Comparison of axillary-atrial and axillary-iliac arteriovenous grafts for hemodialysis access creation. Issue 1 (January 2020) - Lopez-Pena, Gabriel
Objective: The aim of this study was to compare two complex vascular access techniques that utilize the axillary artery as inflow and accesses were created with early cannulation grafts: the axillary-atrial arteriovenous graft versus axillary-iliac arteriovenous graft. Methods: This is a retrospective study of end-stage renal disease patients with occluded intrathoracic central veins that underwent complex hemodialysis access creation in our institution after failed endovascular recanalization attempts. Patients' demographics, comorbidities, number and types of previous accesses, intraoperative variables, and clinical outcomes were collected and compared. Results: Four patients underwent axillary-atrial arteriovenous graft creation with Flixene™ (Atrium™, Hudson, NH, USA) grafts, through a midline sternotomy to expose the right atrium; all were successfully implanted and used for hemodialysis within the first 72 h; one patient developed a pseudoaneurysm in the mid-graft portion, requiring surgical repair, and it is currently functional. Eight axillary-iliac arteriovenous grafts were created; all grafts were patent and were utilized within 96 h after placement. At 6 months of follow-up period, five (62 %) of our patients underwent graft thrombectomy, one (12 %) balloon angioplasty at the vein anastomosis secondary to stenosis, and two (25 %) grafts were removed due to infectious complications. Axillary-atrial arteriovenous graft and axillary-iliac arteriovenous graft primary patency rates at 6 months were 75% and 48%, respectively; 6-month secondary patency of the axillary-atrial arteriovenous graft compares favorably against that of axillary-iliac arteriovenous graft (100% vs 75%, respectively). Conclusion: Despite the invasiveness, direct atrial outflow procedures remain a valid alternative in carefully selected patients with adequate cardiopulmonary reserve.