title: Long-segment plication technique for arteriovenous fistulae threatened by diffuse aneurysmal degeneration: short-term results.
abstract: BACKGROUND
  A substantial number of patients with autologous arteriovenous fistulas (AVFs) develop diffuse aneurysmal degeneration, which frequently interferes with successful access. These AVFs are often deemed unsalvageable. We hypothesize that long-segment plication in these patients can be performed safely with acceptable short-term AVF salvage rates.
  
  
  METHODS
  We reviewed a prospectively maintained database to identify all patients with extensive AVF aneurysmal disease operated on for this problem.
  
  
  RESULTS
  Thirty-five patients, 25 (71%) male and 10 (29%) female were operated on between July 2012 and January 2014. AVFs included 23 (66%) brachiocephalic, 5 (14%) radiocephalic, and 7 brachiobasilic (20%) fistulae (one first stage only but in use). The cohort had one or a combination of local pain, arm edema, cannulation issue, recurrent thrombosis, dysfunctional during dialysis, or extreme tortuousity. Time range for AVF creation to consultation ranged from 3 months to 11 years. All underwent long-segment plication over a 20-Fr Bougie with or without segmental vein resection; 3 underwent concomitant first rib resection for costoclavicular stenosis; 21 patients had tunneled catheter placement for use while healing, whereas 13 were allowed segmental use of their AVF during the perioperative period (1 patient was not yet on dialysis). Early in our experience, AVFs were left under the wound, whereas all but one repaired since early 2013 were left under a lateral flap. All patients were followed by clinical examination and duplex. In the 30-day postoperative period, 2 AVFs (5.7%) became infected requiring excision, 2 occluded (5.7%), 1 day 1 and the other at 24 days out, 1 patient developed steal and required DRIL 1 week postoperatively, and 1 patient died, unrelated to his surgery. Postoperative functional primary patency was 88% (30 of 34). Of the patients needing temporary access catheter, mean time to first fistula use was 44 days. No wound or bleeding complications have occurred in repaired AVF left under skin flaps.
  
  
  CONCLUSIONS
  In this group of patients whose access was threatened by diffuse aneurysmal degeneration, long-segment placation allowed salvage of 88% of fistulae with relatively low morbidity. Fewer complications are associated by covering the revised fistula with intact skin.
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL. Electronic address: apowellr@gmail.com.
authors.forename: Alexis
authors.initials: A
authors.lastname: Powell
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Mathew
authors.initials: M
authors.lastname: Wooster
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Megan
authors.initials: M
authors.lastname: Carroll
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Damian
authors.initials: D
authors.lastname: Cardentey-Oliva
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Sean
authors.initials: S
authors.lastname: Cavanagh-Voss
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Paul
authors.initials: P
authors.lastname: Armstrong
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Murray
authors.initials: M
authors.lastname: Shames
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Karl
authors.initials: K
authors.lastname: Illig
authors.affiliation: Tampa Bay Vascular Center, Tampa, FL.
authors.forename: Wesley
authors.initials: W
authors.lastname: Gabbard
mesh_terms: D000783:Aneurysm / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000379:methods; D064592:Autografts; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000009:adverse effects; D006435:Renal Dialysis; D012086:Reoperation; D016879:Salvage Therapy; D013524:Surgical Flaps / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency