Anterior chest wall arteriovenous grafts: an underutilized form of hemodialysis access

Vascular access dysfunction is a major cause of morbidity in hemodialysis (HD) patients and the maintenance of a functional vascular access is an ongoing challenge. An upper extremity autogenous arteriovenous fistula (AVF) that preferentially involves the cephalic vein is the access of choice for hemodialysis patients, followed by autogenous AVF utilizing the basilic vein and the use of prosthetic arteriovenous grafts (AVG). Unfortunately, upper extremity options for vascular access rapidly become exhausted in a sub-group of patients and use of alternative sites for access becomes necessary. An anterior chest wall graft, in which the axillary artery is anastomosed to either the ipsilateral or contralateral axillary veins, is a reasonable option in patients who have exhausted their upper extremity as vascular access sites, but still have patent central veins. Major indications include patients predisposed to steal syndrome as well as those with stenotic outflow veins necessitating over the shoulder extension of a brachio-axillary graft. Recent data suggest that primary and secondary patency rates in anterior chest wall grafts are equivalent to upper extremity AVGs, making them a reasonable alternative vascular access option. This review will discuss the anatomical variations, percutaneous interventions, patency and longevity of anterior chest wall AV grafts.