The Surgically Created Arteriovenous Fistula: A Forgotten Alternative to Venous Access

Abstract

The care of patients requiring lifelong intravenous access was revolutionized with the development of tunneled catheters and implantable ports. These devices are not without complications, however, and selected patients may benefit from alternative modalities to maintain access for such therapies as parenteral nutrition, phlebotomy, or chemotherapy. Use of surgically created arteriovenous (AV) fistulae as an alternative to central venous access has been described. This report reviews our experience using AV access for central venous access. An AV access database of more than 800 active patients was reviewed and all patients who had autogenous or synthetic AV fistulae created exclusively for central venous access between July 1, 2001, and December 31, 2003, were identified. Outcomes were assessed. A total of 853 new accesses were placed during the time period. Six fistulae in six patients (0.7%) were placed for central access. All patients (5 males, 1 female, mean age, 42.8 years) required access for intermittent parenteral nutrition or intravenous fluids secondary to short-gut syndrome (n = 5) or gastroparesis (n = 1). All patients had failed at least two prior catheter-based accesses before access placement was considered. Procedures were all brachial artery based and included autogenous brachiobasilic vein fistulae with elevation or transposition (n = 3), autogenous brachiocephalic fistula (n = 1), autogenous brachiobasilic graft with transposed greater saphenous vein (n = 1), and a prosthetic brachiobasilic graft with ePTFE (n = 1). There was one perioperative autogenous fistula thrombosis treated with thrombectomy and revision. A total of seven late revisions (thrombectomy, thrombectomy with venous outflow revision, fistula elevation, and 4 percutaneous angioplasties) in four patients were required. All fistulae were patent and functional at the end of the review period (mean follow-up, = 393 days; range, 35-757 days). Daily access was performed by family members (n = 2) or nurses (n = 4). One patient received small bowel transplantation and no longer required use of his patent fistula. One patient died of liver failure 382 days after fistula placement with a patent fistula. These results show that, while often forgotten and infrequently used, AV access can be a durable alternative to catheter-based venous access.