Successful use of partial aneurysmectomy and repair approach for managing complications of arteriovenous fistulas and grafts

Abstract Objective Arteriovenous fistulas and grafts may often be associated with localized complications related to aneurysms/pseudoaneurysms, buttonholes, or structural defects that require proper management to ensure continued access functionality for hemodialysis. Partial aneurysmectomy and repair (PAR) is a targeted surgical approach specifically designed for managing these complications. The basic concepts of PAR include resecting unhealthy or excessive tissue over an access, reconstructing the vascular access lumen using in situ vascular wall or tissue when possible, and closing overlying skin with healthy margins to promote reliable healing. This report analyzes the clinical outcomes of PAR in a large clinical series. Methods The demographic and outcome data of patients who underwent PARs at an ambulatory surgery center from 2009 to 2016 were collected and analyzed. Results A total of 220 PAR operations were performed in 209 patients, of which 185 had fistulas and 24 had grafts. In the fistula group, 11 patients underwent subsequent staged aneurysm repairs. Comparing the fistula group (n = 185) vs the graft group (n = 24): men were 63% vs 29%, the mean age was 60.1 ± 14.8 vs 63.9 ± 16.0 years, diabetic patients were 54% vs 75%, the mean age of the accesses at the time of repair was 5.3 ± 3.2 vs 5.0 ± 4.0 years, the upper arm accesses were 69% vs 88%, the forearm accesses were 31% vs 12%, and the mean follow-up was 27.9 ± 21.9 vs 14.0 ± 11.6 months. A pneumatic tourniquet was used during 81% of the fistula and 42% of the graft operations. Dialysis catheters were required in 2% of the patients in the fistula group and 4% in the graft group to continue hemodialysis. After repair operations, the primary patency, assisted primary patency, and secondary patency rates of the whole access conduit for the fistula group were 45%, 96%, and 98% at 1 year; 28%, 91%, and 96% at 2 years; and 19%, 87%, and 95% at 3 years, respectively. The same patency rates of the graft group were 31%, 70%, and 96% at 6 months and 10%, 57%, and 96% at 1 year, respectively. Two fistulas and one graft were lost ≤30 days postoperatively. Conclusions PAR is a reliable approach for managing localized arteriovenous access complications related to aneurysms/pseudoaneurysms, buttonholes, or structural defects. Given its simplicity and reliability, we recommend PAR as a first-line choice for managing these complications of arteriovenous fistulas and a choice in selected arteriovenous graf