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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

Arterio-Arterial Prosthetic LoopAre we doing enough?

Faisal Alam

Consultant Vascular & General Surgeon

Royal Hospital

  • 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.
introduction cont
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.
introduction cont1
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.
introduction cont2
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
what are the options
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

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,


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.


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
our own experience
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.
the basics of the aapl compared with an av graft
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.
instructions for the dialysis unit
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
in conclusion
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