINA, M.D., F.I.C.A. AND M. MOZE...
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