AV FISTULA CREATION FOR DIALYSIS ACCESS IN AN AMPUTEE

AXILLO-FEMORAL FISTULA CREATION FOR HEAMODIALYSIS – CASE REPORT

A-FISTULA CREATION BY NOW IS A STANDARD PROCEDURE FOLLOWED WORLDWIDE FOR HEAMODILYSIS ACCESS IN CKD PATIENTS.THERE ARE

TIMES WHEN HEAMODIALYSIS BECOMES A CHALLENGE BECAUSE OF NON AVAILABILITY OF VENOUS ACCESS.THE REASONS BEING IN PLENTY LIKE THROMBOSED SUPERFICIAL VEINS,FAILED A-V ACCESS EARLIER SO ON AND SO FORTH .ROUTINELY AN AV FISTULA IS CREATED ON THE FOREARM BETWEEN THE RADIAL ARTERY AND CEPHALIC VEIN FOR VENOUS ACCESS.THE DIALYSIS THROUGH THESE ARTERIALISED VEINS CAN BE STARTED ONCE THE FISTULA MATURES.SOMETIMES THE VASCULAR SURGEON NEEDS TO USE THE BRACHIAL ARTERY TO DIRECT BLOOD INTO THE VEINS FOR FUTURE HEAMODIALYSIS ACCESS.THESE ARE THE ROUTINE SURGERIES DONE FOR CKD PATIENTS FOR DIALYSIS.CERTAIN SITUATIONS DEMAND THE USE OF SYNTHETIC GRAFT FOR HEAMODIALYSIS. VASCULAR SURGEONS WORLDWIDE HAVE THEREFORE COME UP WITH FEMORO-FEMORAL AV FISTULAS WITH PTFE GRATS,BRACHIO- AXILLARY FISTULAS,AXILLO-AXILLARY FISTULAS AND RADIO-CEPHALIC FISTULAS WITH PTFE GRAFTS.THE PATENCY OF NATIVE VESSEL FISTULAS IS CERTAINLY BETTER THAN THE ONES WHEREIN SYNTHETIC GRAFT IS USED BUT THEN THESE GRAFTS ARE USED IN UNAVOIDABLE AND DESPERATE CIRCUMSTANCES LIKE SMALL VEINS,FAILED NATIVE FISTULAS IN THE PAST SO ON AND SO FORTH.ITS AN IMPORTANT WEAPON IN THE ARMEMTARIUM OF THE VASCULAR SURGEON AS IT MAKES THE LIFE OF THE CRF PATIENT RELATIVELY EASY AND IS WORTH THE EFFORT.PTFE IS THE SYNTHETIC GRAFT GENERALLY USED FOR MAKING THESE FISTULAS. WE REPRESENT AN UNUSUAL CASE WHEREIN AN AXILLO-FEMORAL A-V FISTULA WAS CREATED CONNECTING THE LEFT AXILLARY ARTERY WITH THE LEFT COMMON FEMORAL VEIN WITH A 6 MM PTFE SYNTHETIC GRAFT AND TUNNELING IT UNDER THE SKIN FOR VENOUS ACCESS.

THIS PATIENT AGED 55 YEARS MET WITH AN ACCIDENT SOME TWO YEARS AGO .SHE ENDED UP LOSING HER LEFT LOWER LIMB AND BOTH HER KIDNEYS FAILED. SHE IS ON REGULAR DIALYSIS.SHE HAD AN AV FISTULA MADE ON HER LEFT FOREARM IN THE PAST CONNECTING THE BRACHIAL ARTERY AND CEPHALIC VEIN ONLY TO BE CLOSED LATER AS SHE DEVELOPED MASSIVE SWELLING OF HER LEFT UPPER LIMB AFTER FISTULA CREATION. FISTULOGRAM WAS DONE AND IT SHOWED SHE HAD SUPERIOR VENA CAVA SYNDROME.THE PROBABLE CAUSE OF HER SVC SYNDROME SEEMED TO BE IATROGENIC AS HER INTERNAL JUGULAR VEIN WAS CANNULATED EARLIER FOR DIALYSIS.WE HAD LIMITED OPTIONS IN HER AS FISTULA COULD NOT BE CREATED IN THE OTHER UPPER LIMB BECAUSE OF SVC SYNDROME.THE ONLY USUAL OPTION LEFT IN SUCH A SCENARIO WAS TO CREATE AN AV FITULA WITH GRAFT ON HER RIGHT THIGH CONNECTING THE FEMORAL VEIN WITH THE FEMORAL ARTERY AS SHE HAD AN AMPUTATED LEFT LEG(HIGH ABOVE KNEE AMPUTATION).SINCE SHE STILL HAS AN ACTIVE LIFESTYLE MAKING AN AV FISTULA ON THE UNAFFECTED RIGHT LEG WAS NOT THE BEST OPTION BECAUSE OF FEAR OF SYNTHETIC GRAFT INFECTIONS AND WOUND COMPLICATIONS THAT MAY HAVE JEOPARDISED THE VIABILITY OF HER RIGHT LOWER LIMB IN NEAR FUTURE.

WE DID AN INNOVATIVE SURGERY BY CREATING THE FISTULA TAKING THE INFLOW FROM THE LEFT AXILLARY ARTERY AND CONNECTING THE GRAFT TO LEFT COMMON FEMORAL VEIN. THE PATIENT TOLERATED THE PROCEDURE WELL AND THE SURGERY LASTED FOR 90 MINUTES.POST PROCEDURE THE PATIENT IS DOING WELL AND TO DATE HAS UNDERGONE ALMOST 30 HEAMODIALYSIS THROUGH THIS NEWLY CREATED FISTULA.

TO DATE THIS IS THE FIRST OF ITS KIND AV FISTULA CREATED IN THE WORLD IN AN AMPUTEE USING FEMORAL VEIN OF THE STUMP AS PER THE VASCULAR SURGERY LITERATURE .

THE IDEA OF REPORTING THIS ARTICLE IS TO GIVE HOPE TO THOUSANDS OF PEOPLE AROUND SUFFERING FROM CRF WHEREIN VENOUS ACCESS FOR HEAMODIALYSIS IS UNAVAILABLE FOR MYRIAD REASONS. FISTULA FOR HEAMODIALYSIS CAN ALMOST ALWAYS BE CREATED EVEN IN SEEMINGLY DIFFICULT SITUATIONS.

Basic things a general practitioner should know when examining a patient of vascular surgery

Well we have been taught rigorously in our medical schools but still we tend to forget the so called ABC of how to examine a patient when he/she turns to our clinic with a concerned disease.First and foremost is to check and feel for the peripheral pulses.Most of us only feel for the radial artery pulse and just forget to feel for the lower limb pulses which can yield an important clue into diagnosing a vascular disorder.I have come across patients with paraplegia wherein they were admitted under the supervision of a neurologist thinking it to be a neurological disorder.By the time a diagnosis is made either by a clinical examination of the peripheral pulses or a CT angio,patient gets into a state of irreversible ischemia wherein saving the legs become next to impossible .I feel if all of us can add this simple step of feeling for the peripheral pulses in our daily practise many limbs can be prevented from being amputated by referring the patients with absent pulses to qualified vascular surgeon.I end this article with a famous saying by Leonardo Da Vinci Knowing is not enough; we must apply.
Being willing is not enough; we must do.