IFT04 - Creating an “Artificial Aneurysm” over Brachial Artery as an Extraordinary Hemodialysis Access

Objectives: For decades, using the brachial artery as a "shuntless" hemodialysis access for patients unsuitable for conventional arteriovenous shunts has been advocated. Two fundamental methods include axillobrachial artery bypass graft (AABG) and superficialization of the brachial artery (SBA). A new method by suturing a 3cm in length, pillow-shaped polytetrafluoroethylene graft to the brachial artery in side-to-side fashion (Fig 1) has been advocated. In this report, we share our experience with this "artificial aneurysm" (AA) approach.

Methods: All patients who underwent "AA" procedures were retrospectively reviewed over the past eight years. The indications, early and late complications, as well as primary patency (PP), secondary patency (SP), and access survival (AS) of the "AA" were analyzed and compared to the outcomes of AABG and SBA as reported in published articles.

Results: Between October 2014 and August 2022, eight "AAs" were created in five patients with a mean age of 74.6. Indications included bilateral central vein occlusion, exhausted options of catheter access for hemodialysis, and autologous fistulae with a short cannulation segment. All "AAs" achieved functionality within two weeks, except for two cases with poor wound healing. The early complications included two poor wound healing, one subcutaneous hematoma which needed evacuation. One late pseudoaneurysm formation due to suture line dehiscence occurred, necessitating a redo of the "AA" via the original arteriotomy. No occlusion events of "AAs" were observed, with the main cause of loss AS being death. The 12-month and 24-month PP/SP/AS were 100%/100%/75% and 66.7%/66.7%/41.7%, respectively (Table I). Compared to AABG results, which showed approximately 87.9%/90.7% and 70.4%/80.3% PP/SP at 12 and 24 months, respectively, our series demonstrated better early patency. In comparison to a multicenter retrospective study of SBA in 233 cases from Japan, with a mean age of 71.4 and impressive 12-month and 24-month PP/SP of 93.3%/96.5% and 88.3%/92.9%, respectively, our preliminary results appear less favorable due to poorer patient survival. However, noteworthy is the absence of brachial artery occlusion, hand ischemia, or pain during hemodialysis in any single patient in our series.

Conclusions: Using “artificial aneurysm” over brachial artery as a hemodialysis access is a thought outside-the-box. While the numbers might be limited, it offers a potential solution with acceptable early/late complications and patency for patients facing challenges such as small brachial arteries, poor distal run-off, ineligibility for brachial artery superficialization, and axillobrachial artery bypass graft.