Salvage Treatment for Venous Aneurysm Complicating Vascular Access Arteriovenous Fistula: Use of an Exoprosthesis to Reinforce the Vein after Aneurysmorrhaphy

Article Outline

• Abstract
• Introduction
• Material and methods
  • Study population
  • Preoperative assessment
  • Operative technique
  • Postoperative follow-up
  • Endpoints and definition of success
  • Statistical analysis
• Results
• Discussion
• Conflict of interest
• Acknowledgements
• References
• Copyright

Abstract 

Objectives

We report a new salvage technique for treating venous aneurysms (VAs) complicating vascular access arteriovenous fistula (AVF) using externally reinforced venous aneurysmorrhaphy.

Design

A retrospective study over a 20-month period from a single centre.

Patients

Patients presenting to the vascular surgery department, Bordeaux University Hospital for revision of a vascular access AVF were included.

Methods

Reinforced venous aneurysmorraphy consisted in removal of redundant vessel wall followed by reinforcement using an external prosthetic graft. Patency, diameter and flow were assessed by duplex ultrasound at 1, 6 and 12 months after salvage.

Results

Thirty-eight eligible patients were identified. Five were excluded because VA was associated with central vein stenosis; the remaining 33 underwent salvage. Indications were rapidly expanding or painful VA in seven cases; VA with frequent bleeding or damaged overlying skin in eight; VA in close relation to a stenosis in two; and VA associated with high-flow rate in 16. Cannulation was attempted after 30 days. Mean follow-up time was 12 S.D. 5 months (range: 4–22). Two repaired AVFs failed. Primary 1-year patency was 93%. No aneurysm or infection occurred. Reduction of high flow was successful in 12 of 16 patients. The remaining four required re-operation.

Conclusions

Reinforced venous aneurysmorrhaphy is effective in controlling venous dilation and achieving patency. Reduction of high-flow rates was not always achieved. Further study is needed to evaluate long-term efficacy of this treatment.

Keywords: Aneurysmorrhaphy, Haemodialysis vascular access, Aneurysm

Back to Article Outline

Introduction 

Problems arising from haemodialysis vascular access account for more than 20% of hospitalisations involving patients with end-stage renal failure,¹ a steadily growing population worldwide.² The main causes of these problems are stenosis, thrombosis and steal syndrome. However, venous aneurysm (VA) complicating arteriovenous fistula (AVF) has probably been underreported in the literature. The potential severity of VA is high due to the risk of rupture and possibly fatal haemorrhage.³ The safest treatment option is ligation of the fistula and creation of a new access site. Salvage is possible by resection of the aneurysm followed by end-to-end anastomosis, but this technique may require bypass in patients with extensive or multiple aneurysms.⁴ Experience has shown that bypass using a suitable autologous vein is reliable but that prosthetic material gives disappointing results.⁵Recently, Balaz et al.⁶ proposed a new vein salvage technique consisting of venous aneurysmorrhaphy followed by placement of an open-pore external support prosthesis (ProVena^®, B. Braun Medical) to reinforce the wall of the repaired vein. The purpose of this article is to describe our experience with reinforced venous aneurysmorrhaphy to treat VA complicating AVF.

Back to Article Outline

Material and methods 

Study population 

Between August 2007 and May 2009, our vascular surgery department performed 527 vascular access operations including formation of new fistulas and revision surgery. Demographic data, surgical technique and follow-up for all patients were recorded prospectively in a computer database. Informed consent was obtained from all patients for their treatment.

For this study, the database was searched to identify all patients operated on for VA complicating AVF. A VA was defined as a circumscribed fusiform or saccular dilatation having a threefold larger diameter than the vessel segments immediately upstream and downstream from the access site. A VA was considered as an indication for repair if it was associated with one or more of the following:

•short length of the cannulation route and:

○rapidly expanding aneurysm >2cm per 6 months;

○pain in area overlying the aneurysm; and

○high flow associated with multiple aneurysms.

Preoperative assessment 

Colour Doppler ultrasound (US) was performed to determine aneurysm length and diameter, detect intraluminal thrombus, identify stenoses and to measure flow. Ultrasonography of the vessels in the contralateral and ipsilateral forearm and upper arm was also performed to evaluate the feasibility of creating a new access site. If US demonstrated impairment of fistula outflow due to central vein stenosis involving the subclavian vein, brachiocephalic vein or superior vena cava, diagnostic angiography was performed to better assess the stenosis and patients were excluded from this study. If the flow rate exceeded 1.5lmin⁻¹ or if the patient presented with symptoms of heart failure, echocardiography was performed.

Operative technique 

All procedures were carried out under general anaesthesia in an operating room by a vascular surgeon. All patients received 1g of cefuroxime intravenously. If the VA was near or included the anastomosis, the upstream AVF anastomosis was dissected first to allow control of incoming arterial flow. Next, the arterialised vein was disconnected from the artery and dissected with staged cutaneous incisions up to the healthy non-aneurysmal zone (Fig. 1). In patients presenting with extensive erosion of the overlying skin due to repeated cannulation, wide resection of the redundant vein wall and adjacent superficial tissues was preferred (Fig. 1) to limit the extent of dissection and prevent local complications such as infection. The vein was then externalised and a 6–8-mm-diameter atraumatic steel cannula was introduced to allow calibration and location of the healthy and aneurysmal segments. The aneurysms were resected and venotomies were closed using a polypropylene longitudinal running suture without causing stenosis (Fig. 2). In cases of venous stenosis adjacent to the aneurysm, the narrowing was resected with end-to-end anastomosis and the aneurysm was treated as described above. Any uncomplicated aneurysms were corrected during the same procedure to ensure that the length of the healthy cannulation route was greater than 10cm. A saline-filled syringe was used to rinse the vein and detect leakage. The repaired vein was then scaffolded (Fig. 3) with a macroporous polyester external prosthesis (6, 7 or 8mm ProVena^® B. Braun Medical) and tunnelled subcutaneously through an undissected area to the previous anastomosis site (Fig. 4). In most cases, a new side-to-end anastomosis was performed and the exoprosthesis was attached to the artery using a running suture through the mesh. In a few selected cases involving radiocephalic fistula with high flow, the proximal radial artery was ligated and end-to-end anastomosis was performed between the repaired vein and distal radial artery. After placement of a suction drain in dissected areas, the wound was closed using a non-absorbable 3/0 suture (Ethicon Inc., Somerville, NJ, USA). The temporary placement of a jugular vein vascular access catheter was necessary in most of the cases. Cannulation was attempted for the first time 1 month after surgery. The central vein catheter was removed after 10 consecutive uneventful dialysis sessions.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1 

  Dissection of the aneurysmal arterialised vein using staged skin incisions.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 2 

  Aneurysmorrhaphy (arrow) and resection of venous aneurysms after calibration of the lumen with the cannula.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 3 

  Polyester mesh wrapping around the vein; bulldog clamp to control venous outflow.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 4 

  The wrapped vein is tunnelized under healthy skin and reanastomosed.

Postoperative follow-up 

Clinical examination of the fistula was performed by the surgeon before discharge from the hospital, after 1 month and then every 6 months. Colour duplex US to assess patency, measure flow through the vascular access and evaluate the diameter of the repaired vein was performed at 1, 6 and 12 months and yearly thereafter. In cases of persistent high flow, the type of procedure used to reduce flow and the postoperative flow rate measured were noted.

Endpoints and definition of success 

The principal endpoint of this study was primary patency after repair. Secondary endpoints included short-term procedure-related complications, flow rates and diameter of the repaired vessel. Patency at follow-up was defined as less than 50% stenosis of the repaired vein lumen as documented by duplex US. The procedure was considered as a technical success if the length of healthy cannulation route after aneurysm removal was at least 10cm and if the patent vein was palpable immediately under the skin at the end of the intervention. The procedure was considered as a clinical success if the vascular access could be used for routine twin-needle haemodialysis over a period of at least 1 month.

Statistical analysis 

Statistical analysis was performed with StatView software version 5 (SAS Institute, Inc., Cary, NC, USA). Nominal variables were expressed as number and percentage of patients. Continuous variables were expressed as mean and standard deviation. The Kaplan–Meier life table method was used to calculate the primary patency curve.

Back to Article Outline

Results 

We identified 38 patients with VA complicating AVF during the 20-month study period. Patients were referred to our department either by the nephrologists at our institution or by vascular surgeons from local vascular centres. Five patients in whom preoperative US revealed concomitant central vein stenosis that was confirmed by angiography were excluded from the study. The remaining 33 patients were treated by reinforced venous aneurysmorrhaphy. Vascular risk factors and underlying renal disease in these 33 patients are listed in Table 1. The types of vascular access are listed in Table 2. The mean age of the AVFs at the time of repair was 94 S.D. 75 months.

Table 1. Patient characteristics.

Variable	NN (%) or mean±SD (range)
Age,y	55 S.D. 15 (14–86)
Male sex	24 (72%)
Diabetes	2 (6%)
Coronary artery disease	8 (24%)
Hypertension	21 (64%)
Hypercholesterolemia	6 (18%)
Tobacco use	5 (15%)
Past or present renal transplantation	24 (72%)
Other aneurysmal localization	4 (12%)
Underlying renal disease
Unknown	4 (12%)
Polycystic kidneys	5 (15%)
Immunoglobulin A nephropathy	2(6%)
Glommerulonephritides	1 (3)
Renal vascular disease	6 (18%)
Diabetes mellitus	1 (3)
Congenital nephropathy	6 (18%)
Nephronophthisis (Joubert syndrome)	1 (3)
Interstitial nephritis	4 (12%)
Vasculitis	3 (9%)

Table 2. Type of vascular access, number of previous accesses, and surgical indications.

The diameter of the VA ranged from 2.5 to 6cm. The indications for VA repair are shown in Table 2. In six patients, preoperative duplex US indicated that ligation followed by creation of a new access on the contralateral arm was feasible but this option was refused by the patients either because it involved the dominant arm or because of cosmetic considerations. Reconstruction of the AVF anastomosis was required in 25 patients either because the VA was included in the anastomosis (Mickley⁷ type I area) or because the first segment of the arterialised vein was diseased with altered flow on duplex US.

Details of operative techniques are shown in Table 3. In 15 cases, the diseased skin covering the aneurysm was resected in a single block (Fig. 1) along with the redundant vein wall. The diameter of the exoprosthesis was 8mm in 10 cases, 7mm in 12 cases and 6mm in 11.

Table 3. Technical details concerning the procedure and hospitalization.

Variable	Mean±SD (range)
Duration of procedure (min)	156 S.D. 50 (70–255)
Number of aneurysms treated	2.2 S.D. 0.9 (1–4)
Length of skin incisions (cm)	25 S.D. 14 (12–53)
Length of covered vein, (cm)	22 S.D. 8 (8–47)
Diameter of exoprosthesis (mm)	6.9 S.D. 0.8 (6–8)
Duration of hospital stay (d)	4.5 S.D. 1.1 (2–7)

The procedure was a technical success in all patients. Haematoma occurred prior to discharge in two patients, including one requiring surgical evacuation. In another case involving an 86-year-old diabetic patient, extensive necrosis of the skin overlying the repaired vein occurred 1 month after surgery and resulted in exposure of the exoprosthesis. The fistula was ligated with removal of exograft material. A prosthetic AV graft was implanted in the contralateral arm. This case was considered to be a clinical failure. Swelling of the forearm with no effect on flow rate was observed in one patient 5 months after surgery. Duplex US revealed the presence of stenosis in an unreinforced segment of the axillary vein. The patient was treated successfully with percutaneous transluminal angioplasty (PTA).

In the 16 patients with high flow in the access site, the main reason for treatment was short cannulation route in 10 and a symptomatic cardiac failure with exertional dyspnoea in six. Conventional side-to-end anastomosis was performed in 14 patients. In the remaining two patients, end-to-end anastomosis between the distal radial artery and repaired vein was performed with ligation of the proximal radial artery in the same procedure. In 10 of the 14 in whom end-to-end anastomosis was performed, the flow rate dropped below 1.2lmin⁻¹ (mean flow reduction, 51%). In the remaining four patients, including three with radial–cephalic fistulas and one with a brachial–cephalic fistula, the reconstructed AVF was patent but re-operation was necessary to correct the flow rate that initially exceeded 3lmin⁻¹ and stayed above 1.5lmin⁻¹ after reinforced aneurysmorrhaphy. In the three cases involving high flow in a radial–cephalic fistula, proximal radial artery ligation was performed after clinical and duplex US evaluation demonstrated a patent ulnar artery and palmar arch. Flow reduction was satisfactory in two cases but one patient developed AVF occlusion 3 weeks after re-operation and was considered to be a clinical failure. In the case involving high flow in a brachial–cephalic fistula, the patient had had four previous accesses operations and had no further option. Moving the arterial anastomosis distally was impossible because of poor-quality forearm arteries but the first 4cm of the exoprosthesis were recalibrated to decrease the diameter from 8 to 4mm. Following this experience, our current policy when performing aneurysmorrhaphy in patients presenting radial–cephalic fistula with flow rates exceeding 3lmin⁻¹ consists of performing end-to-end anastomosis between the arterialised repaired vein and distal radial artery with ligation of the proximal radial artery when preoperative duplex US scan and the Allen test document patency of the palmar arch and ulnar artery. Application of this policy in the two most recent cases has achieved an 80% reduction in flow rate. Ligation of the radial artery was performed in five patients (two intra-operative, three re-intervention) with no alternative for creation of a new native vascular access site.

During follow-up, US measurement showed that the diameter of the scaffolded segment of the repaired vein remained stable. It was 1mm larger than the diameter of the exoprosthesis even in the needling segment. No infection occurred.

Dialysis could not be performed during the study period in 10 of the 33 patients in this series. These 10 patent AVFs were considered as neither clinical successes nor failures. Two of these 10 patients (operated on due to rupture risk) were dialysed less than 1 month after revision because they underwent kidney transplantation shortly after surgery. In the remaining eight patients, VA revision surgery (indication: high-flow rate in six cases, stenosis in one case and rapid expansion in one) was performed to maintain functional access while their kidney transplant function worsened, including three who required revision to normalise flow rate in the repaired vein. In the remaining 23 patients, dialysis was resumed. However, one occluded after revision to correct high flow and one required removal of the AVF because of skin necrosis. Both of these patients were considered to be clinical failures. A total of 21 of the 23 patients were successfully dialysed. The mean time for catheter removal was 57 days.

During the study period, no patient died or was lost to follow-up (mean, 12 S.D. 5 months; range, 4–22 months). Assisted primary patency was 93% at 6 and 12 months with 28 and 15, respectively, as the numbers at risk. The Kaplan–Meier patency curve is shown in Fig. 5.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 5 

  Kaplan–Meier curve showing assisted primary patency.

Back to Article Outline

Discussion 

According to one meta-analysis including 34 studies,⁵ the incidence of aneurysm and false aneurysm in haemodialysis vascular accesses ranges from 0% to 6%. It is known that grafts have a higher risk of aneurysm formation than fistulas but the pathophysiology of VA in AVF is still unclear.⁸ Cannulation routes appear to be preferential locations for VA due to repeated needling.³ Whenever possible, uncomplicated VA must be managed in accordance with DOQI guidelines³ by abandoning the cannulation route in favour of a healthy segment. At our institution, uncomplicated cases were managed conservatively by nephrologists and these patients were not referred to us.

Another factor influencing the formation of VA as well as management decisions involves downstream or upstream stenosis, that is, pre-stenotic or post-stenotic aneurysm. In pre-stenotic aneurysm, VA develops due to stenosis located in the downstream vein. This type of dilatation is caused by increased pressure in the arterialised vein.³ It can be detected during dialysis sessions or suspected if bleeding time is prolonged after cannula removal or if the vein remains dilated in the elevated arm position. In this series, two true hyperplasic stenoses located immediately downstream from the VA were resected with end-to-end anastomosis. With regard to downstream stenosis, it should be mentioned that the treatment of choice for central vein stenosis is PTA⁹ as in the five cases detected by preoperative US in this study. Vesely et al.¹⁰ also reported successful reduction of intra-graft pressure and blood flow into the false aneurysm after angioplasty of central vein lesions.

In post-stenotic aneurysm, increased turbulence induced by upstream stenosis triggers VA formation in the post-anastomotic venous segment.³, ¹¹ Surgery is recommended over PTA for treatment of this type of stenosis.³ In this series, duplex US usually demonstrated the presence of a highly tortuous and/or calcified venous segment located either upstream from the VA or between two VAs with altered flow. The frequency of this finding and the high incidence of juxta-anastomotic VA explains why reconstruction of the AVF anastomosis was performed in 25 of the 33 cases in this series.

In a large study, including 44 aneurysms involving both AVF and grafts, Georgiadis et al.¹¹ concluded that the outcome of salvage surgery was better for AVF than grafts, for true aneurysms than false aneurysms and for forearms than upper arms. In the 26 patients with VA complicating AVF, primary patency after salvage was 69% at 1 year. Outcomes were also better using autogenous veins than prostheses. Our 1-year patency rate was 93% even though half of our patients had VA associated with high flow. In another study involving patients with stenosed or thrombosed AVF, Georgiadis et al.¹² demonstrated comparable patency after interposition of either short polytetrafluoroethylene (PTFE) segments (<6cm) or autologous vein grafts. Since VA tended to be extensive and multiple in our series, autologous vein was preferred to long PTFE graft in accordance with to DOQI guidelines.³

External reinforcement of vein grafts using external prostheses has been reported previously. The first description was by Parsonnet et al.¹³ in 1963. Melliere et al.¹⁴ reported the use an exoprosthesis to reinforce dilated saphenous vein segments in femoro-popliteal bypass grafts. In a recent prospective multicentre study,¹⁵ promising short-term patency was obtained using ProVena^® (B. Braun Medical) made from macroporous polyethylene terephtalate to scaffold dilated or varicose vein material after infrainguinal bypass. The first to describe the use of Pro Vena^® for VA in haemodialysis patients with VA was Balaz et al.⁶ who treated four patients but provided no follow-up data.

Various partial resection techniques have been proposed for the correction of VA. Lo et al.¹⁶ described simple placation of the vessel using a running suture. This technique was used in a series of 15 cases but no information was given concerning outcome with regard to either patency or cannulation. Several authors¹⁷, ¹⁸ have proposed the use of a surgical stapler to reshape the VA. Pierce et al.¹⁷ reported the use of staples in 12 patients, but follow-up was less than 1 year in six patients and recurrent aneurysm was observed in two. To avoid recurrence after aneurysmorrhaphy, Grauhan et al.¹⁹ proposed wrapping with a metal mesh. In their report, these authors made no mention of cannulation problems but the presence of metal (mesh or stapler) or of a thick plication could hinder needling.

The use of the reinforced aneurysmorrhaphy technique presents several potential problems. General anaesthesia and a long surgical time are important limitations. As observed in one elderly diabetic patient in our series, poor wound healing may occur. In high-risk patients, endovascular treatment or PTFE segment repair is preferable for short VA and, if possible, creation of a new AVF is preferable for extensive VA. Another concern in the use of reinforced aneurysmorrhaphy involves VA associated with a high-flow rate. Although the reduction of flow after placement of the exoprosthesis in high-flow patients was 51% in this series, additional procedures were necessary in four patients in whom pre-treatment flow exceeded 3lmin⁻¹. For VA associated with moderately high flow, we recommend the use of a 6-mm exoprosthesis. In patients presenting with VA associated with flow exceeding 2.5lmin⁻¹, reinforced aneurysmorrhaphy cannot normalise flow; a more appropriate therapy for VA located in the forearm is proximal radial artery ligation and end-to-end anastomosis between the repaired arterialised vein and the distal radial artery, if the ulnar artery is patent and creation of a new AVF is impossible. In the upper arm, the arterial inflow must be moved to forearm arteries.⁴ As in studies using other techniques, our follow-up was too short to evaluate the effect of repeated needling through the exoprosthesis on the repaired AVF and the possible risk of recurrent aneurysm.

In conclusion, reinforcement using an external prosthesis is a safe and effective alternative for repair of extensive VA. Further study will be needed to assess the long-term patency rate, ascertain the risk of recurrence and determine benefits in patients with high-flow rates.

Back to Article Outline

Conflict of interest 

None.

Back to Article Outline

Acknowledgements 

The authors thank Dr. Fleur Delva for providing help with statistics analysis.

Back to Article Outline

References 

1. Rayner HC, Pisoni RL, Bommer J, Canaud B, Hecking E, Locatelli F, et al. Mortality and hospitalization in haemodialysis patients in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2004;19:108–120
   • View In Article
   • MEDLINE
   • CrossRef
2. Grassmann A, Gioberge S, Moeller S, Brown G. End stage renal disease. Global demographics in 2005 and observed trends. Artif Organs. 2006;30:895–897
   • View In Article
   • MEDLINE
   • CrossRef
3. Clinical practice guidelines for hemodialysis adequacy update 2006. Am J Kidney Dis. 2006;48:S234–S242
   • View In Article
4. Management of aneurysms: Vascular Access Society guidelines. http://www.vascularaccesssociety.comOctober 30, 2009;
   • View In Article
5. Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and polytertrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg. 2003;38:1005–1011
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (112 KB)
   • CrossRef
6. Balaz P, Rokosny S, Klein D, Adamec M. Aneurysmorrhaphy is an easy technique for arteriovenous fistula salvage. J Vasc Access. 2008;9:81–84
   • View In Article
7. Mickley V. Stenosis and thrombosis in haemodialysis fistulae and grafts: the surgeon's point of view. Nephrol Dial Transplant. 2004;19:309–311
   • View In Article
   • MEDLINE
   • CrossRef
8. Diskin CJ, Stokes TJ, Dansby LM, Radcliff L, Carter TB. Understanding the pathophysiology of hemodialysis access problems as a prelude to developing innovative therapies. Nat Clin Pract Nephrol. 2008;4:628–638
   • View In Article
   • CrossRef
9. Tordoir J, Canaud B, Haage P, Konner K, Basci A, Fouque D, et al. EBPG on vascular access. Nephrol Dial Transplant. 2007;22(Suppl. 2):ii88–ii117
   • View In Article
   • CrossRef
10. Vesely TM. Use of stent grafts to repair hemodialysis graft related pseudoaneurysms. J Vasc Interv Radiol. 2005;16:1301–1307
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (1350 KB)
    • CrossRef
11. Georgiadis GS, Lazarides MK, Panagoutsos SA, Kantartzi KM, Lambidis CD, Staramos DN, et al. Surgical revision of complicated false and true vascular access related aneurysms. J Vasc Surg. 2008;47:1284–1291
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (676 KB)
    • CrossRef
12. Georgiadis GS, Lazarides MK, Lambidis CD, Panagoutsos SA, Kostakis AG, Bastounis EA, et al. Use of short PTFE segments (<6cm) compares favourably with pure autologous repair in failing or thrombosed native arteriovenous fistulas. J Vasc Surg. 2005;41:76–81
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (101 KB)
    • CrossRef
13. Parsonnet VLA, Shah IH. New stent for support of veins in arterial grafts. Arch Surg. 1963;10:696–702
    • View In Article
14. Melliere D, Le Chevillier B, Kowarsky S. Wrapped autologous greater saphenous vein bypass for severe limb ischemia in patients with varicose veins. Preliminary report. J Cardiovasc Surg (Torino). 1995;36:117–120
    • View In Article
    • MEDLINE
15. Arvela E, Kauhanen P, Albäck A, Lepäntalo M, Neufang A, Adili F, et al. Initial experience with a new method of external polyester scaffolding for infraiguinal vein grafts. Eur J Vasc Endovasc Surg. 2009;38:456–462
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (647 KB)
    • CrossRef
16. Lo HY, Tan SG. Arteriovenous fistula aneurysm. Plicate not ligate. Ann Acad Med Singap. 2007;36:851–853
    • View In Article
17. Pierce GE, Thomas JH, Fenton JR. Novel repair of venous aneurysms secondary to arteriovenous dialysis fistulae. Vasc Endovascular Surg. 2007;41:55–60
    • View In Article
    • MEDLINE
    • CrossRef
18. Hakim NS, Romagnoli J, Contis JC, Akoh J, Papalois VE. Refashioning of an aneurysmatic arterio-venous fistula by using the multifire GIA 60 surgical stapler. Int Surg. 1997;82:376–377
    • View In Article
    • MEDLINE
19. Grauhan O, Zurbrügg HR, Hetzer R. Management of aneurismal arteriovenous fistula by a perivascular metal mesh. Eur J Vasc Endovasc Surg. 2001;21:274–275
    • View In Article
    • Full-Text PDF (77 KB)
    • CrossRef