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Mar06

  

A-V FISTULA CREATION BY NOW IS A STANDARD PROCEDURE FOLLOWED WORLDWIDE FOR HEAMODILYSIS ACCESS IN CKD PATIENTS.THERE ARE

TIMES WHEN HEAMODIALYSIS BECOMES A CHALLENGE BECAUSE OF NON AVAILABILITY OF VENOUS ACCESS.THE REASONS BEING IN PLENTY LIKE THROMBOSED SUPERFICIAL VEINS,FAILED A-V ACCESS EARLIER SO ON AND SO FORTH .ROUTINELY AN AV FISTULA IS CREATED ON THE FOREARM BETWEEN THE RADIAL ARTERY AND CEPHALIC VEIN FOR VENOUS ACCESS.THE DIALYSIS THROUGH THESE ARTERIALISED VEINS CAN BE STARTED ONCE THE FISTULA MATURES.SOMETIMES THE VASCULAR SURGEON NEEDS TO USE THE BRACHIAL ARTERY TO DIRECT BLOOD INTO THE VEINS FOR FUTURE HEAMODIALYSIS ACCESS.THESE ARE THE ROUTINE SURGERIES DONE FOR CKD PATIENTS FOR DIALYSIS.CERTAIN SITUATIONS DEMAND THE USE OF SYNTHETIC GRAFT FOR HEAMODIALYSIS. VASCULAR SURGEONS WORLDWIDE HAVE THEREFORE COME UP WITH FEMORO-FEMORAL AV FISTULAS WITH PTFE GRATS,BRACHIO- AXILLARY FISTULAS,AXILLO-AXILLARY FISTULAS AND RADIO-CEPHALIC FISTULAS WITH PTFE GRAFTS.THE PATENCY OF NATIVE VESSEL FISTULAS IS CERTAINLY BETTER THAN THE ONES WHEREIN SYNTHETIC GRAFT IS USED BUT THEN THESE GRAFTS ARE USED IN UNAVOIDABLE AND DESPERATE  CIRCUMSTANCES LIKE SMALL VEINS,FAILED NATIVE FISTULAS IN THE PAST SO ON AND SO FORTH.ITS AN IMPORTANT WEAPON IN THE ARMEMTARIUM OF THE VASCULAR SURGEON AS IT MAKES THE LIFE OF THE CRF PATIENT RELATIVELY EASY AND IS WORTH THE EFFORT.PTFE IS THE SYNTHETIC GRAFT GENERALLY USED FOR MAKING THESE FISTULAS. WE REPRESENT  AN UNUSUAL CASE WHEREIN AN AXILLO-FEMORAL A-V FISTULA WAS CREATED CONNECTING THE LEFT AXILLARY ARTERY WITH THE LEFT COMMON FEMORAL VEIN WITH A 6 MM PTFE  SYNTHETIC GRAFT AND TUNNELING IT UNDER THE SKIN FOR VENOUS ACCESS.

 

       THIS PATIENT AGED 55 YEARS MET WITH AN ACCIDENT SOME TWO YEARS AGO .SHE ENDED UP LOSING HER LEFT LOWER LIMB AND BOTH HER KIDNEYS FAILEDAND IS ON REGULAR DIALYSIS.SHE HAD AN AV FISTULA MADE ON HER LEFT FOREARM IN THE PAST CONNECTING THE BRACHIAL ARTERY AND CEPHALIC VEIN ONLY TO BE CLOSED LATER AS SHE DEVELOPED MASSIVE SWELLING OF HER LEFT UPPER LIMB AFTER FISTULA CREATION. FISTULOGRAM  WAS DONE AND IT SHOWED SHE HAD SUPERIOR VENA CAVA SYNDROME.THE PROBABLE CAUSE OF HER SVC SYNDROME SEEMED TO BE IATROGENIC AS  HER INTERNAL JUGULAR VEIN WAS  CANNULATED EARLIER FOR DIALYSIS.WE HAD LIMITED OPTIONS IN HER AS FISTULA COULD NOT BE CREATED IN THE OTHER UPPER LIMB BECAUSE OF SVC SYNDROME.THE ONLY USUAL OPTION LEFT IN SUCH A SCENARIO WAS TO CREATE AN AV FITULA WITH GRAFT ON HER RIGHT THIGH CONNECTING THE FEMORAL VEIN WITH THE FEMORAL ARTERY AS SHE HAD AN AMPUTATED LEFT LEG(HIGH ABOVE KNEE AMPUTATION).SINCE SHE STILL HAS AN ACTIVE LIFESTYLE MAKING  AN AV FISTULA ON THE UNAFFECTED RIGHT LEG WAS NOT THE BEST OPTION BECAUSE OF  FEAR OF SYNTHETIC GRAFT INFECTIONS AND WOUND COMPLICATIONS THAT MAY HAVE JEOPARDISED THE VIABILITY OF HER RIGHT LOWER LIMB IN NEAR FUTURE. 

 

                                      WE DID AN INNOVATIVE SURGERY BY CREATING THE FISTULA TAKING THE INFLOW FROM THE LEFT AXILLARY ARTERY AND CONNECTING THE GRAFT TO LEFT COMMON FEMORAL VEIN. THE PATIENT TOLERATED THE PROCEDURE WELL AND THE SURGERY LASTED FOR 90 MINUTES.POST PROCEDURE THE PATIENT IS DOING WELL AND TO DATE HAS UNDERGONE ALMOST 25 HEAMODIALYSIS THROUGH THIS NEWLY CREATED FISTULA.

 

               TO DATE THIS IS THE FIRST OF ITS KIND AV FISTULA CREATED IN ASIA AND IN INDIA AS PER THE VASCULAR SURGERY LITERATURE . 

             

                     THE IDEA OF REPORTING THIS ARTICLE IS TO GIVE HOPE TO THOUSANDS OF PEOPLE AROUND SUFFERING FROM CRF WHEREIN VENOUS ACCESS FOR HEAMODIALYSIS IS UNAVAILABLE FOR MYRIAD REASONS. FISTULA FOR HEAMODIALYSIS  CAN ALMOST ALWAYS BE CREATED EVEN IN SEEMINGLY DIFFICULT SITUATIONS.

 

 

 

 



Comments (4)  |   Category (Vascular & Endovascular Surgery)  |   Views (1728)

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Mar08

WELL THE ANSWERS TOU YOUR QUESTIONS ARE MORE OR LESS IN THE POSTED BLOG ITSELF.STILL AS PER YOUR QUERIES I WOULD LIKE TO SAY THE LENGTH OF THE GRAFT IS AROUND 60CMS,NO NEED TO RESTRICT ARM MOVEMENTS AND YES THE PLANE OF THE GRAFT TO AN EXTENT IS SUPERFICIAL FOR VENOUS ACCESS.YOU GET A GOOD 20CMS OF GRAFT TO PUNTURE FOR DIALYSIS.

Mar08

YOU GUYS CAN LEAVE YOUR EMAIL ADRESSES.I WILL TRY SENDING THE PICS ASAP.

Mar08

Dr Singhal,
A photograph would be nice!
Rajesh

Mar08

Dear Dr Gaurav Singal,

It is an interesting procedure that you have done.Can you tell me the size of the graft taht you inserted and do you advise any movement restriction to the arm at the shoulder.Also is the plane of the graft superficial in the entire extent? Where is the likely puncture point for dailysis?
Regards,
santosh


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