Percutaneous creation of arteriovenous hemodialysis grafts: work in progress

To develop a technique of percutaneous creation and/or revision of arteriovenous hemodialysis access grafts, and to study the feasibility of the technique in the acute setting.

Arteriovenous shunts, consisting of silicone-covered Wallstents 6 (n = 10) or 8 (n = 1) mm in diameter and 11-17 cm in length, were created in 10 mongrel dogs. All shunts were created percutaneously except one, in which the carotid artery was exposed surgically and the jugular vein accessed percutaneously to create a straight external graft. All other grafts were femoral loops (femoral artery to femoral vein). Eight were tunneled subcutaneously and three were left external. All shunts were delivered through 10-F peel-away sheaths.

The 11 shunts were allowed to flow for a mean of 4 hours (range, 1.0-6.5 hours) before the animals were killed. Leakage around the "anastomoses" was not observed. Leaks in the silicone covering were observed, resulting in one early shunt failure. Two attempted survival experiments were aborted due to early shunt dislodgment at 1.5 and 3.5 hours.

Percutaneous arteriovenous shunt creation is feasible through acceptably small sheaths. Peel-away sheath placement of the stent circumvents the technical problem of placing a closed device into both artery and vein. This technique may allow percutaneous revision of existing hemodialysis access grafts and possibly de novo creation of grafts in humans, but modification of the grafts will be needed to prevent dislodgment.