Arterio-arterial synthetic loop graft as a reliable alternative for type 3 end-stage vascular access

Objective Arterio-arterial synthetic loop graft (AASLG), also known as arterio-arterial prosthetic loop, is an alternative hemodialysis (HD) option in a specific group of patients where other HD conventional arteriovenous (AV) access and tunneled central venous catheters are not technically feasible (type 3 end-stage vascular access). The aim of this study is to report our experience with AASLG in this cohort of fragile patients and contrast the outcomes and risks with other artificial dialysis access solutions. Patients and methods A prospective study was conducted on patients who underwent axillary or femoral AASLG using polytetrafluoroethylene graft after exhaustion of all conventional AV access options in these patients with end-stage renal disease undergoing HD. The patients were prospectively observed for graft primary and secondary patency and graft-related complications. Outcomes were reported according to the recommended standards for reporting AV HD accesses. Results Between January 2018 and July 2020, 16 patients (median age, 58.76 years; range, 52-68 years) underwent 19 AASLG access placements. Procedures were done under general anesthesia in 18 occasions, whereas one was done under local anesthesia. A total of 15 patients had 18 axillary AASLG, whereas one had femoral AASLG. Central vein occlusion was present in all patients. Patients were followed up for 3-24 months (mean, 16 months). The technical success of the procedure was 100% despite two cases of postoperative hematoma development, and there were no 30-day perioperative mortalities. Primary patency at 6 months was 78.9%, and the achieved secondary patency rate was 89.5%. At 12 months, the primary and secondary patency rates were 42.2 and 68.4%, respectively. Two procedures were complicated with early postoperative bleeding that required surgical intervention, but no blood transfusion was required. Three procedures were complicated with pseudoaneurysm formation at puncture sites that were repaired surgically by interposition grafts. During follow-up, five AASLGs were thrombosed, three of which had a successful graft thrombectomy and one had a contralateral axillary AASLG done. Two patients developed graft infection, and the graft was excised and replaced by a contralateral axillary AASLG. Conclusion Our early experience with AASLG showed that this procedure has a high early success rate with a considerable risk of complications. This procedure could be offered to patients with end-stage renal disease when other AV access options are not feasible. For long-term outcome assessment, further follow-up is needed.