The role of the prosthetic axilloaxillary loop access as a tertiary arteriovenous access procedure

In the last decade, the Dialysis Outcome Quality Initiative (DOQI) Guidelines have enhanced the longevity of patients with end-stage renal disease (ESRD) on hemodialysis. Consequently, surgeons are increasingly challenged to provide vascular access for patients in whom options for access in the upper extremity have been expended. This situation is even more problematic in the morbidly obese patient on hemodialysis. Our group previously reported a high rate of infection and need for secondary interventions in obese patients with prosthetic femorofemoral accesses. We now report a series of patients who underwent placement of a prosthetic axilloaxillary loop access. This study presents our technique and evaluates our results, particularly as they relate to the obese patient.

From January 1998 to May 2006, 34 prosthetic axilloaxillary loop accesses were placed in 32 patients with ESRD. Eleven patients (12 accesses) were obese, as defined by a body mass index >/=30 kg/m(2). Median follow-up was 16 months. Kaplan-Meier analysis was used to determine primary and secondary patency as well as patient survival for the entire cohort and for the obese and nonobese patient cohorts. Survival curves were compared using the log-rank test for equality over strata.

The secondary patency rate was 59% at 1 year (median, 18 months). The 1-year patient survival was 69%. Infection occurred in 15% patients. Comparison of the obese vs nonobese cohorts demonstrated no statistically significant difference in 1-year primary patency (36% vs 10%, P = .17) or secondary patency (71% vs 65%, P = .34). There were no infections in the obese cohort.

These data show that the prosthetic axilloaxillary loop access has acceptable outcomes and should be considered the tertiary vascular access procedure of choice in the obese patient on hemodialysis.