As I mentioned in a previous post, I became enthused about early cannulation grafts because they let me revise or replace a failing access without needing an interval catheter. Then I started using them primarily, first Flixene, then Acuseal when Flixene went into a prolonged backorder situation. Over a ten year period, I put in several hundred of each. Recently, I became concerned about an abnormal rate of repeat thrombosis in relatively new Acuseal grafts. I no longer use them.

Here, I have images of a graft placed in April 2018, and replaced with a Flixene graft (no catheter) this month, lasting less than 2 years. Ironically, her first graft was a Flixene, placed in 2012, and replaced in 2018 with the Acuseal. I took segments out during this last transition because I wanted to know why the Acuseal did not last as long as the Flixene. In one image, fibrosis in the zone of frequent cannulation pushes a partly disrupted silicone layer further into the lumen. In the other, the graft wall is fairly well preserved, but the lumen is full of an amorphous hyaline material, also present in the other image. I don't see many sectioned dialysis grafts, but I have never seen this kind of hyaline material in a newer graft, and especially not where the graft has not experienced heavy use. Remember that these graft segments were running and not thrombosed when they were excised and replaced. Any ideas? I will be reviewing this with a pathologist this week, and may have better images then. The specimens have been preserved if there is an interest.

I will be doing a retrospective review of the Acuseal versus the Flixene, perhaps with a standard PTFE, and a BVT group as well.