title: Endovascular salvage of a right brachial artery-right atrium hemodialysis graft using a covered endoprosthesis.
abstract: Creation of a functional hemodialysis access in patients with exhausted peripheral access sites and concomitant central venous occlusive disease (CVOD) is a multifaceted challenge; often requiring complex, innovative solutions, not without their own complications. We present a 57-year-old hemodialysis patient with a history of hypercoagulable disorder and multiple failed arteriovenous accesses. Because of inadequate peripheral access sites and chronic occlusions in superior vena cava, brachiocephalic veins and inferior vena cava, in addition to multiple transhepatic catheter related issues; we decided to perform a right brachial artery to right atrium (RA) hemodialysis graft. The access was used without complications for 18 months at which point he had his first episode of thrombosis; open thrombectomy and percutaneous balloon angioplasty (PTA) at the atrial anastomosis were done with success. The following three months, he endured two more thrombectomies and PTAs. During the last intervention we performed an intravascular Ultrasound (IVUS) through the atrial anastomosis, which demonstrated stenosis; and the decision was made to extend the outflow anastomosis with a covered stent into the atrium. Therefore a 10 cm x 10 mm Viabahn stent-graft (W. L. Gore and Associates, Flagstaff, Ariz.) was deployed and post dilated with 8 mm balloon within the graft component. Repeat injection and Intravascular Ultrasound (IVUS) demonstrated significant improvement and free outflow. The brachial-RA hemodialysis graft could be use immediately and at 5 months has remained fully functional and no reinterventions have been necessary.
authors.affiliation: Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX 77030, USA.
authors.forename: Javier E
authors.initials: JE
authors.lastname: Anaya-Ayala
authors.forename: Nyla
authors.initials: N
authors.lastname: Ismail
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Reardon
authors.forename: Eric K
authors.initials: EK
authors.lastname: Peden
mesh_terms: D000800:Angioplasty, Balloon / Q000295:instrumentation*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation*; D001916:Brachial Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D011859:Radiography; D006435:Renal Dialysis; D012086:Reoperation; D016879:Salvage Therapy; D015607:Stents; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D014654:Vascular Patency