Hemodynamics of Venous Cuff Interposition in Prosthetic Arteriovenous Fistulas for Hemodialysis

Purpose: The durability of prosthetic arteriovenous fistulas (AVF) for hemodialysis is jeopardized by thrombotic occlusions due to intimal hyperplastic stenoses. In arterial reconstructive surgery, peripheral arterial bypasses with prosthetic material benefit from a venous cuff at the distal anastomosis. Therefore, a study was performed to assess the effect of a venous cuff at the venous anastomosis of PTFE graft AVFs in terms of stenosis development, hemodynamics and patency rates. Methods: A subset of 40 patients from a multicenter study were enrolled into the study, of which 20 patients were randomized for venous cuff interposition. Duplex measurements to detect stenoses and volume flows were performed at 6, 12, 26 and 52 weeks postoperatively. Relative distension (RD) and wall shear rate (WSR) were calculated by means of vessel wall Doppler tracking (VWDT). Results: The total number of stenoses was significantly less in the cuff group (21 vs. 33; p = 0.045). This feature was found at the site of the venous anastomosis (cuff 5; no cuff 12). Volume flow, graft and efferent vein diameters, RD and WSR in the graft and efferent vein were comparable for both groups. WSR in the venous anastomosis tended to be lower in the cuff group (768 vs. 1,448 s–1, p = 0.068).Volume flows and WSR were significantly lower in failing grafts. Patency rates were similar in both groups (primary patency 13 vs. 29%; secondary patency 78 vs. 67%). Conclusions: A venous cuff at the venous anastomosis of PTFE graft AVFs results in less stenoses, but improved patency rates could not be demonstrated.

[1]  K. Leunissen,et al.  Effects of a venous cuff at the venous anastomosis of polytetrafluoroethylene grafts for hemodialysis vascular access. , 2000, Journal of vascular surgery.

[2]  V. Sottiurai,et al.  The role of vein patch in distal anastomotic intimal hyperplasia: an histologic characterization. , 1994, International angiology : a journal of the International Union of Angiology.

[3]  B. G. Brown,et al.  Intimal fibromuscular hyperplasia at the venous anastomosis of PTFE grafts in hemodialysis patients. Clinical, immunocytochemical, light and electron microscopic assessment. , 1989, Circulation.

[4]  J. Miller,et al.  Interposition vein cuff for anastomosis of prosthesis to small artery. , 1984, The Australian and New Zealand journal of surgery.

[5]  P. Cooperberg,et al.  Predicting failure in polytetrafluoroethylene vascular access grafts for hemodialysis: a pilot study. , 1987, Canadian journal of surgery. Journal canadien de chirurgie.

[6]  R. Depalma,et al.  Vein Cuff Interposition Prevents Juxta‐Anastomotic Neointimal Hyperplasia , 1988, Annals of surgery.

[7]  J. Wolfe,et al.  New prosthetic venous collar anastomotic technique: Combining the best of other procedures , 1991, The British journal of surgery.

[8]  V. Sottiurai.  Biogenesis and etiology of distal anastomotic intimal hyperplasia. , 1990, International angiology : a journal of the International Union of Angiology.

[9]  A. Gotlieb,et al.  Stranger in a strange land: the pathogenesis of saphenous vein graft stenosis with emphasis on structural and functional differences between veins and arteries. , 1991, Progress in cardiovascular diseases.

[10]  R. Schwartz,et al.  Beneficial effects of banding on venous intimal-medial hyperplasia in arteriovenous loop grafts. , 1989, American journal of surgery.

[11]  A. Banes,et al.  Mechanical stress stimulates aortic endothelial cells to proliferate. , 1987, Journal of vascular surgery.

[12]  A. Banes,et al.  Enhanced collagen production by smooth muscle cells during repetitive mechanical stretching. , 1988, Archives of surgery.

[13]  R S Reneman,et al.  A noninvasive method to estimate wall shear rate using ultrasound. , 1995, Ultrasound in medicine & biology.

[14]  J. R. Raymond,et al.  Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses. , 1989, Kidney international.

[15]  H. Koomans,et al.  Graft flow as a predictor of thrombosis in hemodialysis grafts. , 1998, Kidney international.

[16]  J. Wolfe,et al.  Justifying arterial reconstruction to crural vessels—even with a prosthetic graft , 1991, The British journal of surgery.

[17]  R. Depalma,et al.  The protective effect of vein cuffed anastomoses is not mechanical in origin. , 1995, Journal of vascular surgery.

[18]  L. Sauvage,et al.  The direct effect of graft compliance mismatch per se on development of host arterial intimal hyperplasia at the anastomotic interface , 1993, Annals of vascular surgery.

[19]  A P Hoeks,et al.  Anastomotic intimal hyperplasia in prosthetic arteriovenous fistulas for hemodialysis is associated with initial high flow velocity and not with mismatch in elastic properties. , 1995, Journal of the American Society of Nephrology : JASN.

[20]  M. Gimbrone,et al.  Biomechanical activation: an emerging paradigm in endothelial adhesion biology. , 1997, The Journal of clinical investigation.

[21]  J. Miller,et al.  Influence of a vein cuff on polytetrafluoroethylene grafts for primary femoropopliteal bypass , 1995, The British journal of surgery.

[22]  D. Page,et al.  Effect of Blood Flow Rate on Subendothelial Proliferation in Venous Autografts Used as Arterial Substitutes , 1975, Circulation.

[23]  G. Beathard,et al.  Mechanical versus pharmacomechanical thrombolysis for the treatment of thrombosed dialysis access grafts. , 1994, Kidney international.

[24]  J. Tordoir,et al.  Duplex ultrasound scanning in the assessment of arteriovenous fistulas created for hemodialysis access: comparison with digital subtraction angiography. , 1989, Journal of vascular surgery.

[25]  N. Hwang,et al.  Graft Compliance and Anastomotic Flow Patterns , 1990, ASAIO transactions.

[26]  M. Davies,et al.  The integrity of experimental vein graft endothelium--implications on the etiology of early graft failure. , 1993, European journal of vascular surgery.

[27]  V. Sottiurai,et al.  Distal anastomotic intimal hyperplasia: biogenesis and etiology. , 1988, European journal of vascular surgery.

[28]  J. Tordoir,et al.  Long-term follow-up of the polytetrafluoroethylene (PTFE) prosthesis as an arteriovenous fistula for haemodialysis. , 1988, European journal of vascular surgery.

[29]  Shackleton Cr,et al.  Predicting failure in polytetrafluoroethylene vascular access grafts for hemodialysis: a pilot study. , 1987 .

[30]  J. Wolfe,et al.  Experimental evidence to support the use of interposition vein collars/patches in distal PTFE anastomoses. , 1990, European journal of vascular surgery.

[31]  A. Cucina,et al.  Modulation of arterial smooth muscle cell growth by haemodynamic forces. , 1992, European journal of vascular surgery.

[32]  F. Veith,et al.  The effect of adjunctive arteriovenous fistula on prosthetic graft patency: a controlled study in a canine model. , 1990, The Journal of cardiovascular surgery.

[33]  Sottiurai Vs.  Biogenesis and etiology of distal anastomotic intimal hyperplasia. , 1990 .

[34]  P. Hagen,et al.  Myointimal thickening in experimental vein grafts is dependent on wall tension. , 1992, Journal of vascular surgery.

[35]  J. Fareed,et al.  Mechanical and histologic changes in canine vein grafts. , 1988, The Journal of surgical research.

[36]  A. Clowes,et al.  Time course of flow-induced smooth muscle cell proliferation and intimal thickening in endothelialized baboon vascular grafts. , 1994, Circulation research.

[37]  A. Clowes,et al.  Increased blood flow inhibits neointimal hyperplasia in endothelialized vascular grafts. , 1991, Circulation research.