Treatment of angioaccess-induced ischemia by revascularization

Upper extremity ischemia related to the construction of a chronic angioaccess is a serious and occasionally devastating complication. Fourteen patients with end-stage renal disease (mean age 58 +/- 18 years, 13 with diabetes, 10 female) had ischemia after construction of an angioaccess. Twelve patients had a polytetrafluoroethylene brachioaxillary bridge arteriovenous fistula (BAVF), one patient had a radiocephalic arteriovenous fistula (AVF) and one patient had a brachiocephalic AVF. All patients had severe ischemia and five of them had established gangrenous changes. Symptoms appeared immediately after construction of the access in 10 patients. The remaining four patients had late onset of ischemia. The technique used for revascularization in all of these patients consisted of ligating the artery just distal to the takeoff of the AVF or BAVF and establishing an arterial bypass from a point proximal to the AVF or BAVF inflow to a point distal to the ligature. Bypass grafts consisted of saphenous vein in 13 cases and polytetrafluoroethylene in one case. Thirteen patients had a complete recovery, including healing of gangrenous lesions. One patient with severe gangrene of the hand at the time of revascularization required forearm amputation 13 months later because of progressive occlusive arterial disease. All AVFs were patent at 1 year. The 1-year patency rate for the BAVFs was 81.7%. All arterial bypasses were patent at 1 year. It is concluded that this technique offers consistent and durable hemodynamic and clinical improvement in arms affected by access-induced ischemia, with minimal morbidity, and does not affect the longevity of the angioaccess.