title: Creating arteriovenous fistulas in patients with chronic central venous obstruction.
abstract: OBJECTIVE
  Central venous obstruction Occlusion (CVO) has been considered a contraindication for creating a vascular access due to fear of developing a swollen extremity. However, many of these individuals developed large collateral veins and are asymptomatic. We report our experience constructing arteriovenous fistulas (AVFs) in these challenging patients.
  
  
  METHODS
  Patients with a new AVF constructed in the presence of known CVO were identified. Venous imaging confirmed proximal obstruction and extensive collateral venous return. The AVF was constructed in the extremity with the most favorable ultrasound vessel mapping and collateral central venous outflow. Arterial inflow via the radial artery was utilized when feasible.
  
  
  RESULTS
  AVFs associated with known CVO were constructed in 19 patients during an eight-year time period. The mean age was 53 years, 63% were female, and 58% diabetic. Arterial inflow was from the radial artery in 15 patients and the brachial or axillary artery in 5 individuals. Post-operative AVF flow volumes were 415-910 mL/min (mean = 640 mL/min). Eight patients (42%) developed some degree of arm edema. Two resolved without intervention. The others required inflow banding (n = 2), outflow branch coiling (n = 1), and/or recanalization with angioplasty (n = 4) of the CVO to resolve swelling. Mean follow-up was 14 months. Two AVFs failed at 8 and 16 months. Primary and cumulative patency rates were 49% and 100% at 12 months and 39% and 80% at 24 months, respectively.
  
  
  CONCLUSIONS
  CVO need not preclude the creation of a successful AVF. Extensive venous collaterals and avoiding high-flow AVFs are important elements for success. Cumulative patency was 80% at 24 months.
authors: Department of Surgery, University of Oklahoma College of Medicine, Tulsa, Oklahoma - USA.
authors: William C
authors: WC
authors: Jennings
authors: Department of Surgery, University of Oklahoma College of Medicine, Tulsa, Oklahoma - USA.
authors: Charles Miles
authors: CM
authors: Maliska
authors: Department of Surgery, University of Oklahoma College of Medicine, Tulsa, Oklahoma - USA.
authors: John
authors: J
authors: Blebea
authors: Department of Surgery, University of Oklahoma College of Medicine, Tulsa, Oklahoma - USA.
authors: Kevin E
authors: KE
authors: Taubman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001783:Blood Flow Velocity; D002908:Chronic Disease; D003097:Collateral Circulation; D003251:Constriction, Pathologic; D004487:Edema / Q000209:etiology / Q000503:physiopathology; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012039:Regional Blood Flow; D006435:Renal Dialysis; D019233:Retreatment; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014652:Vascular Diseases / Q000000981:diagnostic imaging / Q000503:physiopathology*; D014654:Vascular Patency; D014680:Veins / Q000000981:diagnostic imaging / Q000503:physiopathology*; D055815:Young Adult