title: Staple aneurysmorrhaphy to salvage autogenous arteriovenous fistulas with aneurysm-related complications.
abstract: OBJECTIVE
  Aneurysm-related complications could lead to loss of a functioning arteriovenous fistula (AVF). We report our midterm and long-term results with the staple aneurysmorrhaphy technique to repair and preserve aneurysmal AVFs.
  
  
  METHODS
  We retrospectively reviewed our surgical treatment of patients with aneurysmal autogenous AVF complicated by skin erosion, bleeding, infection, pain, and difficulty with needle access from 2007 through 2014. We identified 52 patients, 40 (77%) of whom underwent repair with the staple aneurysmorrhaphy technique. The operation involved mobilizing the entire aneurysmal segments. A TA (Covidien, Norwalk, Conn) or Endo GIA (Covidien, Mansfield, Mass) stapler was used to resect the redundant aneurysm wall to create a 6- to 8-mm-diameter conduit. A subcutaneous skin flap was created after excising compromised skin. The remodeled vein was repositioned underneath the subcutaneous flap, with the staple line rotated laterally to avoid needle puncture.
  
  
  RESULTS
  We attempted staple aneurysmorrhaphy in 40 patients with complicated AVF aneurysms, of which 38 repairs (95%) were successful. Median patient age was 66 years (range, 29-88 years). Median AVF age was 63 months (range, 12-136 months). Median follow-up was 20 months (range, 5-81 months). At 1 year, primary patency was 67%, assisted primary patency was 88%, and secondary patency was 91%. At 2 years, primary patency was 59%, assisted primary patency was 84%, and secondary patency was 91%. At 3 years, primary patency was 46%, assisted primary patency was 69%, and secondary patency was 85%. Surgery was performed under local-regional anesthesia in 28 patients (70%) and under general anesthesia in the remaining 12 (30%). Proximal venous outflow stenoses were detected in 19 of 40 AVFs (48%) preoperatively and in 11 of 38 AVFs (29%) postoperatively. Aneurysm recurrence occurred in two repaired AVFs.
  
  
  CONCLUSIONS
  Our experience with staple aneurysmorrhaphy shows that it is an effective, safe, and durable procedure to preserve a functioning autogenous AVF with complicated aneurysmal degeneration. Key principles are to reduce the vein to normal adjacent diameter and to provide healthy skin coverage. The remodeled AVF has a low aneurysm recurrence rate and maintains the beneficial properties of superior patency and low infection. It is important to aggressively monitor for and treat proximal outflow venous stenoses to prevent aneurysm recurrence. The surgery can be done safely under local anesthesia in selected patients.
authors.affiliation: Department of Vascular Surgery, Kaiser Permanente, Fontana, Calif. Electronic address: trung.d.vo@kp.org.
authors.forename: Trung
authors.initials: T
authors.lastname: Vo
authors.affiliation: Department of Vascular Surgery, Kaiser Permanente, Fontana, Calif.
authors.forename: Gloria
authors.initials: G
authors.lastname: Tumbaga
authors.affiliation: Department of Vascular Surgery, Kaiser Permanente, Fontana, Calif.
authors.forename: Paul
authors.initials: P
authors.lastname: Aka
authors.affiliation: Department of Vascular Surgery, Kaiser Permanente, Fontana, Calif.
authors.forename: Jason
authors.initials: J
authors.lastname: Behseresht
authors.affiliation: Department of Vascular Surgery, Kaiser Permanente, Fontana, Calif.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Hsu
authors.affiliation: Department of Vascular Surgery, Kaiser Permanente, Fontana, Calif.
authors.forename: Majid
authors.initials: M
authors.lastname: Tayarrah
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000772:Anesthesia, Local; D000783:Aneurysm / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000379:methods; D003251:Constriction, Pathologic; D004867:Equipment Design; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D006435:Renal Dialysis; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D016879:Salvage Therapy; D013528:Surgical Staplers; D013536:Suture Techniques / Q000009:adverse effects / Q000295:instrumentation; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency; D014680:Veins / Q000503:physiopathology / Q000601:surgery