Cardiovasc Intervent Radiol DOI 10.1007/s00270-015-1155-7

REVIEW

Surgical Options in the Problematic Arteriovenous Haemodialysis Access Rachael O. Forsythe1 • Eric S. Chemla2

Received: 25 February 2014 / Accepted: 30 May 2015 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2015

Abstract The aim of the paper is to review surgical options in problematic arteriovenous haemodialysis access—in particular, to explore and discuss some surgical alternatives to interventional radiology in the case of failing, failed or complicated arteriovenous access. There is copious evidence to support endovascular techniques to treat non-maturation, stenosis, thrombosis and other complications of arteriovenous access. However, there may be times when the surgery-first approach might be a useful adjunct, alternative or even preferable, including the creation or revision of an anastomosis in the forearm, which may yield better patency rates than endovascular intervention. The creation and maintenance of haemodialysis access can be a complex process and the surgeon and the interventional radiologist should work closely together. The distinct roles of the surgeon and the interventional radiologist in the treatment of a problematic arteriovenous access remain debatable and the authors suggest a multidisciplinary team approach when planning treatment of access complications, which may require repeated interventions.

& Eric S. Chemla [email protected] Rachael O. Forsythe [email protected] 1

Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK

2

St Georges Vascular Institute, Grosvenor Wing, St George’s Healthcare NHS Trust, Blackshaw Road, London SW17 0 QT, UK

Keywords Dialysis access
End-stage renal disease
Peripheral vascular

Introduction Haemodialysis (HD) is the most widely used method of renal replacement therapy (RRT) for patients with endstage renal disease (ESRD) who may be awaiting, or deemed unsuitable for, organ transplantation. As the number of patients with ESRD increases and life expectancy continues to rise, the issue of establishing, maintaining and preserving RRT continues to challenge the team involved in the care of such patients. In some cases, the establishment and maintenance of arteriovenous (AV) HD access may be straightforward, however, many patients require multiple surgical and radiological interventions to establish or maintain patency. The requirement for an experienced vascular access surgeon working closely with the interventional radiologist (IR) is particularly pertinent. The rapid expansion of IR techniques and the increasingly important role of the IR in HD is addressed in the recently published European Curriculum and Syllabus for Interventional Radiology [1] and minimally invasive interventions continue to play an important role in the upkeep of surgically placed vascular access. In parallel to this, however, the surgical repertoire continues to flourish and knowledge of the surgeon’s role in HD access is important for the IR to grasp. Whilst there is strong evidence to support an endovascular-first approach to many of the problems leading to AV access failure, there may be situations where an alternative primary surgery approach is useful when attempting to salvage access, or treat complications. A previous review published in the same journal addressed the role of the IR

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R. O. Forsythe, E. S. Chemla: Surgical Options in the Problematic Arteriovenous Haemodialysis Access

in the multi-disciplinary team approach to HD access [2]; the scope of this paper is to explore the role of the surgeon in such a team, particularly focussing on surgical options in the case of a failing, failed or complicated AV access. In order to provide a framework and to address the many issues surrounding vascular access, many international organisations have produced consensus guidelines [3–7], however, there is often a discrepancy between official recommendations and actual clinical practice, which may vary substantially between individual HD units and countries [8]. The provision of services for vascular access is complex, and the need for coordinating a range of specialities may be difficult to achieve, particularly in smaller centres. In addition, international variation in practice and health provision means that guidelines may not be easily transferable between countries. The roles of each contributing clinician have also come to overlap in some regions; whilst the creation of surgical HD access is the domain of the vascular access surgeon in the UK, many countries have developed the role of the ‘interventional nephrologist’ to include AV access formation and upkeep [9]. There is a lack of robust evidence to guide teams about treating patients with problematic access, however, treatment of patients by an experienced multi-disciplinary team should lead to good outcomes.

Identifying and Investigating the Problematic Arteriovenous Access Complications and consequences of vascular access can be significant and there is a wide reported variation in primary and secondary patency rates, depending on many variables including the site and type of access created. Recent reports of AVF primary failure and 1 year primary patency demonstrate rates of 23–70 and 40–70 %, respectively (for all types of AVF) [10–12]. The superiority of patency, clinical outcomes and cost effectiveness of AVFs over AVGs is widely recognised [13–15] and autologous fistula should usually be prioritised over AVG [16], unless the patient is clinically unsuitable for native AVF creation (e.g. poor prognosis, or urgent access required) [3, 17, 18]. One exception to this rule is the creation of an upper limb AVG if all upper limb native options are exhausted and preservation of the lower limb is required [6]. The rate of failure differs according to AV access location [19]—a meta-analysis of radiocephalic AVF demonstrated 62.5 and 66 % pooled primary and secondary patency rates for radiocephalic AVF [20], whereas a multicentre study demonstrated primary and assisted primary 1-year patency rates of 46 and 87 %, respectively, for brachio-basilic AVFs, as well as superiority over prosthetic brachial-antecubital loop grafts [21].

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Issues including early failure, infection, thrombosis, anastomotic issues, stenosis, hand ischaemia and aneurysm formation contribute to primary failure; maintaining suitable and adequately functioning vascular access may therefore require multiple interventions. Many access problems may be initially detected clinically—a recent study has demonstrated no significant difference in the level of agreement between physical examination and angiography in the detection of outflow or inflow stenosis [22] and another suggests that experienced vascular access nurses may be able to clinically predict AVF failure at an early stage in 80 % of cases [23]. In addition, bedside tests including flow measurements, transonic ultrasound, recirculation studies and on-dialysis pressure measurements may help to identify the failing fistula, however, more detailed imaging (such as angiography) should be sought if flow falls below 500 ml/min (AVF) or\650 ml/min (AVG), reduces by more than 20 % from baseline [24] or if the access has clearly failed. Whilst conventional angiography is the gold standard for investigating problematic AV access, CT venography may also be used in dialysis-established patients, however, the use of iodinated contrast agents in dialysis-naı¨ve patients (in the case of primary failure of a first AV access) carries a high risk of worsening renal function. Iodinated contrast in patients with residual renal function should be avoided if possible, or the dose minimised and preventative measures taken to reduce the risk of deteriorating renal function, such as the use of low volume doses of iso-osmolar or non-ionic low osmolar contrast agents, prophylactic NAC administration or pre- and post-contrast HD in patients with established access. Alternatively, gadoliniumbased contrast agents have been successfully and safely used when assessing a patient for dialysis [25] and carbondioxide may be used as an alternative contrast agent. However, gadolinium-based agents carry the risk of nephrogenic systemic fibrosis, which is a rare but serious complication; this risk is much lower in cyclical gadolinium-based contrast (such as Gadovist or ProHance), which are less likely to release free gadolinium into the circulation than linear agents (such as Omniscan or OptiMARK). Some clinicians avoid the use of CT venography altogether in these patients, due to concern about iatrogenic damage to peripheral veins, however, views are often inadequate using duplex alone, particularly in the central veins. The less invasive imaging modality of duplex ultrasonography plays an important role in investigating and detecting clinically significant stenosis, particularly within the early post-operative period. A single duplex scan performed within the first 2–4 months with the specific aim of measuring minimum venous diameter and blood flow, is highly predictive of fistula maturation and the ability to dialyse [23]. Studies have shown that over 90 % of AVFs

R. O. Forsythe, E. S. Chemla: Surgical Options in the Problematic Arteriovenous Haemodialysis Access

that fail to mature may be useable after correction of the underlying lesion [26] and early detection and treatment is, therefore, paramount. However, despite guidelines issued to the contrary, there is little robust evidence supporting routine surveillance of AV access or a role for pre-emptive treatment of stenosis. One recent review demonstrated that routine AVG surveillance did not improve graft survival or reduce thrombosis and that AVF surveillance reduced the rate of thrombosis but did not increase AVF survival [27]. A more recent review suggests that surveillance of vascular access blood flow may be useful in screening mature fistulas for early failure [28] and a study by the same group suggests that elective treatment of subclinical stenosis in functioning AVFs significantly reduces the risk of access loss, compared to treatment of stenosis only when it reaches haemodynamically significance [29]. Many centres continue to use a routine surveillance programme and intervene only when access flow and function are compromised by the presence of stenosis, in accordance with KDOQI guidelines [3].

Surgical Treatment of Primary AVF Failure Primary failure rates of AVFs (defined as ‘complication of the AVF prior to first cannulation’) have been shown to vary between centres—the CIMINO (Care Improvement by Multidisciplinary approach for Increase in Native vascular access Obtainment) group has identified that primary failure is strongly related to the centre of access creation [30], thus is the surgeon’s pre-operative planning and decision-making an important role in AV access care. The distinct roles of surgeon and IR in the treatment of AV access failure are still debatable and there are no strong randomised controlled trials to provide adequate evidence for the preference of one over the other to improve functionality of failing access. The decision on the appropriate management strategy should be taken in a multi-disciplinary setting and will be influenced by local expertise. As a starting point, however, the surgeon may know, from the operative events, the possible aetiology of early HD access failure, whether it be the presence of multiple side branches, an atherosclerotic inflow artery or a potential kink in the prosthetic graft as it travels through the tunnel. Firsthand knowledge of the operative details will help to direct the appropriate investigations and intervention. Furthermore, the aim of intervention should be not only to conserve flow but also to preserve functionality of the needling segment. Whilst there is undoubtedly a role for primary endovascular treatment of AVF failure, surgical treatment of AVF failure has a high clinical and technical success

rate [31]; 1 year primary and secondary patency following surgical intervention to treat cannulation complications were 60 and 71 %, respectively, in one study [32]. Non-maturation AVF maturation involves vessel wall remodelling and enlargement of the feeding artery and arterilaized vein as a response to increased flow and pressure [33]. Fistula nonmaturation may be defined as ‘insufficient AVF flow to maintain HD after a maturation period of 6 weeks’ and may occur in up to 60 % of patients [34]. If there is impedance to the increased pressure and flow, non-maturation may result and lead to primary failure; the majority of non-matured AVFs have a stenosis or anatomical issue. However, altered haemodynamics and increased turbulence (worsened by vein-to-artery mismatch) may also contribute to intimal damage, leading to intimal hyperplasia and subsequent stenosis. Surgical trauma at the time of AVF creation may cause intimal damage and predispose to stenosis or thrombus, whilst accessory veins may divert flow away from the AVF, and can also lead to non-maturation. In addition, small arterial diameter increases the rate of AVF failure and a minimal lumen diameter of 2 mm is often quoted, however, this is a controversial issue, with some centres demonstrating good results using arteries \1.6 mm in diameter, using microsurgical techniques [35]. In an AVF with a diameter [4 mm, one review has demonstrated that adequate dialysis may be achieved in 86 % of cases, compared to 44 % with AVF diameter \4 mm [23], however, diseased or narrowed inflow vessels may be amenable to angioplasty in the event of AVF non-maturation [36]. Early treatment of non-mature AVFs is often successful, resulting in secondary patency rates comparable to AVFs that readily mature, however few studies have reported direct comparisons in outcomes between the endovascular or surgical approach. One study reported a 1-year primary patency of 71 % for surgical treatment of non-mature AVFs (due to stenosis), compared to 41 % for radiological treatment [37]. A further group initially demonstrated no difference in AVF survival in surgical or endovascular treatment to promote maturation in AVFs [38] but a subsequent study by the same group suggested that cumulative 1-year survival in patients undergoing surgical intervention to promote maturation was higher when compared to endovascular intervention (83 vs. 40 %) [39]. One hypothesis for this finding is that endovascular treatment may cause endothelial injury, leading to intimal damage and rapid stenosis, whereas the surgical revision or creation of a new anastomosis may be less traumatic on the area of at-risk endothelium [39].

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Low venous flow in the immediate postoperative period (considered by some as \170 ml/min for radiocephalic AVFs and \280 ml/min for brachiocephalic AVFs 10 min after creation) may signal the highest risk of non-maturation [31], whilst the combination of low flow and small venous diameter detected on ultrasound within the first 2–4 months following fistula creation signifies a high risk of non-maturation (flow \500 ml/min and vein diameter \4 mm in upper arm AVF) [23]. Early treatment of nonmaturation is therefore advised and can be facilitated by regular duplex scanning in the first few weeks following AVF creation. In most cases of non-maturation, there is an underlying stenosis, usually amenable to endovascular treatment, with good results [40]. Alternatively, if the stenosis is located directly at the anastomosis, the surgical option of excision and reimplantation may be more useful [40]. The treatment of stenosis in the mature AVF is further discussed later in the article. Another possible cause of a non-maturing AVF is the presence of large accessory veins, which may divert flow from the main vein and are often associated with downstream stenosis [41]. The treatment of accessory veins remains controversial but may include surgical ligation or radiological embolization. Some authors believe that all accessory veins should be treated [42], others maintain that accessory veins only exist in the presence of underlying stenosis (which should be treated) and therefore should not require intervention and some suggest that accessory veins only require treatment if significant filling continues despite successful treatment of the stenotic lesion [43]. If required, surgical ligation of accessory veins may be performed under local anaesthetic, by introducing a phlebectomy hook introduced through small stab incisions to locate the veins, bringing them out of the wound to allow ligation. Alternatively, coil emobolisation of the largest accessory vein may be performed successfully, with concurrent angioplasty [43]. A further reason for non-maturation is a deeply located vein, which will require a surgical correction if the AVF is too deep to safely cannulate. The vein may be superficialised by elevating and transposing the vein directly under the wound, or creating a tunnelled transposition to a more accessible location for needling. This may require reimplantation of the anastomosis. An alternative to the transposition approach is the method of second-stage surgical lipectomy, which has been shown to effectively allow superficialisation of arterialized vein in the case of an AVF which is not amenable to needling [44] and may cause less trauma to the AVF. Lipectomy involves removing the excess adipose tissue between the vein and the skin, by excising the fat pad and fascia overlying the vein and has high rates of primary and secondary patency (71 and 98 %

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at 1 year, respectively) [32]. This technique may prove useful in the future in the case of obese patients who may have relatively preserved veins due to the depth beneath the skin. Therefore, a deeply located vein should not be a contraindication for AVF creation. Stenosis in Mature Fistulas There are comparative studies evaluating the treatment of peri-anastomotic stenosis in mature fistulas with surgical versus endovascular treatment, however, no prospective randomised studies to inform on the feasibility and outcomes in an unselected population. Most centres avoid endovascular intervention to treat early stenosis (within the first few weeks following AVF creation) due to the risk of disruption of the anastomosis. In general, the intervention criteria for stenotic AV access may include: poor flow, poor dialysis or thrombosis with an associated 50 % reduction in diameter due to stenosis [45, 46]. Forearm AVF stenoses are often amenable to primary endovascular treatment by PTA, however, restenosis is more common following endovascular treatment when compared with surgical revision—almost 3 times higher, in one study [47]. Despite this, with strict surveillance, there may be a similar assisted primary patency rate and cost effectiveness between PTA and surgery to treat juxtaanastomotic stenosis in forearms AVFs [47] and the goal should be secondary patency and preservation of the access in the long term. In the case of lower forearm AVF stenosis, surgical revision of the anastomosis is preferable to endovascular intervention, due to wide reports of improved patency [39]. Surgical revision may include creation of a neo-anastomosis proximal to the stenosis, vein patching, a short synthetic graft interposition to exclude the stenosis or vein-to-vein re-anastomosis. Outcomes after angioplasty for cephalic arch stenosis are relatively disappointing, due to early re-stenosis, vein rupture and resistance to dilatation in this area. Stenting is difficult in this area, as a stent may protrude into the subclavian vein, fracture or migrate—and is therefore usually avoided. Such lesions may be successfully treated by surgical reimplantation of the healthy distal vein onto the basilic or axillary vein; this approach nearly always requires subsequent angioplasty, however, outcomes are improved when compared to repeated angioplasty alone (92 vs. 8 % secondary patency at 12 months) [48] and patients usually require less frequent reintervention [49]. Reimplantation of the cephalic arch onto the axillary vein will sacrifice the basilic vein, however, this option is sometimes required. An important potential barrier to successful endovascular treatment of stenotic HD conduits is recoil and restenosis, which often necessitates multiple repeated

R. O. Forsythe, E. S. Chemla: Surgical Options in the Problematic Arteriovenous Haemodialysis Access

interventions. Recurrent AVF stenoses may be treated with stents, however, surgical intervention may be the appropriate step, including reconstruction or reimplantation, surgical curettage, interposition graft creation, full fistula revision or abandonment and creation of a new access, particularly in the case of early recurrence of stenosis.

Thrombosis in Arteriovenous Access Thrombosis and occlusion of HD conduits is an important cause of vascular access failure, with prosthetic grafts being much more prone to thrombosis than their autologous counterpart. The location, duration and cause of AVF or AVG thrombosis are important factors to consider when evaluating and planning the appropriate treatment strategy, however, the most efficacious method of access salvage after thrombosis remains unclear. One recent meta-analysis of randomised trials comparing surgical and endovascular treatment for thrombosed vascular access [50] found that the reporting of patency is poor and there are no randomised trials comparing surgical and endovascular intervention in thrombosed autologous access. AV access thrombosis should be treated within 48 h, if at all possible, [46] however, may be successfully declotted up to 1 month following the onset of thrombosis. The most common cause of AVF thrombosis is due to an underlying stenosis, often at the venous anastomosis, caused by intimal hyperplasia. In the case of short-segment stenosis, this may be readily amenable to endovascular intervention with angioplasty alone, or in combination with thromboaspiration, low-dose urokinase, tPA, or mechanical devices. In the acute setting, low-dose local infusions of urokinase in combination with thromboaspiration or angioplasty may be useful. In the event that endovascular treatment is unsuccessful, in the case of long-segment or recurrent thrombosis, or significant underlying stenosis, surgical thrombectomy and salvage may be performed under local, regional or general anaesthetic, depending on the location of the fistula, patient preference, comorbidities and local expertise. This may be complemented by angioplasty of any accompanying stenosis. Incision at the venous anastomosis or re-opening of the original incision followed by thrombectomy with a fogarty catheter is the usual starting point. This may be followed by PTA, a patch angioplasty or bypass of a stenotic segment, ensuring that both the thrombus and the underlying cause are addressed. Improved secondary patency is gained if surgical salvage is performed early (\6 h from presentation; 67 %) vs. late ([6 h from presentation; 50 %) [51]. Whilst there are no randomised trials to such effect, population-based data on the outcomes in surgical treatment of AVFs demonstrate that surgical thrombectomy

alone achieves secondary patency rates at 1 year of around 70 % and concurrent reanastomosis or angioplasty increases this up to 95 % [52]. Endovascular-alone intervention (including PTA with mechanical thrombectomy and pharmacological thrombolysis or thromboaspiration), produces overall patency rates of 50 % at 12 months [53]; forearm AVFs do better than upper arm fistulas in terms of patency, however, many require subsequent reintervention. Thrombosis of AVG is much more common, however, only one randomised study from 3 decades ago reports secondary patency at 1 year—86.7 and 62.5 % for endovascular versus surgical treatment of thrombosed grafts [54]. A more recent meta-analysis in 2002 demonstrated superiority of surgery over endovascular intervention for thrombosed grafts [55], however, there is a high rate of reintervention following AVG thrombectomy using any method. In the case of recurrent AV access stenosis, a jump graft or revision to a more suitable venous outflow vessel may be required. A hybrid approach is encouraged, involving surgical thrombectomy with on-table evaluation of the entire access circuit, proceeding to angioplasty or surgical revision of the anastomosis if required. In order to address the issue of early thrombosis in patients receiving a prosthetic graft, heparin-bonded PTFE grafts and anti-coagulation have been used, however, there is insufficient evidence to recommend the routine use of heparin-bonded grafts [56, 57], warfarin [58] or enoxaparin in these patients [59]. Anti-coagulation should therefore probably be reserved only for those with another indication for long-term anti-coagulation, such as atrial fibrillation, mechanical heart valve, or hypercoagulable state. There is some evidence that anti-platelets may significantly prolong primary patency in AVG [60, 61], however, they do not increase the proportion of HD access which become suitable for dialysis [34].

Other Complications of AV access Aneurysmal Haemodialysis Access Aneurysms (defined in one series as three times the diameter of the adjacent normal vein with a minimum diameter of 2 cm [62]) are an under-reported complication of HD access and usually do not require treatment unless symptomatic, very large, have a large thrombus load or technical problems prevent use of the fistula. In addition, peri-anasomotic aneurysms should be actively treated. In the case of an aneurysm requiring intervention, appropriate imaging of the AV system must be carried out to investigate for underlying venous outflow or central vein obstruction before proceeding to aneurysm repair or

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intervention. Aneurysmal fistula segments may be treated by endovascular means with covered stents, which may be feasible even in moderate sized aneurysmal areas [63, 64], however, true aneurysms of the anastomosis, those containing large amounts of thrombus or massive AVF aneurysms should be treated surgically. This may include ligation and abandonment of the fistula, exclusion bypass using prosthetic graft or native vein, or an interposition graft [65]. Alternatively, a reduction/revision approach has been described in the treatment of patients with massive tortuous diffusely aneurysmal AVF, involving surgical resection of excess AVF length, diameter reduction and retunnelling, which spares the use of prosthetic material or abandonment of the AVF [66]. A longitudinal stapler may be used to reduce the AVF diameter [67]. Steal Syndrome and Distal Hypoperfusion Ischaemic Syndrome (DHIS) Steal syndrome and distal hypoperfusion ischaemic syndrome (DHIS) are uncommon but important complications of vascular access that can lead to digital necrosis, tissue loss and amputation if inadequately treated. The term ‘steal syndrome’ is often used in the literature to describe hand ischaemia caused by distal arterial insufficiency due to flow diversion into the fistula, however, most conduits show physiological evidence of arterial steal into the access and the majority do not result in any symptoms. Moreover, ischaemic symptoms such as pain during dialysis, rest pain and tissue necrosis may be caused by other factors including stenotic lesions or distal arteriopathy, particularly in smokers and patients with diabetes [68]. Therefore, the term DHIS encompasses all causes of dialysis-related ischaemia, including the retrograde flow associated with steal syndrome. Less common in forearm access, DHIS may affect up to 28 % of patients with an elbow or upper arm AVF [69] and risk factors include female gender, age, diabetes, hypertension and known peripheral arterial disease. Severe access-related ischaemia requiring intervention varies between 1 and 2 % in radiocephalic AVFs, 5–15 % in brachiocephalic, brachio-basilic or upper arm grafts and 16–36 % in femoral access [70]. Symptoms of early DHIS may be similar to those of acute occlusive ischaemia and it is important to ensure the correct diagnosis. When evaluating a patient with suspected DHIS, comprehensive evaluation of the entire arterial system is important, to ensure upstream stenoses are detected, treated and do not compromise treatment outcomes. In a limb-threatening situation, the access may need to be surgically sacrificed; however, other options exist for less emergent situations. Endovascular treatment of ischaemia due to arterial stenosis aims to increase the arterial diameter or occlude the vein. In a high-flow AVF

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with symptomatic retrograde flow, banding of the access inflow vessel will reduce flow, although this procedure has been largely abandoned due to its poor success rate due to subsequent thrombosis. An alternative surgical banding method of flow reduction has been described—the MILLER procedure (Minimally Invasive Limited Ligation Endoluminal-assisted Revision)—which involves a small skin incision over the AVF, placement of a ligature and use of an endoluminal balloon to achieve the desired reduction of inflow [71]. This can be performed in an outpatient setting. For severe symptoms, surgical revision using distal inflow artery (RUDI) narrows the inflow and allows perfusion via the ulnar artery and may salvage the AVF [72]. Ligation of the distal radial artery will correct retrograde flow in wrist AVFs in the presence of a patent ulnar artery and palmar arch. Alternatively, the distal revascularisation interval ligation (DRIL) [73] or proximalization of arterial inflow (PAI) procedures is used in low-flow AVF. DRIL involves ligation of the distal artery with creation of a bypass from the inflow artery proximal to the AV anastomosis to the artery just distal to the ligation. PAI allows transfer of the inflow to a larger artery more capable of adapting to increased flow and this procedure is useful in patients with diseased run-off that may otherwise compromise a DRIL procedure. Central Venous Obstruction Central venous stenosis and obstruction (CVO) is a concern amongst HD patients, a potential source of major morbidity and is strongly associated with prior use of CVCs, which should be avoided in most patients if possible. In addition, PICs, defibrillator wires and pacemakers may contribute to CVO [74]. CVO may be defined as [50 % stenosis in the central veins [75], including the IVC or SVC, however, the syndrome associated with CVO is of more clinical relevance than the degree of stenosis. CVO may affect at least 30 % of patients on HD and is often an incidental finding, with up to 50 % of patients experiencing no symptoms at all [76]. CVO becomes problematic when symptoms develop—in a patient with occult CVO, the creation of an AV access on the ipsilateral limb may unmask the obstruction, causing rapid venous hypertension, due to the dramatic increase in blood flow through the extremity. This may overwhelm the collateralised venous system and cause upper limb, face or neck swelling, pain, chest wall collaterals or venous ulceration. In addition, the patient may experience excessive post-cannulation bleeding, inefficient dialysis, elevated venous pressures due to venous hypertension, leading to access failure. The definitive treatment of symptomatic access-associated CVO is surgical ligation and abandonment of the vascular access, however this is usually unacceptable for

R. O. Forsythe, E. S. Chemla: Surgical Options in the Problematic Arteriovenous Haemodialysis Access

such patients, in whom there are often limited or no other options for access creation. Therefore, the aim should be to maintain vascular access and provide adequate unobstructed venous outflow. This may be achieved by the surgeon, the IR or a combination of the two—patients with CVO often require repeated interventions to sustain adequate dialysis and this should be anticipated by the team. According to the literature, endovascular intervention remains the first-line treatment for CVO with varying results—percutaneous transluminal angioplasty (PTA) alone has a reported 1-year primary patency of 20–77 % in CVO [77–81]. In the case of failed angioplasty or recurrent disease, PTA with bare-metal stents (BMS) or covered stents (CS) has been used with variable results, however, is vulnerable to propagation of intimal hyperplasia and restenosis, and may fracture or migrate, particularly when used around the costo-clavicular junction. Surgical treatment of CVO is often considered a secondline therapy, particularly as endovascular options become increasingly sophisticated; however there is sometimes a role for the surgeon in the treatment of CVO. A recent review found 80–90 % primary patency at 1 year following surgery for CVO in HD patients [82], however, repeated intervention is usually required. Although treatment pathway algorithms have previously been proposed [83], there remains no absolute consensus on the management of these complex patients with CVO and most of the evidence is based on small series or case reports. There is little data regarding the comparative procedural morbidity and mortality of surgical versus endovascular treatment for CVO. Most reported surgical series contain small numbers of patients and primarily report patency outcomes. At the most basic end of the spectrum, surgical abandonment and fistula ligation carries with it the morbidity associated with anaesthesia, whilst major bypass surgery will clearly carry much higher risks, including a significant rate of death from complications in patients requiring sternotomy. One study of 11 patients undergoing surgery for CVO included one early death (within 30 days, due to sepsis), one symptomatic pleural effusion and a further death within 2 years [84]. A larger study (including 126 patients over 10 years) of radiological intervention reported no peri-procedural morbidity or mortality (excluding haematomas or minor bleeding) but did not report long-term mortality [77]. Whilst procedural mortality is likely to be a greater risk in patients undergoing surgical intervention than radiological intervention (however no studies identified by the authors have reported incidents of peri-operative mortality in surgically treated patients), the longer term mortality in both groups has been shown to be similarly high—31 % at 1 year, in one retrospective case series [85]. This is likely related to the overall poor prognosis in this group of highly co-morbid patients.

Depending on the site and severity of CVO and previous attempts at revascularisation, surgical methods may be anatomical or extra-anatomical, including patch angioplasty, central venous extra-anatomical bypass [86], AVF distal segment mobilisation with re-implantation and translocation or interposition grafts to bypass the lesion [87]. In one study, secondary patency of central venous bypass was low at 56 %, however, the authors demonstrated a secondary AVF patency rate of 67 % at 6 months [84]. This may suggest that a central venous bypass graft which fails within a few months, may still afford enough time for the development of collaterals to allow symptom relief and adequate HD. The Haemodialysis Reliable Outflow (HeRO) vascular access device was initially developed as an alternative AVG [88] but has recently been used successfully in patients with CVO and no distal access options. The HeRO device consists of a PTFE graft component connected via a titanium connector to a rigid nitinol-reinforced silicone venous outflow component with a radio-opaque tip. The graft component is anastomosed to the brachial or axillary artery, tunnelled subcutaneously and attached via a titanium connector (using a counter-incision in the deltopectoral groove) to the venous outflow component, which is tunnelled percutaneously via the IJV, subclavian vein or a large collateral to the right atrium. If it is difficult to advance the venous outflow component due to CVO or stenotic peripheral veins, balloon angioplasty may be performed simultaneously, to allow the device to pass. Similar to AVGs, the HeRO device is cannulated by inserting a needle into the graft component. Whilst the published literature contains only a handful of case series of the HeRO device used to treat CVO, it has shown some promising results in high-risk patients with no other access options or those at high risk of line-related infection. One study (sponsored by the manufacturers of the device) demonstrated a significant reduction in bacteraemia when compared to CVC and a secondary patency of 72.2 % (mean follow-up period of 8.6 months), based on historical controls and a sample size of 36 patients [88], whilst a smaller study of 11 patients receiving the HeRO device demonstrated a secondary patency of 45.5 % at 1 year [89]. The HeRO device has also been used in complicated patients with SVC and IVC obstruction otherwise reliant on HD via a transhepatic CVC [90], however, the device is associated with reintervention rates exceeding 70 % [89, 91], often due to thrombosis. Some authors prefer the placement of a HeRO device rather than lower limb grafts—one comparative study demonstrates similar rates of patency, infection and all-cause mortality in such patients [92], however, this included patients who received HeRO for indications other than CVO. The HeRO device is an expensive graft, however, cost analysis in one recent study demonstrated it to be more cost-effective than a tunnelled dialysis catheter or thigh graft,

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R. O. Forsythe, E. S. Chemla: Surgical Options in the Problematic Arteriovenous Haemodialysis Access

when accounting for the cost of treating access-related complications associated with those modalities, such as sepsis and limb loss, respectively [93].

Conclusion HD access is a complex speciality, which requires input from a range of specialised health professionals. Whilst there are a range of surgical and IR techniques used to treat the complications of vascular access, there is no definite consensus as to the distinct roles of the surgeon and the IR and randomised evidence is sparse. First-line endovascular treatments for access failure or complications are increasingly popular, due to the low invasiveness associated with radiological intervention, however, surgical alternatives should not be overlooked in the event that local IR expertise is unavailable, or if radiological treatment fails. There are also some cases where first-line surgical intervention may be preferable (including patients with stenosis of a lower forearm AVF, early thrombosis, large aneurysms and early access failure following endovascular intervention) and this may include simply creating a new anastomosis in the forearm, in some cases. With their range of complimentary skills, close collaboration between the vascular access surgeon and the IR is essential in the management of HD access—each clinician should understand their own limits of treatment and each other’s skill sets, which will vary from centre to centre, depending on experience. In the event of access failure or complications, a multi-disciplinary approach should be taken, to ensure that investigations and interventions are carried out at the appropriate time, by the appropriately experienced practitioner. The combination of surgical and IR techniques in a hybrid theatre may be the appropriate setting for managing the failing fistula, particularly as reintervention is commonly required despite early technical success. More detailed reporting of surgical and radiological outcomes and techniques in the failing, failed or complicated AV access (including randomised trials) will increase awareness of the treatment options of both specialities. Compliance with Ethical Standards Conflict of interest Rachael O Forsythe, No conflict of interest; Eric S Chemla, Consultant for Gore, Atrium and Proteon Medical. Human and Animal Rights and Informed Consent This article does not contain any studies with human participants or animals performed by any of the authors.

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