title: Partial excision of infected fistula results in increased patency at the cost of increased risk of recurrent infection.
abstract: Reliable vascular access is often an issue of ongoing frustration for those requiring dialysis. Synthetic arteriovenous fistulae (SAVF) have been widely used to provide vascular access; however, the risk of infection at the SAVF site is significant, especially because the SAVF is potentially exposed to pathogens on a regular basis due to the cannulation required for dialysis. Between 11 and 35% of all SAVF become infected and require surgical removal. The purpose of this investigation was to: (1) compare the risk of recurrent infection with complete versus partial excision of the infected SAVF (ISAVF) and (2) explore the risks and benefits of attempting to preserve patency of noninfected portions of ISAVF. In a retrospective review to determine the risk of recurrent infection after removal of ISAVF, charts of 77 patients undergoing surgery for the removal of an ISAVF from the arm were identified with 84 instances of excision of an ISAVF. Of the 84 ISAVF, 26 (31 %) were treated with complete excision (CE), 30 (35.7%) grafts were partially excised with blood flow restoration through a new interposed PTFE segment (PERF), and 28 (33.3%) grafts were partially excised with no flow restoration (PENF), leaving portions that were not grossly infected. Fourteen of 30 (46.7%) PERF grafts, 4/28 (14.3%) PENF, and 0/26 CE grafts developed further infection at the excision site. These differences were significant when comparing PERF to CE (p < 0.001) and PERF to PENF (p < 0.025), but no significance was found when comparing CE to PENF. Patency was significantly greater for the PERF group at 1 and 2 years than for both CE (p < 0.001) and PENF (p < 0.001). In conclusion, the data suggest that restoring blood flow to the remainder of a partially excised ISAVF significantly increases patency without necessitating catherer placement and a new hemoaccess site, but at the cost of significantly increased risk of recurrent infection.
authors.affiliation: Indiana/Ohio Heart Cardiothoracic and Vascular Surgeons, Indiana University School of Medicine, Fort Wayne Center, Midwest Alliance for Health Education, Fort Wayne, IN, USA. patrickcwalz@hotmail.com
authors.forename: Patrick
authors.initials: P
authors.lastname: Walz
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Ladowski
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D002408:Catheters, Indwelling / Q000009:adverse effects; D020878:Device Removal; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011138:Polytetrafluoroethylene; D011474:Prosthesis Design; D016459:Prosthesis-Related Infections / Q000382:microbiology / Q000601:surgery*; D012008:Recurrence; D012039:Regional Blood Flow / Q000502:physiology; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000601:surgery; D014654:Vascular Patency
chemical_list: D000900:Anti-Bacterial Agents; D011138:Polytetrafluoroethylene