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Surgical management of cephalic arch occlusive lesions: are there predictors for outcomes?

Shouwen Wang1, Ammar Almehmi, Arif Asif

  • 1AKDHC-ASC, Arizona Kidney Disease and Hypertension Center, Phoenix, AZ 85012, USA. swang@akdhc.com

Seminars in Dialysis
|March 6, 2013
PubMed

Insights

Surgical revisions effectively salvage brachiocephalic arteriovenous fistulas with cephalic arch occlusive lesions (CAO). However, prior angioplasty of the cephalic vein may negatively impact outcomes after cephalic transposition and venovenostomy (CTV).

Area of Science:

  • Vascular Surgery
  • Nephrology
  • Interventional Radiology

Background:

  • Cephalic arch lesions frequently cause brachiocephalic arteriovenous fistula (AVF) dysfunction.
  • Cephalic arch occlusive lesions (CAO) encompass total occlusion, recurrent stenosis, and high-grade stenosis resistant to endovascular treatment.
  • Surgical intervention is considered for CAO when endovascular methods fail.

Purpose of the Study:

  • To evaluate the efficacy of surgical revisions for patients with cephalic arch occlusive lesions (CAO).
  • To assess the outcomes of cephalic transposition and venovenostomy (CTV) in salvaging dysfunctional AVFs.
  • To identify predictors of patency following surgical revision for CAO.

Main Methods:

  • Retrospective analysis of 40 patients undergoing surgical revision for CAO.
  • Surgical techniques included cephalic transposition and venovenostomy (CTV), basilic transposition and venovenostomy, stenotic segment resection, and cephalic-jugular vein bypass graft.
  • Patency rates (primary, assisted primary, secondary) were assessed at 12 months post-CTV; predictors of patency were analyzed.

Main Results:

  • Cephalic transposition and venovenostomy (CTV) was performed in 37/40 patients.
  • At 12 months post-CTV, fistula assisted primary and secondary patency rates were 82% and 97%, respectively; primary patency of the transposed cephalic vein was 25%.
  • Pre-CTV angioplasty of the proximal cephalic vein was a significant predictor of low primary patency (HR 4.5, p=0.002), with rates of 12% vs. 58% in patients with vs. without prior angioplasty.

Conclusions:

  • Surgical interventions, particularly CTV, are effective in salvaging AVFs complicated by CAO.
  • Prior angioplasty of the proximal cephalic vein adversely impacts the primary patency of CTV.
  • Careful consideration of prior endovascular interventions is crucial when planning surgical revision for CAO.

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