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Single-Institution Learning Curve for Management of Mega-Fistulae Revision.

Stephanie Rodriguez1, Benjamin J Pomy2, Sowmya Mangipudi1

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Summary

Complete mega-fistula resection and replacement with Acuseal graft preserves arteriovenous access and may avoid long-term catheter use. This technique shows promise for managing complex AV access issues.

Keywords:
continuous AV accesshigh flow AV accessmega-fistulaemega-fistulae repairmega-fistulae revision

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Area of Science:

  • Vascular Surgery
  • Interventional Nephrology
  • Dialysis Access

Background:

  • Mega-fistulae are large, aneurysmal dilations in arteriovenous (AV) access, posing risks of hemorrhage and cardiac failure.
  • Existing treatments like ligation or graft replacement have limitations, including loss of access or recurrence.
  • Advanced mega-fistulae require innovative solutions to preserve AV access and patient health.

Purpose of the Study:

  • To evaluate the early outcomes of complete mega-fistula resection and prosthetic graft replacement.
  • To assess the technique's ability to maintain existing AV access and reduce long-term catheter dependence.
  • To identify lessons learned from initial cases using this novel approach.

Main Methods:

  • A retrospective review of 12 patients undergoing mega-fistula resection and prosthetic graft replacement (Propaten, then Acuseal) from March 2018 to February 2021.
  • Complete resection of aneurysmal segments followed by anastomosis of a prosthetic graft to the native arterial and venous ends.
  • Outcomes assessed included technical success, need for long-term catheters, time to cannulation, and complications.

Main Results:

  • 100% immediate technical success was achieved in all 12 patients.
  • Time to cannulation was significantly shorter with Acuseal (4.5 days) compared to Propaten (6 weeks).
  • Complications included skin necrosis, seroma, hematoma, central venous occlusion, and graft infection; five of six patients with follow-up maintained access, though some required interventions.

Conclusions:

  • Complete mega-fistula resection and replacement with an Acuseal graft effectively preserves AV access.
  • This technique shows potential to eliminate the need for long-term catheter placement in patients with complex AV access.
  • Further follow-up is necessary to confirm the long-term durability of this AV access management strategy.