STENT-GRAFT ARTERIOVENOUS-FISTULA - AN ENDOVASCULAR TECHNIQUE IN HEMODIALYSIS ACCESS

Purpose: To determine the feasibility and safety of a new endovascular technique for creating an arteriovenous (AV) fistula utilizing cathet er-directed techniques and stents. Methods: Stent-graft AV fistulas we re offered on an experimental basis to 8 patients who had a history of multiple failed access procedures or very small arm veins unsuitable for standard vascular access techniques. The device consisted of a bal loon-expandable Palmaz stent attached to the designated venous end of a polytetrafluoroethylene graft, The balloon-mounted stent-graft was i nserted into the brachial vein through an arteriotomy and advanced ove r a guidewire into the axillary vein. After the stent-graft was deploy ed, the arterial anastomosis was completed in standard surgical fashio n using an end-to-side anastomosis of the graft to the brachial artery . Results: The stent-graft was inserted successfully in all patients, but there were two early failures. The first resulted from a steal phe nomenon secondary to high flows through the stent-graft, necessitating ligation of the fistula. Another stent-graft was placed too periphera lly in the upper arm, and the stainless steel stent was crushed by ext ernal compression. Three of the 6 remaining grafts were patent for ove r 1 year, and 2 grafts are still functioning at 22 and 13 months. Conc lusions: Endoluminal stent-grafts can be successfully inserted into th e axillary vein for creation of an AV fistula and remain patent for 2 years or more. This method may be most useful in patients with very sm all, unusable arm veins or multiple failed AV grafts.