Endoscopic surgery for fistula creation

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Repeated dialysis needling can cause painful aneurysmal fistulas that must be removed.
Repeated dialysis needling can cause painful aneurysmal fistulas that must be removed.

At a glance

  • Primary autogenous arteriovenous (AV) fistulas are the preferred means of vascular access for hemodialysis.
  • The minimally invasive endoscopic approach reduces a two-stage surgery to a single stage.
  • Additional benefits of the endoscopic approach include a smaller incision, faster wound healing, reduced pain, and lower risk of infection.
  • Minimally invasive sugery has become the standard of care.

Minimally invasive surgery is the desired approach to reduce scarring, improve cosmesis, lessen postoperative pain, limit potential for infection, and promote faster recovery. Renal-failure patients are at higher risk for complications from any surgery, and immunosupressant therapy places kidney transplant recipients at greater surgical risk. NewYork-Presbyterian Hospital-Weill Cornell Medical Center, has begun to offer minimally invasive endoscopic arteriovenous (AV) fistula creation with simultaneous transposition and minimally invasive endoscopic ligation and excision of aneurysmal AV fistulas.

Incidence and prevalence

The incidence and prevalence of end-stage renal disease (ESRD) continues to increase. There were 569,985 patients with ESRD as of the second quarter of 2009.1 In December of 2007, there were 527,283, with an incidence of 111,000.1 These patients require vascular access for dialysis. Some will require temporary access while waiting a kidney transplant (assuming they are an acceptable candidate), while others may require dialysis for the rest of their lives. Because the demand for kidneys exceeds the supply of both deceased- and living-donor kidneys, more patients require AV fistulas and multiple interventions for access maintenance.

Types of access for hemodialysis

Some patients may require immediate hemodialysis access, typically through a tunneled hemodialysis port catheter, commonly known as a perma­cath. Typically, the permacath is not considered a means of long-term access secondary to the risk of infection. Tunneled port catheter systems should be used in conjunction with a plan for permanent access.2

Decisions about the type of dialysis and the best method of access for dialysis require collaboration among the patient, nephrologist, and access surgery team. Patient suitability for peritoneal dialysis requires that the peritoneal cavity is free of significant adhesions and that the patient will tolerate the increased volume load associated with this type of dialysis. In patients who choose to have hemodialysis, an AV fistula is created pre-emptively, allowing time for the fistula to mature pending usage.

Primary autogenous AV fistulas are the preferred means of vascular access for hemodialysis.3 If the anatomy permits, surgically created vascular access starts distally on the upper extremity. The radial-cephalic path is the most distal access option. In the upper arm, the brachial artery is anastomosed to either the basilic or cephalic veins. Patients with deep veins or extensive adipose tissue typically require a two-stage surgery: The first stage completes artery and vein anastomosis (the fistula), and the second completes the transpositioning of the vein.

Vein transposition is also referred to as superficialization, as the vein is dissected from the deep tissue and embossed directly under the skin to allow easier access of the hemodialysis catheters. (For consistency, the term transposition will be used throughout.)

Many hemodialysis patients lack common superficial veins used for standard AV fistula options and therefore require transposition of a deep vein for autogenous hemodialysis.4 Initially, a deep cephalic-vein-to-brachial-artery fistula is created through a 3- to 5-cm horizontal incision near the antecubital fossa. In many patients, the cephalic vein in the upper arm is superficial enough for direct cannulation for hemodialysis. After a six- to eight-week period of maturation, the AV fistula is assessed for palpable thrill, audible bruit, and the ability of the vein to be accessed through the skin for dialysis. If necessary, ultrasound may be used to assess fistula size and depth. If the vein (whether cephalic or basilic) remains too deep (thereby increasing the difficulty to access for dialysis), the patient is scheduled for a second surgery for transposition. This is done through a separate vertical incision from the antecubital fossa to the axillary area.

Conventionally, an open AV fistula transposition surgical incision is 20-25 cm in length (Figure 1). People who undergo this conventional procedure are at risk for increased infections, bleeding, and more painful surgical sites. Each surgical procedure lends itself to scarring and potential deformities. Many of these patients also have comorbidities, predisposing them to poor wound healing.

Over time, chronic-renal-failure patients may require revisions or develop painful aneurysmal fistulas that necessitate removal of the AV fistula. Traditionally, these ligations and excisions are completed through incisions that extend the length of the aneurysmal fistula. The minimally invasive endoscopic approach described here provides an alternative method for a select group of patients.

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