Patient Profile:
H.H. is a 70-year-old female with end stage renal disease (ESRD) secondary to Type 2 diabetes. Her past medical history includes chronic heart failure (CHF), chronic foot ulcers, and obstructive sleep apnea. Hemodialysis (HD) was initiated with an internal jugular catheter. She had no prior dialysis accesses at the start of HD.

H.H. presented to the vascular surgery clinic for evaluation of an arteriovenous fistula (AVF) placement. Vein mapping demonstrated a left upper arm cephalic vein of 2.9 mm up to 3.3 mm in diameter, which has been documented to be adequate for fistula placement (Mendes et al., 2002). Needle access for hemodialysis was a potential challenge due to the size of H.H.’s arm and the amount of adipose tissue present there. It was decided to perform a brachiocephalic fistula and allow extra time for the vein to mature.

1. The fistula will be cannulated successfully and fully functional after lipectomy.
   
2. The tunneled catheter will be removed.
   

Discussion:
The National Kidney Foundation’s (NKF) K-DOQI Guidelines recommend that at least 50% of patients who start dialysis should have an AVF placed (NKF, 2000). A functioning AVF can provide a problem-free HD access for many years as compared to prosthetic devices. Surgical approaches to create fistulae are becoming more and more challenging in a population of patients with a high degree of comorbidity. Finding healthy arteries and veins that are large enough can often be very challenging without adding vein depth issues. Vein transpositions are frequently utilized to enable the HD staff to access the AVF. However, in cases of arm obesity, lipectomy (fat tissue dissection and removal) can be a viable option.

The fistula surgery was successful and the vein was allowed to mature for 8 weeks. The initial cannulation was performed successfully at the arterial site, but the venous needle cannulation attempt was unsuccessful. An ultrasound was performed that indicated a very large, well-developed cephalic vein measuring 7.0 to 8.0 mm.

However, the vein was too deep for needle access, and it was decided to go ahead with a lipectomy procedure, which was performed using sharp dissection and electrocautery over the length of the vein. The procedure took approximately 1 hour without any complications. The incision over the fistula measured 5 cm. There was minimal residual swelling, which resolved within 1 week. Two-needle cannulation was performed 4 weeks after surgery and successful access was obtained. The blood flow rate and arterial and venous pressures were all within acceptable ranges.

H.H. was very happy to have a functional fistula and her catheter removed. The appearance of her access arm changed only minimally from her baseline. The interesting variable that was not predicted was the change in the location of the incision scar due to tissue shifting. The cannulating dialysis nurse could use the scar as a guide, although that was not really needed in a vein this size. However, 2 months later, the scar was no longer located over or near the vein. The nurse noticed she had to cannulate the venous site more laterally than usual as time went by. This actually made the vascular team feel more at ease, due to concern that scar tissue would form and the incision itself could become a barrier to cannulation.

Summary
Many studies have demonstrated that functioning AVFs provide better vascular access outcomes compared to prosthetic devices. In April 2004, the Centers for Medicare and Medicaid Services (CMS) launched a “safe vascular access through collaborative fistula first initiative” (CMS, 2004). This breakthrough proposal cites studies that show increased mortality in patients who do not dialyze with a fistula. Veins too deep for needle cannulation are usually free of scars from intravenous (IV) sticks and, thus, are excellent options for fistula creation. Lipectomy can remove barriers, such as vein depth and limb obesity, creating an opportunity to have a functioning fistula.

References

Centers for Medicare and Medicaid Services (CMS). (2004, April 14). CMS launches “fistula first” initiative to improve care and quality of life for hemodialysis patients (Press Release). Retrieved from www.cms.hhs.gov/media/press/release.asp?Counter=1007

Mendes, R.R., Farber, M.A., Marston, W.A., Dinwiddie, L.C., Keagy, B.A., &  Burnham, S.J. (2002) Prediction of wrist arteriovenous fistula maturation with preoperative vein mapping with ultrasonography. Journal of Vascular Surgery, 36(3), 460-463.

National Kidney Foundation (NKF). (2000). K/DOQI clinical practice guidelines for vascular access. American Journal of Kidney Disease, 37(Suppl. 1), S137-S181.