Improving longevity of prosthetic dialysis grafts in patients with disadvantaged venous outflow

Objective: Angioaccess for hemodialysis in an extremity with disadvantaged venous outflow has reduced long-term patency. We hypothesized that arteriovenous bridge graft patency could be improved in patients with disadvantaged venous outflow by preoperative venous duplex mapping. Methods: The charts of 114 patients who underwent 115 prosthetic arteriovenous bridge grafts were reviewed. Disadvantaged venous outflow was defined on the basis of any combination of prior arteriovenous bridge graft, multiple venipunctures, and clinical examination. Patients were grouped according to the presence or absence of disadvantaged venous outflow. Three groups were analyzed: those with normal venous outflow who had an initial arteriovenous bridge graft (NML), those with disadvantaged venous outflow who had only a clinical examination before redo arteriovenous bridge graft (REDO/DVO), and those with disadvantaged venous outflow who underwent preoperative duplex scanning venous evaluation (MAP/DVO). Life table primary and secondary 12-month patency rates were compared by means of log-rank analysis. Results: Life table analysis yielded 6-month primary patency rates of 65.9% ± 5.7%, 66.4% ± 7.3%, and 43.8% ± 10.9% for NML, MAP/DVO, and REDO/DVO, respectively. The secondary patency rates at 6 months for NML (91.9% ± 3.4%) and MAP/DVO (91.1% ± 4.9%) were statistically equivalent, and both were significantly better than the patency for REDO/DVO (75.0% ± 10.0%; P =.004 and P =.04, respectively). This trend persisted beyond 12 months. Conclusion: Preoperative evaluation of venous anatomy in patients with disadvantaged venous outflow results in an arteriovenous bridge graft patency comparable to that seen in patients undergoing initial arteriovenous bridge grafts. Vein mapping improves arteriovenous bridge graft durability in the patient with disadvantaged venous outflow by allowing the surgeon to select venous return that is in direct continuity with the central venous system. (J Vasc Surg 2000;32:997-1005.)