Stent-Graft Arteriovenous Fistula: An Endovascular Technique in Hemodialysis Access

Abstract

Purpose: To determine the feasibility and safety of a new endovascular technique for creating an arteriovenous (AV) fistula utilizing catheter-directed techniques and stents. Methods: Stent-graft AV fistulas were 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 balloon-expandable Palmaz stent attached to the designated venous end of a polytetrafluoroethylene graft. The balloon-mounted stent-graft was inserted into the brachial vein through an arteriotomy and advanced over a guidewire into the axillary vein. After the stent-graft was deployed, the arterial anastomosis was completed in standard surgical fashion 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 phenomenon secondary to high flows through the stent-graft, necessitating ligation of the fistula. Another stent-graft was placed too peripherally in the upper arm, and the stainless steel stent was crushed by external compression. Three of the 6 remaining grafts were patent for over 1 year, and 2 grafts are still functioning at 22 and 13 months. Conclusions: Endoluminal stent-grafts can be successfully inserted into the 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 small, unusable arm veins or multiple failed AV grafts.