Document Detail

Subclavian vein to right atrial appendage bypass without sternotomy to maintain arteriovenous access in patients with complete central vein occlusion, a new approach.
MedLine Citation:
PMID:  19359137     Owner:  NLM     Status:  MEDLINE    
Given the increasing numbers of patients requiring long-term hemodialysis, there is an inevitably increasing population of patients with occluded central venous inflow (subclavian, innominate, and caval) despite access or access possibilities in the arm. In an effort to avoid sternotomy, we have attempted to treat these patients with a substernally tunneled subclavian to right atrial bypass. Patients treated in this fashion have an existing fistula with symptomatic venous hypertension or good fistula options but complete central vein obstruction, a patent subclavian/axillary vein to the costoclavicular junction, and no other options in the contralateral arm. Claviculectomy is performed and the subclavian vein isolated. Through a third intercostal space "minipericardiotomy," the right atrial appendage is exposed. A retrosternal tunnel is fashioned, and bypass is performed from the subclavian vein to atrial appendage. Eleven patients aged 20-70 (mean 46) years underwent surgery at our institution between February 2004 and March 2007. Three bypasses were performed with autogenous vein (two femoral and one saphenous), while eight were performed with polytetrafluoroethylene in an effort to preserve the superficial femoral vein for later leg bypass. There was one early mortality due to sepsis, and early morbidity was limited to one patient with a symptomatic pericardial effusion. Mean follow-up was 16 (range 3-43) months. Sixty-seven percent and 33% of arteriovenous fistulas remained functional at 6 and 10 months, respectively; and one patient's fistula remained functional at 21 months. Four patients (36%) developed central bypass stenosis or occlusion, one requiring a redo bypass and three angioplasty. Infection occurred in two patients (18%), with removal of autogenous vein graft in one. While a significant number of these bypasses fail, upper extremity access is maintained in a reasonable number of patients (67% at 6 months) who are not candidates for local repair or stenting and would thus have no other upper extremity access options. This technique offers an alternative to sternotomy and brachiocephalic vein reconstruction, although the superiority of one method over the other will require direct comparison.
Carolyn Glass; Victor Maevsky; Todd Massey; Karl Illig
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Publication Detail:
Type:  Journal Article     Date:  2009-04-08
Journal Detail:
Title:  Annals of vascular surgery     Volume:  23     ISSN:  1615-5947     ISO Abbreviation:  Ann Vasc Surg     Publication Date:    2009 Jul-Aug
Date Detail:
Created Date:  2009-06-22     Completed Date:  2009-08-27     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  8703941     Medline TA:  Ann Vasc Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  465-8     Citation Subset:  IM    
University of Rochester Medical Center, Rochester, NY, USA.
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MeSH Terms
Arteriovenous Shunt, Surgical / adverse effects,  methods*
Atrial Appendage / surgery*
Blood Vessel Prosthesis
Blood Vessel Prosthesis Implantation* / adverse effects,  instrumentation
Catheterization, Central Venous / adverse effects
Constriction, Pathologic
Femoral Vein / transplantation*
Middle Aged
Prosthesis Design
Renal Dialysis*
Retrospective Studies
Saphenous Vein / transplantation*
Sternum / surgery
Subclavian Vein / surgery*
Time Factors
Treatment Outcome
Vascular Diseases / etiology*,  physiopathology
Vascular Patency
Young Adult
Reg. No./Substance:

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