title: When Arteriovenous Fistulas Are Too Deep: Options in Obese Individuals.
abstract: BACKGROUND
  Obesity in the hemodialysis population is roughly twice that of the general population. An arteriovenous fistula (AVF) remains the recommended vascular access; however, obesity results in fewer autogenous accesses, more complexity, and higher AVF failure rates. We reviewed our vascular access experience in obese individuals in whom the depth of an AVF prevented reliable cannulation.
  
  
  METHODS
  We reviewed our database of consecutive vascular access patients, identifying individuals in whom the planned venous outflow cannulation segments were too deep and required additional surgical procedures to establish a functional hemodialysis access. These additional procedures included lipectomy, outflow elevation, cephalic transposition, liposuction, or an implantable cannulation guide.
  
  
  RESULTS
  During the study period, 1,874 consecutive new patients had an autogenous vascular access constructed. We identified 120 patients in whom an additional procedure was required due to the depth of the cannulation sites; these comprised this study group. Ninety-nine (83%) were female, 85 (71%) were diabetic, and 53 (45%) had previous access operations. Body mass index was 25.4 to 62.8 kg/m(2) (mean 40.8 kg/m(2)), age range was 27 to 81 years (mean 54 years), and follow-up was 1 to 101 months (mean 25 months). Primary and cumulative patency rates for all patients were 63% and 93% at 1 year and 46% and 91% after 2 years, respectively. The most common additional procedure performed was a lipectomy (n = 78), with 1-year primary and cumulative patency rates of 78% and 97% and 2-year rates of 69% and 91%, respectively.
  
  
  CONCLUSIONS
  A variety of surgical options were found to be successful in establishing a functional autogenous vascular access for individuals in whom cannulation sites were simply too deep. Cumulative patency rates for all patients were 93% at 1 year and 91% after 2 years.
authors.affiliation: Department of Surgery, University of Oklahoma College of Medicine, Tulsa, OK.
authors.forename: C
authors.initials: C
authors.lastname: Miles Maliska
authors.affiliation: Department of Surgery, University of Oklahoma College of Medicine, Tulsa, OK. Electronic address: william-jennings@outlook.com.
authors.forename: William
authors.initials: W
authors.lastname: Jennings
authors.affiliation: Department of Vascular Surgery, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Alexandros
authors.initials: A
authors.lastname: Mallios
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical; D015992:Body Mass Index; D002406:Catheterization, Peripheral; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy*; D015187:Lipectomy; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications*; D006435:Renal Dialysis; D012189:Retrospective Studies; D014654:Vascular Patency