Grafts and Graft Materials as Vascular Substitutes for Haemodialysis Access Construction

An organic prosthesis of 6mm in diameter is anastomosed to the left brachial artery of 2.9mm. The arteriotomy should not be over 2.3mm, to reduce the risk of steal syndrome.

A straight AVG in the upper arm in a child, showing the ‘pleating’ of the organic prosthesis during the arterial anastomosis to taper the graft and match it to the arteriotomy.

A forearm PTFE loop graft: (A) the arterial anastomosis (a) between a tapered e-PTFE and the right brachial artery has been completed. Some oozing of blood through the PTFE can be seen. The venous anasomosis (b) is to a vena comitans of the brachial artery (rather than the cephalic or basilic veins since if these were present an autologous brachial fistula would have been constructed). (B) The completed PTFE loop after skin closure showing the graft in a subcutaneous tunnel in the forearm, with a distal counter-incision. The scars of previous failed access sites are also seen.

The ‘O’ shaped AVG in the distal third of the upper arm preserves more proximal sites for potential future straight AVGs. The compliance of the biological graft is crucial for this technique, as the prosthesis is placed between the brachial artery and its vena comitans in a very narrow loop. This AVG is functioning well at 9 years.

(A) An infected forearm AVG has been just treated by partial excision; a new organic interposition graft is anastomosed in an end-to-end fashion to the arterial limb of the old AVG. (B) The new interposition graft bypasses the infected area involved through a new, concentric, subcutaneous tunnel. (C) The skin incisions are closed and covered with occlusive dressing. (D) The infected area is treated by removing the AVG and leaving the wound to heal by second intention.