MO767: Severe Bleeding and Infectious Complications Associated with Dialysis Access—an 11 Year Experience in Treating and Salvaging Problematic Accesses
Authors: Hill Stephen 
Published: May 2022

Abstract

BACKGROUND AND AIMS
Penetrating ulcers and cellulitis of autogenous fistulae have become significant and common complications of haemodialysis access. Their presentation can be associated with exsanguinating haemorrhage or a severe septic picture—both endangering the access and the very life of the patient. Over a 12-year period, we have seen and treated over 70 patients requiring treatment of these types of difficult complications.

METHOD
There were 762 autogenous fistulae and 26 prosthetic grafts performed in the 11-year period for dialysis access. In this collection of patients, there were 76 patients who presented with severe complications of infection, bleeding ulcers, exsanguinating haemorrhage, exposed graft, or massive aneurysms. In order to apply some order to these diverse complications—they were divided into five groups.
There were 12 patients and 16 procedures treated with interventional techniques of covered stent placement. There were 30 patients with 34 procedures who presented with bleeding, massive, or intermittent and were treated operatively urgently or emergently depending on their stability.
A total of 23 patients were presented with ulcers on their autogenous fistula or aneurysmal dilatation of the autogenous fistula.
There were 11 patients who presented with obvious and significant infection in autogenous or prosthetic grafts.
There were 10 patients who presented with a prosthetic graft with persistent bleeding, an ulcer with penetration to the graft, or an exposed graft.

RESULTS
No patient was exsanguinated from these complications at the time of operative intervention. In reviewing the 12 patients treated with stents and interventional radiology, the range of time from the repair until death or occlusion of the graft ranged from 1–89 months and an average of 15 months.
In the 30 patients who presented with bleeding—the individual patients who could be primarily repaired (20) had the best results. This entailed wide excision of the ulcer/bleeding site, repair of the vein, and a two-layer closure over the repaired vein. These patients were able to resume dialysis in 24-h through their repaired fistula.
In reviewing the patients who presented with large ulcers on the fistula or aneurysm with no history of bleeding—these numbered 23 patients requiring 29 procedures. There were 13 patients who had a primary repair and excision of the ulcer and these had the best results. There were two patients with large aneurysmal Cimino fistulae who had a conversion to a mid-forearm fistula, excluding the massive aneurysm.
A total of 11 patients presented with severe infection and cellulitis involving the dialysis access unresponsive to antibiotics. There were 4 patients with postoperative infections from autogenous fistula construction, and these were all treated with debridement and secondary closure.
There were 10 patients with a prosthetic graft who presented with an ulcer, exposed graft, or a severe infection involving the dialysis graft. These were treated with secondary closure and irrigation. As to be expected the majority (60%) were functional for only 1–2 months.

CONCLUSION
The results of our study continue to affirm the use of autogenous fistula in the construction of dialysis access for those patients requiring long-term haemodialysis.
In each of the five groups the best results, unequivocally, were found in those patients with an autogenous fistula repaired with autogenous tissue.
The fact that these autogenous fistulae were in place for several years before requiring repair allowed their walls to become thickened and have a larger diameter. It is these two characteristics, which allowed the excision of the ulcerated/bleeding area to be excised and repaired. The size of the functioning fistula allowed the closure of the defect with no compromise of the lumen and the thickened vein walls allowed a good haemostatic closure.
This study emphasizes the need for autogenous tissue for both construction and repair of haemodialysis access—whether it is for ulcers on the fistula, ulcers actively haemorrhaging, or infected fistula.