Midterm Experience of Ipsilateral Axillary-Axillary Arteriovenous Loop Graft as Tertiary Access for Haemodialysis

Objectives. To present a series of ipsilateral axillary artery to axillary vein loop arm grafts as an alternative vascular access procedure for haemodialysis in patients with difficult access. Design. Retrospective case series. Methods. Patients who underwent an axillary loop arteriovenous graft from September 2009 to September 2012 were included. Preoperative venous imaging to exclude central venous stenosis and to image arm/axillary veins was performed. A cuffed PTFE graft was anastomosed to the distal axillary artery and axillary vein and looped on the arm. Results. 25 procedures were performed on 22 patients. Median age was 51 years, with 9 males and 13 females. Median number of previous access procedures was 3 (range 0–7). Median followup was 16.4 months (range 1–35). At 3 months and 1 year, the primary and secondary patency rates were 70% and 72% and 36% and 37%, respectively. There were 11 radiological interventions in 6 grafts including 5 angioplasties and 6 thrombectomies. There were 19 surgical procedures in 10 grafts, including thrombectomy, revision, repair for bleeding, and excision. Conclusions. Our series demonstrates that the axillary loop arm graft yields acceptable early patency rates in a complex group of patients but to maintain graft patency required high rates of surgical and radiological intervention, in particular graft thrombectomy. 1. Introduction Arteriovenous fistula (AVF) is the recommended modality of access for patients on haemodialysis for end-stage renal failure. Guidelines from the National Kidney Foundation (KDOQI) suggest that all AVF options should be exhausted before resorting to central venous access catheters [1]. In the majority of patients, arm fistulas will be all that is required; however, there is a cohort of patients in whom vascular access is problematic who require more complicated access procedures. Once all native arm and forearm AVF have failed, then the options are limited and are broadly, either a graft involving the axillary or central vessels, or a lower limb arteriovenous access procedure. Lower limb access is typically the last resort and has high infection rates, risk of limb loss and potentially compromises the iliac arteries for future transplants; therefore an upper limb synthetic graft should be the next procedure of choice [1–4]. There are three groups of patients that have benefitted from axillary grafts to date: first, those noted above in whom the upper limb vein options are exhausted, usually due to thrombosis from previous AVF; second, those with severe vascular steal syndrome from a