Download Arterio-Arterial Prosthetic Loop Are we doing enough? Faisal Alam

Faisal Alam
Consultant Vascular & General Surgeon
Royal Hospital
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.
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 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 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?!
All central accesses are occluded
2. All peripheral venous and PD options have been
exhausted.
3. Heart Failure with very low ejection fraction
1.
Is Arterio-Arterial
Prosthetic Loop an option?
 First proposed by Butt and Kountz in 1976
 Janow et al. J Vasc Surg. 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 Vasc Surg. 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.
Gdoura Moncef 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
 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:
 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
 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
 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