Ultrasound Guided Liposuction For Superficialization Of Difficult To Access Arteriovenous Fistulas
Alan T. Nguyen, BS1, Venita Chandra, MD2, Rahim Nazerali, MD, MHS, FACS3.
1Oakland University William Beaumont School of Medicine, Auburn Hills, MI, USA, 2Division of Vascular Surgery, Stanford University Medical Center, Palo Alto, CA, CA, USA, 3Division of Plastic & Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA, USA.
PURPOSE: Arteriovenous fistulas (AVF) remain the preferred method of vascular access for hemodialysis. Even in the setting of adequate maturation, successful cannulation is also a required prerequisite for a functional AVF. Cannulation can be challenging for a number of reasons including tortuosity, inadequate length or excessive subcutaneous tissue resulting in deep fistulas that are difficult to visualize. With the increasing comorbidities such as diabetes and obesity this last issue if becoming an increasingly common challenge. Superficialization by mobilization of the venous outflow tract is common and required for basilic vein transpositions, however this technique requires extensive manipulation of the venous outflow tract as well as long incisions. Even despite this technique however, access can still be challenging depending on how “superficial” the fistulas were placed. Minimally invasive options (lumpectomy and liposuction) have been introduced to reduce complications of poor wound healing and obstructed flow seen with manipulation of vessels. We report our experience with ultrasound guided liposuction (UGL) as a minimally invasive alternative to traditional surgical superficialization procedures.
METHODS: Four patients from January 2017 through September 2019 experiencing difficulty cannulating their arteriovenous fistula due to depth of overlying adipose tissue were offered liposuction via a small incision to reduce adipose tissue overlying needle access points. All procedures were performed with intraoperative ultrasound guidance. Liposuction under ultrasound guidance was used until needle access points were <6mm in depth and palpable through overlying skin.
RESULTS: 3 patients had a brachiocephalic fistula and one had a basilic vein transposition. All patients had excellent flow rates of >600 ml/min. Body mass indices ranged 27.3 to 34 kg/m2 (mean 31.1). the mean depth of AVF pre- and post-UGL were 14mm and 5.25mm respectively. There were no postoperative complications.
CONCLUSION: UGL is a safe and effective minimally invasive procedure for superficialization of difficult to access AVF.
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