الفهرس 
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Abstract
This study is a prospective clinical experiment that was done at Minia University Hospital over a duration of 20 months, spanning from July 2021 to March 2023.
This study involved a cohort of 20 patients diagnosed with chronic renal failure (CRF) who exhibited limited upper limb access options and had at least one side with patent central veins.
The patients were provided with a comprehensive explanation of the procedure, potential complications, benefits, risks, and alternative interventions. Subsequently, an informed permission was acquired from each patient.
Comprehensive documentation of patient records has been completed, encompassing all relevant information contained within the vascular sheet. This includes personal medical history, duration of renal failure and hemodialysis treatment, history of central venous occlusion and hemodialysis catheter implantation, as well as any chronic illnesses and disorders.
A comprehensive evaluation of all patients has been conducted, encompassing physical, general, abdominal, and local examinations.
Comprehensive laboratory tests, including cardiological and internal medicine consultations, as well as nephrological consultations, have been conducted for our patients.
All patients underwent a Duplex study of the venous and arterial systems, encompassing both the upper limbs and central regions, as well as Venography.
Prior to the administration of anaesthesia, all patients had a series of preparatory procedures, including preoperative dialysis, post-dialysis laboratory tests, as well as consultations with cardiology and chest specialists.
All patients provided informed written consent before to their participation in the trial.
In our experimental protocol, the patient is positioned supine under general anaesthesia, with the shoulders supported by a shoulder cushion. The patient’s head is stretched, and sterilisation is performed using betadine from the angle of the jaw up to the umbilicus. Incisions were performed bilaterally on the anterior chest wall, namely 1 cm below the lateral third of each clavicle.
The dissection of the pectoralis major muscle was performed, followed by the dissection and splitting of the pectoralis minor muscle. Subsequently, the clavi-pectoro-axillary fascia was incised, allowing access to the axillary artery and the contralateral vein for dissection.
A concave subcutaneous passage located anteriorly to the top third of the sternum was created to facilitate the implantation of a 6*50mm polytetrafluoroethylene (PTFE) graft.
The procedure involved venotomy, which was performed after heparinization of the vein. The venous end of the graft was aligned parallel to the direction of the vein, leading towards the central venous system. The venous anastomosis was then created first, utilising a 5-0 polypropylene running suture at an acute angle. Heparinization (2500 IU) was administered intravenously prior to this step. Subsequently, the arterial end of the graft was aligned towards the centre, and the arterial anastomosis was performed using a 5-0 polypropylene running suture at an acute angle.
To mitigate the occurrence of steal syndrome and minimise the risk of intimal hyperplasia, the arteriotomy was modified to a size that was less than 80% of the artery diameter, while ensuring an anastomotic angle of 15°.
Hemostasis was achieved, and the wounds were subsequently closed using two suction drains.
The majority of patients were discharged during the second week following their instruction on risk factors and post-procedure treatment, including antibiotics. Monitor the progress of our patients in our ambulatory care facility.
The present investigation comprised a sample of 20 patients diagnosed with chronic renal failure (CRF) who exhibited limited upper limb access options and possessed patent central veins on at least one side.
The outcomes of the subsequent examination revealed that the primary patency rate was 70% after 3 months, 45% after 6 months, and 30% after 1 year. The secondary patency rate demonstrated a complete success of 100% at both the 3-month and 6-month follow-up intervals, however it decreased to 50% after 1 year. There have been four instances whereby surgical revisions were conducted successfully to address graft thrombosis. This finding, when compared to other studies, suggests that it is beneficial to prioritise patients with limited upper limb access by ensuring the presence of patent central veins on at least one side.
Several complications occurred during the study, including thrombosis in three cases, which were successfully managed through thrombectomy. Additionally, three cases experienced venous hypertension, which was effectively managed through medical interventions. One case involved the rupture of an anastomotic aneurysm and was subsequently terminated. It is worth noting that one case resulted in death, although the cause was unrelated to access-related complications. Lastly, three cases presented with thrombosed and infected access, but due to delayed intervention, these cases were terminated.