title: Experience with chest wall arteriovenous grafts in hemodialysis patients.
abstract: BACKGROUND
  Maintaining long-term hemodialysis access in end-stage renal disease patients presents a serious challenge to surgeons. Over time, patients' remaining access sites diminish while complications and comorbidities simultaneously multiply; often resulting in the use of permanent tunneled catheters, which have a well-known high rate of complications and short-term usefulness. In this study, we report the results of a dialysis graft based on the axillary artery and ipsilateral axillary vein and tunneled in the subcutaneous tissues of the chest.
  
  
  METHODS
  We identified patients who had a chest wall arteriovenous graft (CWAVG) placed at our institution between May 2007 and December 2012. After institutional review board approval, the patients were retrospectively and then prospectively identified and followed for 2 years to document the performance, required maintenance, and complications of the graft.
  
  
  RESULTS
  Sixty-seven grafts in 67 patients were reviewed, representing 0.56% of our 1,192 total dialysis access creations during the study period. The average patient was 55-year-old with an average history of 3.97 explicitly documented prior accesses. Sixty interventions were performed postoperatively including 32 for thrombosis and 28 for venous stenosis. Six documented graft infections occurred (9%). Three minor wound complications occurred, but the graft was preserved. Notably, no patient developed symptoms of steal syndrome. The primary and secondary patency rates at 1 and 2 years were 69.5% and 36.9% and 81.6% and 57.6%, respectively. Twenty-three of the 67 patients died in the 2-year follow-up period (34%).
  
  
  CONCLUSIONS
  CWAVGs are useful and appropriate for patients with difficult upper extremity access. The patency rates for this "exotic" procedure are at least equivalent to other upper extremity grafts. The infection rate is lower than that for femoral grafts or tunneled catheters, and there is no risk of steal syndrome. CWAVGs can even be considered for primary use in patients who have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome.
authors: Division of Vascular Surgery, Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX.
authors: Joseph M
authors: JM
authors: Liechty
authors: Division of Vascular Surgery, Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX.
authors: Tammy
authors: T
authors: Fisher
authors: Division of Vascular Surgery, Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX.
authors: Wilson
authors: W
authors: Davis
authors: Division of Vascular Surgery, Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX.
authors: Wes C
authors: WC
authors: Oglesby
authors: Division of Vascular Surgery, Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX.
authors: Monica
authors: M
authors: Bennett
authors: Division of Vascular Surgery, Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX.
authors: Brad
authors: B
authors: Grimsley
authors: Division of Vascular Surgery, Baylor University Medical Center, Baylor Scott & White Health, Dallas, TX. Electronic address: williash@baylorhealth.edu.
authors: William
authors: W
authors: Shutze
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D001366:Axillary Artery / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D035441:Thoracic Wall / Q000098:blood supply*; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D055815:Young Adult