Arterio-Arterial Prosthetic LoopAre we doing enough?

Faisal Alam Consultant Vascular & General

SurgeonRoyal Hospital

Introduction:Number of patients with end-stage renal

disease (ESRD) requiring hemodialysis is constantly rising worldwide

Consequently number of ESRD patients with difficult access and comorbidities also increasing.

Introduction cont..Patients are living longer and good number of

them undergo many procedures for dialysis access.

Increase in the number of patients whose vascular access options are exhausted keeps us vascular surgeons in dilemma regarding the next step.

Introduction cont..Similarly high incidence of diabetic

population in Oman ( about 11-12 %) has led to an increase in ESRD patients.

In 2012, 65% of the vascular surgical load at the Royal Hospital was related to vascular access.

Introduction cont..Majority of our patients refuse pre-emptive

AVF creation. Pre-emptive procedures hardly reaches 5-10% of the actual load.

As a consequence, we have high number of patients on central venous lines for dialysis

What are the options?!

1. All central accesses are occluded2. All peripheral venous and PD options have

been exhausted. 3. Heart Failure with very low ejection fraction

Is Arterio-Arterial Prosthetic Loop an option?

First proposed by Butt and Kountz in 1976

Janow et al. J Vasc Surg. 2005 June34 patients with 36 AAPL (31 axillary / 5femoral) (Apr 1996 - Sept 2004) central vein occlusion 64%, steal sy 11%, severe peripheral arterial disease in 22%, and congestive heart failure in 3%Primary /secondary patency 73%/96% at 1yr and 54% and 87% at 3 years,

Bunger et al. J Vasc Surg. 2005 Aug20 patients (May 2001 - Dec 2004). Exhausted AV access options in 14 patients (70%), central vein occlusion in 5 patients (25%),ischemia from steal sy in 12 patients (60%) High-output cardiac failure in one patient. Median f/u was 7.4 months. The 30-day peri-operative mortality rate was 5%. Access thrombosis in four patients (asymptomatic). Early post-op bleeding in four patients. Late graft infection in one after repeated thrombectomy. The primary and secondary patency rate was 90% and 93%, respectively, at 6 months.

Gdoura Moncef et al. Saudi Journal ofKidneydiseases and transplant. 2005

Arterio-Arterial Interposition Graft in 9 patientsMedian period of use was 18 monthsNo limb loss

Stephenson et al. J Vasc Access. 2012 Nov

Axillary-axillary inter-arterial chest loop graftEarly dialysis within one day

Our Own experience60 years old with severe heart failure (EF

15%)Exhausted peripheral access options and

failed PD catheter.Had trans-lumbar Perm cath insertion (both

iliacs and subclavian veins were occluded.Had left axillary inter-arterial PTFE loop

graft under LA. Used for 14 months without any problems.Patient died from cardiac causes.

The basics of the AAPL compared with an AV graft:

1. A vein is not essential.2. The distal perfusion is not decreased.3. The cardiac load is not increased.

Instructions for the dialysis unitNephrologists should be informed about the

specifics of this access and position of needles.

Advise to compress puncture site for 20 minutes after the removal of the needles.

Refrain from infusion of medications through the AAPL

In conclusionAAPL is a viable option which seems to be

under-utilizedIt should be considered more frequently,

specially in cases of venous hypertension, steal phenomenon and congestive heart failure

can be done under LA and has good medium term patency rate

Complication rates are comparable with AVG and no reports of limb loss