Arteriovenous fistula

Aneurysmorrhaphy

Surendra Shenoy MD., PhD.Washington University School of Medicine

Barnes Jewish HospitalSt. Louis, Missouri

DisclosuresLaboratory and clinical research

support from industry forresearch related to transplant and

vascular access

None of the research or nonFDA approved productswill be discussed in this

presentation

PathophysiologyVenous aneurysms are a result of

dilation of needle access segment over a period of time

Every needle access heals with a scarwhen the pressure in the system is

high the scar tends to thin outresulting in aneurysmal dilation

Hypothesis

Most AVF aneurysms are ‘true aneurysms’ of the native vein

Acute needle access infiltrates canget infected and present as acute

infected pseudoaneurysms

AVF aneurysms

Absence of extraneous material permitsprimary reconstruction in most

circumstances

Clinical presentation and Indications for aneurysm repair

UrgentEmergent Elective

•H/O Bleed•Pulsatile clot

• No H/O Bleed• Chronic Needle access site ulcer

•Expanding aneurysm

•Thinned out skin

Treatment options

Excision

Plication(Surgical repair)

Abandonment

1. Safe2. Loss of site3. Loss of access4. Need TDC

1. Future risk2. Loss of access3. Loss of site4. Need TDC

1. No access loss2. No loss of site3. Need TDC?4. Safety?5. Results?

Principles of surgical repair (Plan to avoid catheter)

1. Mark site for needle access during healing2. Plan skin coverage for defect3. Excision of ulcer/aneurysm4. Repair of underlying vessel

Direct repair ofvessel wall

•Excision of aneurysm•Reconstruction of vein

End to end Tubular reconstruction

5. Provide planned skin coverage

Principles of local repair to avoid catheter

Techniques to plan for skin coverageRhomboid flap (Limberg flap)

Z-W plasty

Bi-convex advancement

Z - W plasty for oblong defects

Bi – convex advancement flap

Infected Buttonhole –pseudo aneurysm

AVF acute pseudo-aneurysm

Results

Shenoy S. CiDA 2013

• Aneurysm patients (n=83) 2000 – 2013 96

• Given up previously 9

• Technical success reconstruction 100%

• Cumulative patency 5 years 92%

• Skin flap reconstruction <95%

• Recurrent aneurysm 3

• Active AVF with aneurysm 84

• AVF repaired (84) 97%

• Repair without catheter 72%

• Threatened/active bleed 58%

Diligent preoperativeplanning

Excision with repair of vesselProviding skin coverage

Often able to avoid a catheter

Summary

Arteriovenous fistula

Aneurysmorrhaphy

Surendra Shenoy MD., PhD.Washington University School of Medicine

Barnes Jewish HospitalSt. Louis, Missouri