title: Prosthetic axillary-axillary arteriovenous straight access (necklace graft) for difficult hemodialysis patients: a prospective single-center experience.
abstract: BACKGROUND
  It is not uncommon for all usual upper limb autogenous access sites to fail, often in patients for whom neither peritoneal dialysis nor transplantation is an appropriate option. Axillary-axillary arteriovenous bypass grafts could be used as the last option before a thigh autogenous access even in case of unilateral central venous stenosis or obstruction. We describe our experience with this procedure in a series of patients.
  
  
  METHODS
  A consecutive series of 18 patients for whom all possible arm accesses had failed and neither peritoneal dialysis nor transplantation was possible underwent a necklace graft formation over a 2.5-year period. All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (PTFE, Gore-Tex Intering Vascular Graft, W. L. Gore and Associates, Inc, Flagstaff, Ariz) anastomosed end to side the axillary artery and contralateral vein, and tunneled straight in the subcutaneous space before the sternum. All patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and dialysis adequacy were reviewed. They also had at the same time a transonic assessment where graft flows and recirculation rates were measured. In case of low flow (<600 mL/min) or drop of 20% between two measurements or recirculation >5% a fistulogram was obtained, and an intervention was performed to restore patency.
  
  
  RESULTS
  We operated on 10 males and 8 females; mean age was 55.1 years. The primary patency was 83% and 72.2%, and the secondary patency was 94.4% and 88.9% at 6 months and 1 year, respectively. Five successful surgical revisions were carried out for four clotted grafts and one post dialysis rupture. One surgical revision for thrombosis failed and one local infection lead to thrombosis and was not amenable to surgical revision. Three patients died of causes unrelated to their vascular access during the study period.
  
  
  CONCLUSIONS
  The reasonable patency and minimal complications associated with these bypasses show that they are a valid option for complex patients. We advocate the use of this bypass in patients with exhaustion of all access possibilities in both arms with a patent superior vena cava, subclavian, and brachiocephalic veins. We also indicate it in case of unilateral central venous stenosis or obstruction with complete exhaustion of all other access possibilities on the contralateral side.
authors.affiliation: South West Thames, Surrey and Sussex Renal Transplant Network, London, United Kingdom.
authors.forename: Mohamed A
authors.initials: MA
authors.lastname: Morsy
authors.forename: Asif
authors.initials: A
authors.lastname: Khan
authors.forename: Eric S
authors.initials: ES
authors.lastname: Chemla
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001366:Axillary Artery / Q000503:physiopathology / Q000601:surgery*; D001367:Axillary Vein / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011474:Prosthesis Design; D006435:Renal Dialysis; D012086:Reoperation; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency