"Two is better than one": a composite graft made of two different vascular prostheses for urgent hemodialysis access in a troublesome case.
BACKGROUND
Multiple failed hemodialysis access and poor vascular anatomy can jeopardize an end-stage renal disease patient's survival, frequently leading to the urgent need for rapid and durable new vascular access. In these circumstances, the extensive use of central venous catheters (CVC) can led to serious complications, such as infection, thrombosis, and often vessel scarring with obstruction of the central veins. More recently, new self-sealing prosthetic grafts may be cannulated within a few days after implantation, avoiding the need for extensive CVC. However, similar to all synthetic arteriovenous grafts (AVG), the new grafts are prone to rapid and aggressive venous neointimal hyperplasia (VNH), which is responsible for outflow stenosis and access thrombosis. Endoluminal sutureless anastomosis has been demonstrated to have better hemodynamics at the venous outflow with a supposed reduction of VNH, thus potentially improving graft patency.


METHODS
We report a case of a successful creation of a composite prosthetic access in a patient with severe comorbidities and nearly complete exhaustion of all vascular sites and with the need for immediate access for hemodialysis. Two relatively novel vascular expanded polytetrafluoroethylene prostheses were used jointly in this patient for a brachial-axillary AVG to allow early cannulation and with the aim of being less vulnerable to outflow stenosis. A multilayer self-sealing graft and a graft with a nitinol reinforced section, which permits endoluminal sutureless anastomosis, were sewed together to create a unique prosthesis with both features.


RESULTS
The composite graft was cannulated 48 hr after implantation and continued to function well at 10 months of follow-up without signs of venous stenosis.


CONCLUSIONS
This simple technique allows the creation of a customized composite graft with self-sealing properties and improved hemodynamics at the venous outflow.
Division of Vascular and Endovascular Surgery, San Giovanni Bosco Hospital, Turin, Italy. Electronic address: agosurgery@gmail.com.
Andrea
A
Agostinucci
Division of Nephrology and Dialysis, San Giovanni Bosco Hospital, Turin, Italy.
Pasqualina
P
Cecere
Division of Nephrology and Dialysis, San Giovanni Bosco Hospital, Turin, Italy.
Giacomo
G
Forneris
Division of Vascular and Endovascular Surgery, San Giovanni Bosco Hospital, Turin, Italy.
Andrea
A
Cumino
Division of Vascular and Endovascular Surgery, San Giovanni Bosco Hospital, Turin, Italy.
Roberta
R
Suita
Division of Vascular and Endovascular Surgery, San Giovanni Bosco Hospital, Turin, Italy.
Andrea
A
Bellan
Division of Vascular and Endovascular Surgery, San Giovanni Bosco Hospital, Turin, Italy.
Marco
M
Trogolo
Division of Vascular and Endovascular Surgery, San Giovanni Bosco Hospital, Turin, Italy.
Ferruccio
F
Ferrero
D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D001807:Blood Vessel Prosthesis; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D006435:Renal Dialysis / Q000379:methods*; D014654:Vascular Patency