Surgical management of hemodialysis-related central venous occlusive disease: a treatment algorithm.

BACKGROUND

Creation and preservation of dialysis access in patients with central venous occlusive disease (CVOD) is a complex problem. The surgical approach and decision-making process remains poorly defined. We evaluated our experience in the surgical management of hemodialysis-related CVOD. Surgical technique, demographics, complications, reinterventions, access function rates, and factors influencing morbidity and mortality were examined.

METHODS

From January 2006 to May 2010, we performed a total of 1,703 dialysis access-related procedures, 1,021 arteriovenous fistulas (AVFs), 335 arteriovenous grafts (AVGs), and 314 access revisions including endovascular salvage procedures. Seventeen patients (10 women [58%] with a mean age of 44 ± 27 years) with CVOD who were not suitable for peritoneal dialysis or kidney transplant underwent 20 complex vascular access procedures. The indications were need for access creation in 14 cases (70%) and preservation in the remaining 6 (30%). Polytetrafluoroethylene (PTFE) was used for all surgical bypass grafts (BPG). All patients had previously undergone multiple access surgeries and had failed percutaneous interventions for CVOD.

RESULTS

The surgical planning centered on finding venous outflow for an arteriovenous (AV) access; central venous reconstructions were necessary in 10 (50%) cases (seven [35%] in the thoracic central venous system and three [15%] in infradiaphragmatic vessels) and extracavitary venous BPG in two (10%) cases. Non-venous access options included axillary arterial-arterial chest wall BPG in five (25%) cases and brachial artery to right atrium BPG in three (15%). Technical success was achieved in all cases (100%). Mean follow-up was 14.1 months, both BPG and AV access patency rates were 66% at 6 months and overall average AV access function time was 9.2 months. Of these, 85% of patients were discharged home and following 19 (95%) cases they returned or improved their baseline functional status. One death occurred from multiorgan failure during the 30-day postoperative period. Four additional patients died within 3 years of the procedure secondary to nonsurgical-related comorbidities.

CONCLUSION

The need for complex vascular accesses will continue as the number of patients with end-stage renal disease increases. CVOD is an access surgical challenge and with this article we propose a decision-making algorithm.