Humeral-cephalic graft fistula in patients requiring hemodialysis

Aim. Prosthetic grafts for vascular access are prepared in patients with chronic renal insufficiency (CRI) requiring vascular access for hemodialysis when the surface and humeral veins of the upper limbs are not suitable for the preparation of a direct arteriovenous shunt. Between 1985 and 1995, a humeral/cephalic graft (HCG) was prepared as the procedure of choice in patients requiring hemodialysis vascular access in the arm and presenting patency of the medial and/or proximal third of the cephalic vein in the arm. All grafts underwent regular ultrasonographic Doppler control (every 3 months in the first year and every 6 months in subsequent years). This study reports the immediate and late results of HCG and discusses the value of this access as a means of prolonging the mean hemodialytic life of each arm. Methods. Twenty HCG in PTFE were prepared under local anesthesia in 17 patients with CRI after a phlebographic study of both arms. Results. Intraoperative and immediate postoperative mortality was nil. Immediate patency was equivalent to 90% (graft length <10 cm=100%, graft length >10 cm=84.6%); at 12 and 30 months patency (life table analysis) was respectively 75.5 and 39.3%. A new shunt was prepared in 8 cases of late thrombosis: 4 homolateral humeral- axillary grafts (HAG), 3 contralateral HCG (patients in whom it was possible to prepare a homolateral HAG), 1 graft fistula at the groin. A graft which was >10 cm long was removed because of infection after 8 months. Conclusions. HCG showed good immediate and late patency and guaranteed vascular access for technically simple hemodialysis along the length of the graft and cephalic vein; in HCG with graft length <10 cm, hemodialysis can be carried out using a dual access and the failure of HCG does not usually prevent the subsequent preparation of a homolateral graft fistula with venous anastomosis in an axillary site (HAG). HCG increases the mean hemodialytic life of the upper limbs and should be used as first choice in patients requiring hemodialysis in the arm who present patency of the median and/or proximal third of the cephalic vein.