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Tertiary Vascular Access Surgery for Chronic Hemodialysis

Most chronic hemodialysis patients eventually require revision of their angioaccess grafts or fistulae. When an adequate superficial vein is not available for a primary arteriovenous (AV) fistula, a bridged arteriovenous fistula must be constructed usually of expanded polytetrafluoroethylene (ePTFE). The placement of these conduits is conventionally in the upper extremities, preferably in the forearm and secondarily in the upper arm. When venous outflow obstruction andlor graft infection preclude the use of the upper extremities, even for revisions, vascular surgeons are forced to turn to tertiary (exotic) vascular access surgery. The exotic vascular access procedures are limited only by the imagination of the vascular surgeon and the availability of adequate arterial inflow and venous outflow. The purpose of this paper is to review the surgical literature on creative and unusual (exotic) vascular access techniques that may be used to continue hemodialysis in patients with chronic renal failure and failed upper-extremity dialysis grafts or fistulae .