gms | German Medical Science

Background: The ruptured arteriovenous fistula (AVF) with bleeding is an emergency situation in end stage renal disease (ESRD) patient who is already anaemic patient with co-morbid conditions. Infection, pseudo-aneurysm and complete disruption of anastmotic suture line may be found in these cases. There is no report regarding the salvage of the ruptured native AVF with bleeding and the current literature is mainly about ligation.

Aim of the work to report the safety and efficacy of a surgical technique for management of ruptured AVFs. After arrest of bleeding, creation of a new one by end to end anastomosis, using the same artery and already mature vein at the same situation to maintain the valuable vascular access.

Methods: Prospective study involved 80 patients with mean age 48.5 years with ESRD who presented as emergency bleeding ruptured AVFs during a three-year time period. In 78 cases there were complete disruption of the anastomotic suture line (53 brachio-cephalic, '26 radio-cephalic), and in the middle of one saphenous loop in the thigh. Under general anesthesia, tourniquet was applied for bleeding control, creation of the AVFs was done by end to end anastmosis of the proximal part of the healthy artery and mature vein fashioned as smooth U figure in proximal healthy tissues.

Results: Mean tourniquet time was 13 minutes .No intra-operative blood transfusion was needed. Postoperative mean digital Oxygen saturation was 92%. Mean operative time was 50 minutes. Mean duration of hospital stay was two days. Peri-operative broad spectrum antibiotics were given and after that according to the culture and sensitivity. One patient had nerve concussion due to tourniquet, another had infection and secondary hemorrhage after one week and the fistula was ligated and another patient had short fistula not accessible for dialysis after successful salvage. Mean time of postoperative use of salvaged AVFs for hemodialysis was one week .No morbidity or mortality due to the procedure or during the time of the study related to the technique was recorded. 76 out of 80 AVFs in mean period of follow-up (18 months; range 3 to 36) were functioning.

Conclusion: This is an effective procedure that achieves many goals: continued patency of the native fistula without sacrifing the mature vein, avoidance of creation of new AVF in another site with exhaustion of the available veins and waiting for their maturation, so decreasing morbidity and mortality.