title: Optimal timing for secondary arteriovenous fistula creation: devastating effects of delaying conversion.
abstract: A chronic hemodialysis patient was referred to interventional nephrology for evaluation of arteriovenous access dysfunction. The patient had been receiving hemodialysis using a left forearm brachiobasilic loop graft for the past 3 years. Physical examination revealed a hyperpulsatile graft. Angiography documented a critical stenosis at the vein-graft anastomosis and a well-developed basilic vein from the elbow to the axillary region. Central veins were patent all the way to the right atrium. All attempts to navigate the wire across the stenosis failed. The patient was educated and counseled regarding the possibility of surgical creation of a secondary arteriovenous fistula (AVF). The images obtained were shared and discussed with the surgeon. A plan to create a secondary AVF using the basilic vein in the arm was made. A few months later the patient was referred to interventional nephrology, this time for thrombectomy of the same left arm loop graft. Thrombectomy could not be performed and a right internal jugular tunneled catheter was inserted. The patient again was referred to the surgeon for AVF creation. Six weeks later the patient was seen in the interventional laboratory for removal of the right internal jugular tunneled catheter. It was noted that instead of a fistula, the patient had received a right forearm brachiocephalic loop graft. Devastating consequences, such as the lost opportunity to create a fistula, insertion of a tunneled dialysis catheter, arteriovenous graft placement, exhaustion of available sites for fistula creation, and exposure to increased morbidity and mortality associated with grafts and catheters, can result if the opportunity to create a secondary AVF is not availed in a timely manner. This concept must be understood by every member of the vascular access team.
authors.affiliation: Section of Interventional Nephrology, Division of Nephrology, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. Aasif@med.miami.edu
authors.forename: Arif
authors.initials: A
authors.lastname: Asif
authors.forename: Carlos
authors.initials: C
authors.lastname: Leon
authors.forename: Donna
authors.initials: D
authors.lastname: Merrill
authors.forename: Renee
authors.initials: R
authors.lastname: Ellis
authors.forename: Bhagwan
authors.initials: B
authors.lastname: Bhimani
authors.forename: Phillip
authors.initials: P
authors.lastname: Pennell
mesh_terms: D000368:Aged; D000800:Angioplasty, Balloon; D001166:Arteriovenous Shunt, Surgical / Q000379:methods*; D006083:Graft Occlusion, Vascular / Q000628:therapy; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D006435:Renal Dialysis; D012086:Reoperation; D013997:Time Factors; D017211:Treatment Failure