Aneurysmal dilatations of the vascular access for hemodyalisis: surgical treatment

Abstract

The aim of the research is to choose the optimal methods of diagnosis and rational surgical treatment in patients with aneurysmal type dilatations (ATD) who are on dialysis. Dilatation type aneurysms (DTA) are part of the late complications of arterio-venous fistula (AVF) and can be seen in all types of fistulas, as a result of both repeated puncture and decreased vein elasticity. Surgical management is controversial for DTA. In the study were included 15 patients with CRF, stage V (KDOQI) who are on dialysis in the department of Hemodialysis (HD) in the CNŞPMU with AVF dysfunction caused by DTA between 2006-2009. The mean age was 51,07±3,05 years (34 - 75 years). The male/female ratio was 6/8. The mean treatment period of iterative HD was 6,54±0,76 years (2-12 years). The mean period of time of aneurysm occurrence from the formation of AVF was 45,38±9,47 months (6-84 months). Using Dupplex ultrasound preoperative is compulsory both for the assessment of peripheral vascular system condition, and for setting the diagnosis. In 9 patients indications for surgical treatment were: a) decrease of blood flow in AVF (n=2); b) spontaneous rupture of the aneurysm of the AVF with external bleeding (n=2); c) pseudoaneurysm with PTFE graft infection (n=l); d) presence of calcinates in the aneurysm wall and of pain syndrome (n=l); e) aneurysm of the AVF in association with stenosis and partial thrombosis (n=3). According to location, the DTA are situated: on anastomosis line (n=2), at the puncture site (n=4), partial venous aneurysm (n=2), pseudoaneurysm of the polytetrafluoroethylene (PTFE) graft (n=l). Surgical treatment was performed in 9 (60%) from 15 patients. Following types of surgical correction were used: aneurysmectomy + AVF formation using PTFE graft (n=2), resection of the aneurysm with the reestablishment of native AVF with a segment of PTFE (n=l), resection of the aneurysm + reconstruction of the native AVF (n=4), aneurysmectomy + central venous catheter (n=l), reconstruction of synthetic AVF (PTFE) (n=l). The surgical option is made according to the size of the aneurysm, blood flow in the AVF and the patient’s vascular supply. The goal of the surgical treatment is to preserve the native AVF, but in case of absence of necessary peripheral vascular reserves - synthetic PTFE graft is recommended to form a new vascular access.