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Arterio -Arterial Prosthetic Loop Are we doing enough?

Arterio -Arterial Prosthetic Loop Are we doing enough?. Faisal Alam Consultant Vascular & General Surgeon Royal Hospital. Introduction:. Number of patients with end-stage renal disease (ESRD) requiring hemodialysis is constantly rising worldwide

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Arterio -Arterial Prosthetic Loop Are we doing enough?

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  1. Arterio-Arterial Prosthetic LoopAre we doing enough? Faisal Alam Consultant Vascular & General Surgeon Royal Hospital

  2. Introduction: • Number of patients with end-stage renal disease (ESRD) requiring hemodialysis is constantly rising worldwide • Consequently number of ESRD patients with difficult access and comorbidities also increasing.

  3. Introduction cont.. • Patients are living longer and good number of them undergo many procedures for dialysis access. • Increase in the number of patients whose vascular access options are exhausted keeps us vascular surgeons in dilemma regarding the next step.

  4. Introduction cont.. • Similarly high incidence of diabetic population in Oman ( about 11-12 %) has led to an increase in ESRD patients. • In 2012, 65% of the vascular surgical load at the Royal Hospital was related to vascular access.

  5. Introduction cont.. • Majority of our patients refuse pre-emptive AVF creation. Pre-emptive procedures hardly reaches 5-10% of the actual load. • As a consequence, we have high number of patients on central venous lines for dialysis

  6. What are the options?! • All central accesses are occluded • All peripheral venous and PD options have been exhausted. • Heart Failure with very low ejection fraction

  7. Is Arterio-Arterial Prosthetic Loop an option?

  8. First proposed by Butt and Kountz in 1976 • Janow et al. J VascSurg. 2005 June 34 patients with 36 AAPL (31 axillary / 5femoral) (Apr 1996 - Sept 2004) central vein occlusion 64%, steal sy 11%, severe peripheral arterial disease in 22%, and congestive heart failure in 3% Primary /secondary patency 73%/96% at 1yr and 54% and 87% at 3 years,

  9. Bunger et al. J VascSurg. 2005 Aug 20 patients (May 2001 - Dec 2004). Exhausted AV access options in 14 patients (70%), central vein occlusion in 5 patients (25%), ischemia from steal sy in 12 patients (60%) High-output cardiac failure in one patient. Median f/u was 7.4 months. The 30-day peri-operative mortality rate was 5%. Access thrombosis in four patients (asymptomatic). Early post-op bleeding in four patients. Late graft infection in one after repeated thrombectomy. The primary and secondary patency rate was 90% and 93%, respectively, at 6 months.

  10. GdouraMoncef et al. Saudi Journal ofKidney diseases and transplant. 2005 • Arterio-Arterial Interposition Graft in 9 patients • Median period of use was 18 months • No limb loss Stephenson et al. J Vasc Access. 2012 Nov • Axillary-axillary inter-arterial chest loop graft • Early dialysis within one day

  11. Our Own experience • 60 years old with severe heart failure (EF 15%) • Exhausted peripheral access options and failed PD catheter. • Had trans-lumbar Perm cath insertion (both iliacs and subclavian veins were occluded. • Had left axillary inter-arterial PTFE loop graft under LA. • Used for 14 months without any problems. • Patient died from cardiac causes.

  12. The basics of the AAPL compared with an AV graft: • 1. A vein is not essential. • 2. The distal perfusion is not decreased. • 3. The cardiac load is not increased.

  13. Instructions for the dialysis unit • Nephrologists should be informed about the specifics of this access and position of needles. • Advise to compress puncture site for 20 minutes after the removal of the needles. • Refrain from infusion of medications through the AAPL

  14. In conclusion • AAPL is a viable option which seems to be under-utilized • It should be considered more frequently, specially in cases of venous hypertension, steal phenomenon and congestive heart failure • can be done under LA and has good medium term patency rate • Complication rates are comparable with AVG and no reports of limb loss

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