SAVE AN ACCESS - REDEEM A LIFELINE

What an impeccable timing for a case this week.

As we celebrate National Vascular Day on August 6th, the chosen theme for this year by our regional body - Vascular Surgeons of Kerala (VASK), is surgical haemodialysis access and care. The emphasis is to highlight both the superiority of this option as well as the importance of preserving one.

When I had a 37 year old, who was a transplant recipient but unfortunately ended up with rejection, and presenting with a grossly aneurysmal AV fistula causing incipient ulceration and ready to rupture, I knew I had a good day’s work ahead.

To add to the task, when I realised that all available veins were exhausted and he had long term dialysis catheters on both sides of the neck with a possible venous hypertension, I questioned whether the work would end up Sisyphean.

This required not just careful planning but also a tailored one.
I chose a hybrid approach, beginning with a fistulogram on the clinical suspicion of a cephalic arch stenosis. Surely as expected, that was the case and a moderate dilatation with a non-compliant balloon was my go-to-strategy.

I proceeded with an open aneurysmorrhaphy with segmental excision of stenotic segments to straighten up the fistula and there you go, Laplace’s fear eliminated and laminar’s love re-established. This was easlier said than done considering the extensive atherosclerotic changes within the intima causing shortage of length to refashion. To make things interesting, incision planning had to be precise, to allow both closure and plan needling.

This was particularly instructive to myself and re-emphasised how to approach such scenarios. The combination of age old principles of surgical technique, an astute tailor’s call for measured judgement and judicious use of the modern endovascular armamentarium can translate to success that you might not have believed possible to begin with.

This patient was initially seen elsewhere and the only option offered was access closure with no other strategy in place. This only strengthens my earlier conviction that education and awareness is key with a strong argument for centralization of care for rare and difficult conditions with ‘no option’.

Happy National Vascular Day to all my colleagues and friends! 💉 🩸 🩻 🕺

#SaveeveryAVfistula #NationalVascularDay #VSI #VASK