Hemodialysis (HD) remains the chosen treatment for patients with kidney failure. Arteriovenous fistula (AVF) remains the preferred access over arteriovenous graft (AVG), but AVG is used as crucial alternative access for patients who cannot have an AVF created. AVG complications include infection, aneurysm, thrombosis, steal syndrome, and graft to vein fistula (GVF). GVF can reduce the blood flow to the AVG, leading to frequent thrombosis. We report a case of a 62-year-old patient with end-stage renal disease (ESRD) on hemodialysis for two years, whose AVG has a functional iatrogenic fistula occasionally created by cannulation. Partial thrombosis was found in the venous limb of the AVG under sonogram analysis. We finally chose to leave GVF as an alternative HD access without further intervention after careful examination. This new vascular access, formed from GVF and the arterial limb of AVG, maintains patency for more than one year without significant complications. It may change the practice pattern of GVF in the future.
Case Report
Graft to Vein Fistula with Partial Thrombosis: A Case Report and Literature Review
https://doi.org/10.21203/rs.3.rs-3639994/v1
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Arteriovenous graft
Graft to vein fistula
Percutaneous transluminal angioplasty
The number of end-stage renal disease (ESRD) patients is increasing worldwide. According to the China National Hemodialysis and Peritoneal Dialysis Registry, 243,863 people received HD in 2012[1]. According to data from China, hemodialysis (HD) is the treatment of choice for 86% of all incident patients with kidney failure[2]. Over the last 60 years, HD vascular access options have remained mainly limited to arteriovenous fistula (AVF), arteriovenous graft (AVG), and central vein catheter (CVC). AVF is still preferred over AVG due to its lower infection rate, fewer thrombosis events, and higher long-term patency[3]. AVG, on the other hand, is an alternative access for patients who cannot create an AVF. Although well-functioning hemodialysis vascular access is a "lifeline," vascular access complications continue to cause morbidity and mortality in hemodialysis patients significantly. AVG complications include infection, aneurysm, thrombosis, steal syndrome, and iatrogenic fistula[4, 5]. Once an iatrogenic fistula forms, it can reduce the blood flow to the AVG, leading to frequent thrombosis. Here, we report a case of AVG with a functional iatrogenic fistula occasionally created by cannulation. We chose to leave GVF as an alternative HD access option without further intervention. Based on the previous reports and our case, we discussed the etiology, treatment, and prevention of GVF and partial thrombosis.
We present a 62-year-old patient with ESRD on hemodialysis for two years who were deemed unsuitable for creating a fistula due to no suitable superficial vein and, therefore, had surgical creation of left brachial-cephalic AV graft. The graft immediately thrombosis after the surgery; thus, AV graft reconstruction was performed. Eight months after creating the reconstructed AVG, he presented with decreased thrill over the AVG. Sonogram showed that an embolism occurred in the venous segment of AVG, and an iatrogenic fistula formed between the arterial segment of the arteriovenous graft and nearby veins (Fig. 1 and Fig. 3). Percutaneous transluminal angioplasty was performed with 6mm balloon in the venous segment of AVG and cephalic vein. Within one month, his AVG was found to have thrombosis in the venous segment during the follow-up clinic, while the outflow vein of the iatrogenic fistula had intact thrill (Fig. 2). Under the sonogram examination, we noted the GVF is patency and has an 8.4mm diameter without outflow stenosis. The brachial artery flow is 1282ml/min; the resistance index (RI) is 0.33. During HD, the patient used arterial segment and GVF as an alternative HD access with blood flow from 240 to 260 ml/min. We decided to leave the GVF as HD access without further intervention. Until this case report present, this GVF has been patented for more than a year and is still doing well.
Common complications of grafts in hemodialysis patients include thrombosis, infection, steal syndrome, pseudoaneurysms with a risk of bleeding, venous hypertension, seromas, and heart failure[4]. Thrombosis and infection occur more frequently with grafts than with fistula. Graft to vein fistula (GVF) means the fistula connection between AVG and adjacent veins. It was first reported by Dousset et al. using a color Doppler flow image in two of twenty-two patients with hemodialysis grafts [6]. Kanterman et al. also identified abnormal fistulas between dialysis grafts and adjacent native veins in five patients. Remarkably, all of them had venous anastomotic stenosis or venous outflow occlusion. However, venous stenosis is the most critical factor that predisposes the graft to thrombosis since the small caliber of the fistula is not likely to reduce the flow to the more distal loop. In the follow-up, no further functioning problems occurred in these five grafts [7]. A few cases reported described [8–10], such as partially thrombosed polytetrafluoroethylene (PTEF) grafts maintained by fistulation to adjacent forearm veins. After reviewing these cases, they put forward four points about this abnormal fistula, i.e., the unusual presentation, incidence, etiology, and appropriate treatment. The suspicious clinical finding that points to GVF with partial thrombosis included a palpable thrill over the arterial limb only, dilated superficial forearm veins, thrombosed graft only found in the venous limb, and aspiration of pulsatile blood on the arterial side with dark blood or clot from the venous side. When abnormal routine graft surveillance tests, e.g., increasing venous resistance, increased recirculation, or alteration in the graft efficiency (KT/V), are noted, GVF should be considered. The duplex examination may demonstrate flow within only a partial limb of the graft and the presence of a fistula to adjacent veins. An angiogram can show the contrast dye going from the graft to the adjacent vein via the fistula, which is the gold standard of diagnosis. In our present case, a palpable thrill over the arterial limb only and thrombosed graft only found in the venous limb were noted, which strongly indicated GVF formation. The ultrasonogram examination confirmed the diagnosis.
The report by Standage also discussed the incidence of the fistulae as about 9%, 3.9%, and 0.027% according to the existing case reports. There are over seven hundred thousand dialysis patients in China, of which less than 3% use grafts as hemodialysis access[11]. We are the first to report this kind of GVF with partial thrombosis graft in China. Despite the consideration of underreported due to small caliber, the incidence of GVF with partial thrombosis is rare. They also suggest the outflow of venous stenosis is the main factor that needs to be corrected. The other two cases of GVF with thrombosis from South Korea, the report by Seung et al. [12], were treated through fistula ligation. They deem it the opposite that GVF is the reason for AVG thrombosis due to decreased blood flow in the graft. Is the outflow of venous stenosis or the reduced blood flow in the graft playing a vital role in causing AVG thrombosis? It still arouses great controversy in different reports. Interestingly, no evidence of outflow of venous stenosis was found in our case, but AVG's recurrent venous limb thrombosis was present. Therefore, we propose that AVG to GVF shunt is the main reason for AVG thrombosis in the present case. Haddad et al. [13] reported five cases of GVF formation, of which the GVF of case number 3 resolved after PTA and case number 4 was not found at the time of thrombectomy. It is possible that GVF can be a natural “cure.” Interestingly, in some instances, thrombosis has already happened, or graft infection occurred. GVF can be an alternative treatment approach to thrombectomy and total graft excision[14, 15].
The process of GVF development is still unknown, but we believe that traumatic cannulation is the primary reason for GVF development. The GVF may resolve spontaneously if there is no increased intra-graft pressure caused by pre-existing venous outflow stenosis. We can continue to monitor the blood flow of GVF and AVG. When venous outflow stenosis gradually increases intra-graft pressure, the caliber of GVF may increase, allowing the GVF to persist, especially when there is no other cause for the arm swelling, a pseudoaneurysm, or intra-graft limitation, venous outflow stenosis, and GVF should be treated with PTA or fistula ligation before thrombosis occurs. However, in our current case, partial thrombosis had already happened when he arrived at our center. PTA was performed once without ligation of the fistula, and his AVG showed partial thrombosis again within a month. GVF was functional for HD as an alternative outflow and had optimal blood flow during the Doppler examination. The length of the arterial limb of AVG and nearby vein is enough for cannulation. Meanwhile, Quan Zheng et al. demonstrated that the postintervention patency rates of the AVG group at 3, 6, and 12 months are 78.5% %, 57.4%, and 20.0%, much lower than the AVF group[16]. In our case, less than a month's patency time after the first time PTA makes us believe that it likely would not last longer if we performed the second PTA. The patient may have to consider CVC for alternative access, increasing the risk of infection and central vein thrombosis. Since adequate blood flow was detected and the patient reported no complaint during HD, we left it as an HD access without further intervention. As a result, the GVF has been kept patency for over a year without other complications like stenosis or thrombosis. Based on the available literature and our case, we propose that GVF can be both a risk factor for graft thrombosis and an alternative access point for continuous HD.
To prevent GVF development, proper cannulation techniques are essential. It is possible to avoid this complication by avoiding cannulation with an adjacent vein that could penetrate the graft, rotating the cannulation site to allow for adequate healing of the previous cannulation site, and adequately compressing the cannulation site at the end of HD to prevent a persistent connection between the graft and the vein.
To conclude, we present a partial thrombosis graft with graft to vein fistula, which we keep persist and routine follow-up without PTA and fistula ligation. We believe it provides further insight into managing this uncommon complication based on existing reports.
Author’s contributions
Bo Hu is the overall supervisor and major contributor in writing the manuscript; Zhen-Nan Liao is also the major contributor in writing the manuscript; Guo-Liang Li contributed to treatment and case discussion; Zi-Ming Wan contributed to the case discussion and manuscript write-up.
Financial Disclosure
The authors declare that they have no relevant financial interests.
Patient Consent
The authors declare that they have obtained informed consent from patient reported in this article for publication of the information about him/her that appears within this Case Report.
Data Availability
The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethics and privacy.
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No competing interests reported.