Midterm results of a novel technique to salvage autogenous dialysis access in aneurysmal arteriovenous fistulas

PurposeOver the last decade, K-DOQI guidelines have increasingly emphasized the importance of autogenous arteriovenous fistulas (AVF) for dialysis access. A complication of AVF is aneurysmal dilatation with a subset developing massive diffuse aneurysm. Treatment of massive aneurysmal AVF generally involves either ligation or resection with use of prosthetic interposition. To maintain an all-autogenous access, we developed a procedure to treat massive aneurysmal AVF in which the luminal diameter is reduced, excess length is resected, and the new reconstructed AVF is re-tunneled for continued use. The purpose of this study is to examine the midterm outcomes of this novel procedure.MethodsOver a 4-year period, the reduction/revision procedure was performed on 19 patients with an AVF diameter of 4-7 cm. Indications for operation were thrombosis, skin breakdown, infection, bleeding, and/or poor flow. Revision was performed by resecting redundant length, reducing diameter, and then reconstructing the fistula.ResultsThe median patient age was 47, interquartile range (IQR) 29. There were 13 men and 6 women. The median follow-up was 23 months, IQR 22. The median primary patency was 14 months, IQR 24. The median secondary patency was 16.5 months, IQR 26. Two patients died, one AVF thrombosed, and two were ligated secondary to infection. Three fistulae developed a stenosis that was treated with percutaneous angioplasty. There are no recurrent aneurysms to date.ConclusionSurgical resection of excess length, reduction of luminal diameter, and reconstruction is a viable option for the treatment of complicated massive diffusely aneurysmal AVF. This technique offers the ability to maintain the benefits of an all autogenous dialysis access while conserving future dialysis sites