TIED PROXIMAL AND DISTAL VESSELSCreating Venous access for dialysis is a common surgery done all over the world by the vascular surgeons,urologists and even the plastic surgeons.Its not uncommon to come across with venous access complications esp.if we use a synthetic graft for AV fistula creation.Needless to say we should only attempt creating venous access if we are well verse with its probable complications and are up for it.
We recently had a patient in his late sixties who came with copious pus exuding from the groin wound which was sutured with drains .This patient was discharged from a reputed hospital a couple of days back.History of the patient revealed creation of a venous access in his groin by using a synthetic graft only few months ago.I learn from the attendants that the operating surgeon told the patient had no choice but to go for this surgery as attempts to salvage the elbow fistula by endovascular means failed in him(Patient had a steal syndrome ).The surgery was done in a different hospital and the removal of infected synthetic graft was done at some other hospital (graft excision by urologist)before the patient finally landed with us.The discharge summary was suggestive of graft excision with vein patch repair of the femoral artery a few days back.The patient started bleeding profusely from the groin and went into shock.We had no other choice than to shift the patient to the Emergency OP and explore the wound.The investigations done in our hospital by then revealed that the patient was in severe sepsis with deranged biochemical parameters.
Wound exploration revealed a large rent in the common femoral artery.Vein patch was conspicuous by its absence.We had no choice other than to tie off the vessels to save the life of the patient.Doing a bypass simultaneously to restore the circulation of the limb was not done in view of the critical situation of the patient.Postoperatively patient kept deteriorating due to ongoing sepsis and was on ventilatory support.The affected lower limb became cold due to irreversible ischemia and and was finally amputated.Even this did not help and the patient finally died.
I learn the from the attendants that the patient spent something like 25-30 lakh rupees in a span of just four months related to the venous access creation and thereafter before turning to us.The situation leaves alot of questions that went unanswered.Firstly was there really no other choice than to create a venous access in the groin using synthetic graft?Secondly was doing a patch venoplasty the best of surgical procedures in a grossly infected groin in a patient who I suppose was hemodynamically better than when we received him in our ICU?
Not sure about the first question but i feel the vessels should have been tied as vein patchplasty is never a good option in a situation like this. This way the groin could have been left open and closed later with or without VAC therapy.
