Fellow ASDIN members,

In the last 20 some years of my IN career, I have come across few patients with AV accesses created intentionally or unintentionally ipsilateral to axillary LN dissection (+/- XRT, often associated in this case with axillary vein stenosis). The outcome was (unanimously) the development of arm swelling, namely significant lymphedema, leading (with only 1 exception in my experience) to the ligation of the access. Some entertain the option of a "low flow system". I have not seen that work... 

Logically speaking, an ipsilateral HeRO graft, should not lead to the same outcome (from the severity standpoint), since it is bypassing the outflow veins/drainage system of the ipsilateral UE. I assume, there is still a concern of developing central vein stenosis from the outflow component of the HeRO graft, but I don't see that being a major deterring factor. 

I came across a situation like that today, the patient has an occluded right innominate vein and widely patent left sided central veins (left UE venogram was not performed) where an extensive axillary LND was performed. A left IJV TDC was placed and I am exploring the option of a HeRo on that side.

Has anyone done that? What was the outcome?

Thx

Tony Samaha, MD

Cincinnati, Ohio

A hemodialysis patient with a history of CABG (coronary artery bypass graft) operation visited my center for arteriovenous access creation.

This patient had undergone multiple AV access placements on his right arm. When I examined the current AV graft of his right upper arm, it was found to end its longevity, and no more AV access placement was feasible on his right arm. In contrast, he had never had vascular access surgery on his left arm because his physician emphasized that any AV access should not be placed on his left arm to avoid coronary steal syndrome. In fact, the patient underwent CABG using the left internal thoracic artery. I'd like to recommend a new AV access creation in the left arm, but the patient is afraid that he will die of AMI if he gets AV access in his left arm. So, I'm here to ask you for advice.

First,

Would it lead to coronary steal syndrome if I created an AVF or AVG on his left arm? How high is the probability for the patient to encounter a coronary steal in such a case?

Second,

If an AVF creation was planned in the left arm, would limiting blood flow, for example, to 600-800ml/min or less help to reduce the risk of coronary steal?

Third,

When a patient with a CABG history needs an AV access creation, should we always confirm which graft for CABG was used and which way of CABG operation was performed?

I'd like to appreciate your comments.

Hyungseok Lee, MD, FASDIN

Hallym University Sacred Heart Hospital, South Korea.

pcsacred@gmail.com

Hello all,

Our center is looking to purchase another ultrasound for dialysis access procedures and flow measurements.  Currently we have a nice GE Logiq and also a really old Sonosite.  Any suggestions on a portable U/S machine that is good quality and relatively affordable?  Any thoughts on the Butterfly?

Dr. Anatole Besarab has shared the text (attached as Word file) of an ASN Blog Post originated by Dr. Monnie Wasse.  Dr. Besarab thinks our ASDIN membership would be interested and might like to chime in.

Original post:

One of the large dialysis organizations measures dynamic venous pressure, rather than static venous pressure, as their sole AVF and AVG surveillance metric.

Please comment on whether you find this useful or reliable.

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