Short-term follow-up for percutaneous extra-anatomic intervascular anastomosis in salvage of a thrombosed native arteriovenous fistula.

Percutaneous extra-anatomic intervascular anastomosis (PEIA), i.e., the nonsurgical connection of two anatomically unrelated vascular lumina, has rarely been reported in peripheral applications. Chen et al. [1] recently described a PEIA technique applied in peripheral vascular intervention. Using the same technique, the authors successfully salvaged an occluded native arteriovenous (AV) fistula with obliterated outflow veins. The vascular access has been followed up for more than 6 months and access-related complications are reported here. A 54-year-old woman with a failed and diffusely thrombosed native radiocephalic fistula in the right forearm was referred for shunt salvage. The fistula had been used for about 13 years. Informed consent was obtained. The institutional review board was not required for this retrospective report in our hospital. On physical examination, a hard and dilated forearm cephalic vein was noted, terminating as a venous stump not far below the elbow crease. Using local anesthesia, a 7-Fr introducer sheath was inserted in antegrade fashion in the forearm cephalic vein about 4 cm downstream of the AV anastomosis. A 4.1-Fr angiographic catheter was advanced to the venous stump and a small test bolus of contrast material was injected. No outflow vein from the venous stump could be identified on fluoroscopy. Under sonographic guidance, small thrombosed veins were catheterized, but attempts to get access into the dilated venous stump failed (Fig. 1A). During the search for small thrombosed veins around the venous stump, an upper arm basilic vein near and medial to the venous stump was noted. The patent basilic vein was catheterized under sonographic guidance and the venogram revealed no direct anastomosis with the venous stump (Fig. 1B) and the finding was comfirmed by sonography. A new vascular access creation was therefore suggested but the patient refused surgery after a thorough explanation to her and her family. In order to restore sufficient shunt flow, a good outflow drainage tract from the venous stump was required. Therefore, we attempted to salvage the fistula using the technique reported by Chen et al. [1] by stent-graft insertion between the venous stump and an adjacent patent basilic vein. An 8 · 60-mm stent-graft (Wallgraft; Boston Scientific, Natick, MA) was used to bridge the two ends of the fistulous tract. The stent-graft was dilated with an 8mm ·4-cm PTA balloon catheter. Thrombolysis was performed thereafter using 500,000 IU of urokinase. Thromboaspiration was performed with an 8-Fr Desilets-Hoffman sheath (Cook, Bloomington, IN, USA). Before thrombolysis, a bolus of 5000 IU heparin was given through a peripheral intravenous line. The AV fistula was successfully salvaged and the immediate follow-up fistulography showed brisk flow with presumed compression of a segment of the runoff basilic vein by hematoma (Fig. 1C; arrow). No immediate complications were noted and the patient underwent successful hemodialysis the next morning. The patient was called back for a fistulography 1 month after M. C.-Y. Chen (&) R.-H. Wu W.-S. Tzeng S.-C. Chang Department of Diagnostic Radiology, Chi-Mei Medical Center, Yung-Kang Campus, No. 901, Chung Hwa Road, Yung-Kang City, Tainan County 806, Taiwan e-mail: jjychen@gmail.com