Ongoing issues with av graft

Hello Dr. Agar,
I was refered to this thread and hoping you could help with an ongoing access issue. I’m an in center hemo patient and I have an av graft not a fistula. This is my second graft. It was installed in my right upper arm on April 8, 2010. From the gitgo this graft has always been hard to stick, when they stick it it rolls and a lot of the times the needle doesn’t advance do to clots which are pulled out with heprin. Each tech on the unit has problems with this, even the most experienced ones. It started that I was having alarms on the machine, it’s usually the venus that alarms… On July 6 I had a shuntagram which revealed a small narrowing of the vain which was repaired, other then that the vascular surgeon saw no issues. After that it was still hard to stick but ran at my perscribed blood flow of 450. That lasted about a month then on august 31, the graft totally clotted so I was admited to the hospital where their radiologist desolved the clot and vacuumed the rest of it out. He also put a stent in it. After that it had a thrill but not very good and my preassures where ranging from 350 but on a good day 400. A month later it was bairly running to where they could only get it to about 200, again it was mostly the venus that was giving us issues,so on Oct 13, I went to see my vascular surgeon who got me in to the radiologist the next day to do another shuntagram. This time the same spot had narrowed and so he put a stronger stent in it which he said it was steel. He said he other then that there were no other issues with the graft. It has a great thrill now and runs at 450 but we are still having canulation issues. The needles won’t advance sometimes and we are pulling clots. Sometimes we do have to flip the venus needle so it will run without any alarms. Keep in mind the graft is so troublsm that they have to use a ternakit just to bring it to the surface, the center says the further you go up the deeper it gets but my surgeon or the radiologist never said anything about the graft being too deep. Also my center said it looks like they tied two grafts together, that I knew nothing about but when I feel it it feels like my normal graft, then under the armpit there’s a peace of hard material which I’m guessing is what my center is refering to as the other peace of graft. They said you can also see the stent which I don’t know is normal or not.

Basically the bottom line is this access issue is frustrating me because all I do is get it revised, revised, and revised. The surgeon thinks it might be my vains are too weak because I can’t get a fistula, I’ve had a graft in both arms. The other one failed because they could not get the vain reopened.
If you have any ideas of what might be best for me or what I should be considering please let me know.

Dear Troy

I am so sorry to read of your problems. Vascular access is the true Achilles heel of dialysis and causes us all, patients and professionals, more trouble than any other aspect of dialysis. Sadly, it is one of those areas where a small number of patients bear the brunt of the problems. Many have no issues at all - for years or decades - with the same access, while others take punch after punch. It can (and is) so often so unfair.

While I clearly cannot advise directly on your specific issues … I have not seen, touched, felt, your access, I know nothing of your medical history or your vascular status and your past history, nor do I have access to the x-ray pictures of your fistulogram … I can still make some general comments that may help.

Firstly, patients with a history of vascular disease - and especially if their history includes diabetes (sometimes the diabetes itself made more difficult by the added problem of excess weight) - commonly have the most trouble with vascular access. I do not know if you are diabetic or are overweight, but if so, these may be complicating factors in your access history.

Further, patients who ‘present late’ … in both the USA and Australia, this is about 20% or a little more of all patients coming into dialysis programs where end-stage kidney disease has not been discovered until just before dialysis has been needed … these patients do not have the ‘luxury’ of early and planned access surgery. ‘Luxury’ may seem to you to be an odd word to use, but by ‘luxury’, I mean the time and forethought to fashion a good and maturing fistula well ahead of the need to use it. We like to get a fistula (always, always, always native and never a graft) into place at least 6 months prior to any likelihood of the start of dialysis. Now, that does not always happen - for a start, 20% or more of patients present late to renal services (these are typically those who need dialysis in less than 3 months from 1st diagnosis) - and clearly these cannot have a fistula made in a timely fashion. But, at least six months aforehand should be an attainable goal for most patients. This gives time to sort out and correct fistula problems before dialysis use dependence interferes with and complicates the picture.

Late presenters or those who, for one reason or another, have their fistula formation delayed, may end up with a catheter. Years ago, these were often ‘subclavian’ catheters - but we have learned that subclavian catheters have a high central vein damage rate and lead commonly to stenosis (narrowing) of the vein at or near the point of entry. Straight ‘north/south’ internal jugular catheters have replaced subclavian catheters and though these are less likely to cause stenoses (narrowings) … they still can and do!

So … if you have has any prior central lines, I would want to know that the fisulography that you have had done has followed the vein right into the chest to the heart - including the great veins of the chest cavity, the (L) innominate vein and the superior venacava. Narrowings here can be major causes of peripheral fistula (or graft) malfunction, with high pressures, sluggish flows and recurrent clotting. One clue can be small visible (blueish) veins under the skin over the shoulder and across the chest wall on the side of the stenosis. Central vein ‘patency’ … In other words, good clear, open and unobstructed central veins should be assured … especially in your case … though I suspect that this has already been carefully checked and looked for. However, it can be easy to focus only on the arm fistula (or graft) and miss a central vein issue as a result.

Our vascular surgeons (I do love them so) have a rule of thumb … "if there is a vein large enough to successfully join a piece of ‘artificial vein’ to (i.e.: a graft) then it is large enough to join a native vein to. Indeed, you need a larger native vein to connect a graft to than to connect a native vein to … sorry, Troy, for the number of “to’s” in that sentence, but if you read it through a couple of times, you will get the sense of what I just wrote. Our surgeons prefer (as do we, their referring nephrologists) to use native veins at all cost. We transpose (move and relocate) native veins within the arms. We remove veins and reverse them (to avoid problems with their valves) from the legs … just as cardiac surgeons often do for bypass grafting in the heart. We will bend over backwards to find veins to form loops with, to use as skips or straight connectors, to use as vein patches … anything to avoid stents (which always block) or grafts (which never last and often fail). And, find them we do. All over the place. Again, our own personal preference, our ‘rule of thumb’ is … “always native, always”.

You have a graft. I do not know the circumstances of that graft - but it’s there. Sadly, angioplasties of vein stenoses almost always re-stenose (no, not always, just usually). Also sadly, stents tend to block … leading to another, and then another stent. This is the way of stents. This leads to repeated interventions - a frustration for the team and a nightmare for the patient. It may be worth trying to dilate (angioplasty) and stent a recurrently narrowing, clotting or blocking graft while an alternative access is being fashioned - though please, please, let it be a native fistula!

I do not know whether there is a prospect of forming an fistula on the other side, your other arm, or even in the thigh … we have had a number of very successful long term femoro-femoral native fistulae over the years both used in our facility program and for patient self-puncture by patients on home dialysis … But if there is, that’s where I would likely be going. Arms are clearly easier and best - there is no doubting that - but if the arms are exhausted, legs do well too. If the loop can be ‘looped’ well down and away from the groin skin fold (this area can get moist and a bit ‘whoofy’ in some people, they can be very clean, very big, very easy to cannulate loops. They can be very successful. Preferably that than another graft from and to small arm arteries and veins which may be doomed to the same risk of failure.

Depth is a real issue with fistulae. This is especially so in people who are carrying too much body weight. I have written previous answers to posts on this issue. Can I refer you back to my answer to the post entitled:

“Fistula/Needle Problems” posted by ‘needled88’ on December 18th 2009

Here I dealt with the problem (common) of fistula depth and the need for superficialisation of native fistulae.

I know yours is a graft … and for technical and scarring reasons, once a deep graft, always a deep graft as they don’t take kindly to being superficialised. It would be important to ensure, from the outset, that a graft (if a graft is being used and you will already now know my feelings about grafts) is superficially placed. Once too deep, all the wishing in the world wont bring it up.

For you, Troy, it would be important to take into account …

Your age, diagnosis, prior vascular history and diabetic status
Your prior (and present) smoking status
Your prior catheter history (if any)
Whether any prior surgical work has used or troubled your leg veins
Whether your ‘other’ arm is unused
Whether your great internal chest veins have been well examined
If your ‘imaging’ has had the benefit of rapid sequence CT 3D fistulography or has been simple 2D angiography
And other things as well …

That is probably the best I can do from afar

I hope things resolve for you. I feel your frustrations - but they are shared by many who are in the same boat.

Keep your courage up, ride the punches and keep asking questions.

I hope that has been some use to you.

Hello Dr. Agar,
Thanks for your answer. I’m 27 and yes I had to go on dialysis right away. I’ve had two catheters, both in the same vain going down to my chest. They never have looked at my legs, that’s a good thing to bring up but unfortunetly our surgeons here where I live only do grafts in the legs, I’ve never even heard of fistulas in the legs until you said something which I was interested in anyways, my surgeon wants to try a hero device but from your post I think I can advise otherwise and have them check the legs. I’m not diabetic and I’m young just my arm vains are small for whatever reason.
Thanks again and we’ll see what happens.

Dear Troy

If you are only 27 and not diabetic, I am utterly surprised - no, I am shocked - that you cannot get a normal, good, well functioning, long-lasting fistula made. I really and truly am. That’s got to be a first.

I am sorry, but I am finding it hard to contemplate a situation where a 27 yr old non-diabetic male cannot get a surgically successful fistula made. Not a graft. A fistula. A native fistula. If not at the wrist with a radiocephalic anastamosis (join), then, at a minimum, a brachiocephalic or a brachiobasilic with or without vessel transposition.

Have you had US mapping? We map all arms, both (L) and ® in all patients. A vein 3mm or more at US mapping is almost always suitable for a native fistula.

From what I understand, you have presented with end-stage or near-end stage renal failure - at least not a long drawn out history of illness - and without a long history of prior renal failure with the IVs and recurrent blood tests that might go with such a history and be a reason to have wrecked veins for fistula use.

Seriously, I would go back and be reassessed!

Forget using or even considering the leg veins for now. I don’t think you have even gone close to finishing the options for a highly successful forearm or upper arm native fistula.

(1) Ultrasound mapping
(2) Chose best vein 3mm or more … bigger is better but anything 3mm and up will (or should) do OK
(3) Have it done.

In my view, and if you were me, I wouldn’t be allowing graft material within a mile of my arms in your situation.

Clearly I do not know you or your arms … but, even if you are very very much overweight, the veins are there - just deeper.

Go back.

Get re-assessed - and go from there.

I agree, I will get it done, but first I gotta find a very very very good surgeon, one who is top notch.

Good lad … go for it … no mucking around now … and no more grafts!