Case Study Brachiocephalic Fistula with Cephalic Arch Stenosis Vascular Access

Vascular Access
Case Study
Brachiocephalic Fistula with Cephalic Arch Stenosis
Courtesy of Eric S Chemla, Consultant Surgeon & Honorary Senior Lecturer,
Renal Transplant and Vascular Surgery, St. George’s Healthcare NHS Trust
A 58-year-old male patient, on dialysis for the past 25 years, had three
transplants that ultimately failed. At present, he has a very high rate of panel
reactive antibodies (PRA) which makes him unsuitable for another transplant.
Attempts at peritoneal dialysis (PD) ended in peritonitis. He was currently
being dialyzed through a precious 12-year-old right brachiocephalic
arteriovenous fistula. The patient is well aware of his disease and very
cooperative.
Cephalic Arch Stenosis
During the past year his vascular access flow measurements, as measured by
the Transonic Hemodialysis Monitor, have dropped. Fistulograms revealed a
tight cephalic arch stenosis (Figs. 1,2). The stenosis was successfully dilated
three times, but, recently, the interval between the last dilation and the next
decrease in access flow was only eight weeks.
Fig. 1: Fistulogram showing
cephalic arch stenosis.
Clinically, the fistula was pulsatile with no thrill or bruit. Dialysis was painful
and inefficient with very high venous pressures, low pump speed and poor
inflow (200-250 mL/min). It was decided to correct the problem surgically
through creation of a new arch by ligating the cephalic vein, just before the
stenosis, mobilizing it and swinging it over to anastomose with the axillary
vein.
Procedure
The surgeon dissected the fistula in the delto-pectoral groove as well as the
axillary vein just below the pectoralis minor.
Fig. 2: Right brachiocephalic fistula &
cephalic arch stenosis.
Before reconstructing the fistula, fistula outflow on the cephalic vein
measured 36 mL/min (range: 18-114 mL/min). The fistula was clamped, as was
the axillary vein which was opened. The distal part of the fistula was then
tied off (Fig. 3a), and the vein was cut and trimmed to obtain a nice surface
for an anastomosis. The vein was then mobilized and anastomosed, end to
side, to the axillary vein (Fig. 3b). The diameters of the cephalic and axillary
veins were 7 mm. The length of the anastomosis was 20 mm.
Post-op Flows
Post-procedure fistula flow measured 600 mL/min (range: 359-1004 mL/min).
Clinically, a thrill and a bruit were present and dialysis could be resumed
through the brachiocephalic fistula.
FISTULA OUTFLOW SUMMARY
CONDUIT
SIZE
PRE-CORRECTION
Cephalic vein
7 mm
36 mL/min
Axillary vein
7 mm
POST-RECONSTRUCTION
Fig. 3: Cephalic vein is ligated (a).
The stenosis is mobilized &
anastomosed to the axillary
vein (b).
600 mL/min
Reference:
Case study courtesy of Eric S. Chemla, MD, consultant surgeon and honorary senior
lecturer, Renal Transplant and Vascular Surgery, St. George’s Healthcare NHS Trust.
CephalicArchStenosis(VA-20-cs)RevC2014USltr
www.transonic.com