Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 107-110

Management of infected brachial-axillary prosthesis for hemodialysis: Report of three cases


Department of Vascular Surgery, Faculty of Medicine and Pharmacy of Fes; Department of Vascular Surgery, Chu Hassan II, Fes, Morocco

Date of Web Publication3-May-2018

Correspondence Address:
Prof. Hamid Jiber
Department of Vascular Surgery, Faculty of Medicine and Pharmacy of Fes; Department of Vascular Surgery, Chu Hassan II, Fes
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_3_18

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  Abstract 


Brachial-axillary bridge graft is an alternative to native fistula in the absence of vein access or defect of maturation. Infection of the prosthetic graft is a serious complication. It is a relatively common complication and is the second leading cause of graft loss. It should be prevented by the adoption of extreme rigor concerning monitoring of access, their care and punctures. We report three cases with different aspect clinic and therapeutic of infected brachial-axillary prosthesis for hemodialysis.

Keywords: Arteriovenous graft, excision, femoral vein, infection, prosthesis


How to cite this article:
Jiber H, Bouarhroum A. Management of infected brachial-axillary prosthesis for hemodialysis: Report of three cases. Indian J Vasc Endovasc Surg 2018;5:107-10

How to cite this URL:
Jiber H, Bouarhroum A. Management of infected brachial-axillary prosthesis for hemodialysis: Report of three cases. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2021 Oct 15];5:107-10. Available from: https://www.indjvascsurg.org/text.asp?2018/5/2/107/231846




  Introduction Top


Infection of the prosthetic graft is a serious complication. It is the second leading cause of graft loss.[1] It should be prevented by the adoption of extreme rigor concerning monitoring of access, their care and punctures. We report three different cases of infected brachial-axillary prosthesis for hemodialysis with different management.


  Cases Reports Top


Case N1

A 45-year-old woman was maintained on chronic hemodialysis through left brachial-axillary prosthesis using expanded polytetrafluoroethylene graft. During the last dialysis session, the patient was febrile with chills, erythema, and warmth were observed over the prosthetic graft. The patient was transferred to our hospital, and she was admitted to the surgical emergency to prevent sepsis and to save the access. The patient was operated under general anesthesia. After achieving proximal control, total resection of the infected prosthesis [Figure 1], which we send to laboratory for bacteriology examination. The access was precious because it was a final access after three native arteriovenous fistulas (AVF) nonfunctional. To avoid ligation and loss of the AVF, we opted for interposing a femoral vein segment, which was harvested from ipsilateral lower limb, for the reconstruction of the access [Figure 2]. A thrill was palpable immediately after allowing flow in the fistula. We put the patient under amoxicillin-clavulanate, which was changed by imipenem after isolation of Staphylococcus aureus METI-resistant in microbiology result. The patient was maintained on dialysis by temporally femoral vein catheter. After 15 days, a thrill was palpable, and examination of a left lower limb was normal. We stopped antibiotic after 20 days, and we authorized a punction of the fistula. The fistula was used reliably for hemodialysis with a follow-up of 10 months.
Figure 1: Peroperative view of infected brachial-axillary prosthesis

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Figure 2: Reconstruction of the fistula with femoral vein autograft

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Case N2

A 38-year-old man was maintained on chronic hemodialysis through right brachial-axillary prosthesis constructed 1 year before. The patient was addressed by his nephrologist because he was febrile and purulence observed over the prosthesis [Figure 3]. Immediately, he was admitted to the surgical emergency. The patient was operated under general anesthesia. In peroperative exploration, we found a proximal segment of the prosthesis infected from proximal anastomosis [Figure 4]. The distal segment was not infected. After achieving brachial artery control, we resected the infected part of the prosthesis, and we interposed a new prosthesis (because of limited infection and for more rapidity of the act) to preserve the vascular access which was a last permanent dialysis access after use of all other sites [Figure 5]. We put the patient under amoxicillin-clavulanate, microbiology of infected prosthesis was sterile; hence, we continued the same antibiotic for 10 days. A thrill was palpable immediately after allowing flow in the fistula. The patient was maintained on dialysis by temporally femoral vein catheter. The fistula was used reliably for hemodialysis with a follow-up of 5 months.
Figure 3: Photography of clinical aspect of infected brachial-axillary prosthesis

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Figure 4: Peroperative view showing infected segment of the prosthesis

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Figure 5: Peroperative view after resection of the infected part and replacement by prosthesis graft

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Case N3

A 42-year-old man was maintained on chronic hemodialysis through right brachial-axillary prosthesis constructed 8 months before. During the last dialysis session, the patient was febrile with chills, erythema, and warmth were observed along the arm. The patient was transferred to our department and he was admitted to the surgical emergency. The patient was operated under general anesthesia. In peroperative exploration, we found a totally infected prosthesis from proximal anastomosis with fragile wall of brachial artery to distal anastomosis in axillary vein. After achieving brachial artery control and section of the fragile parts of the wall and control of the axillary vein, we removed the prosthesis [Figure 6]. The vein breach was sutured directly, and we were obliged to interpose a segment of vein, taken from the great saphenous vein, to repair the brachial artery [Figure 7]. Microbiology result was sterile; hence, we put the patient under amoxicillin-clavulanate for 10 days. Ten days later, surgical site was healed, and the patient doing well. We created a permacath for dialysis because we used, before brachial-axillary prosthesis, all veins of the upper limbs.
Figure 6: Photography of the removed infected prosthesis

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Figure 7: Peroperative view showing repaired brachial artery with segment of the saphenous vein

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  Discussion Top


Brachial-axillary bypass is an alternative to native fistula in the absence of vein access or defect of maturation. Infection of vascular access for hemodialysis complicates 2%–3% of native AVF and up to 11%–35% of prosthetic grafts during their period of use.[2] Presence of cutaneous inflammation in front of the site of the graft doesn't mean it's infected. Occasionally, immediately following graft placement, a cutaneous inflammatory reaction occurs. This is characterized by a bright-red flare that is restricted to the skin immediately overlying the graft. Typically, it is generalized to the entire course of the graft. With a loop graft, this erythematous flare does not spread to the skin lying within the loop only the immediate course of the graft itself. There is generally little to no swelling, it is not fluctuant, and there is frequently no pain. This is probably a dermal reaction related to the graft being placed more superficially than usual.[3]

These infections are recognized on physical examination by the classic combination of erythema, frequently localized, but not just to the skin overlying the graft and swelling which on occasion is also fluctuant. Pain may be present but is variable. The area generally feels warm, but this is not a very reliable sign because the skin overlying a flowing graft is always warmer than normal.[3]

Septic shock may occur as a result of a systemic infection. In addition to the above, these patients may exhibit signs or symptoms of mental confusion, malaise, and/or hypotension.

Deep infections involve the graft and are serious problems. Surgical treatment is always required.[3]

Usually, an angioaccess is infected with common skin microorganisms represented by Gram-positive bacteria. In most cases, the causative organism of the angioaccess infection is S. aureus or other Gram-positive pathogens such as coagulase-negative staphylococci. S. aureus is demonstrated in almost 68% cases. Less commonly, Gram-negative bacteria are the cause of infection with the demonstration in 28% of cases.[4] We must make microbiology study of the infection prosthesis, start probabilistic antibiotic (generally for Gram-positive microorganism), and adjust it with results of microbiology.[4]

In literature, we do not have consensus for the type of excision in arteriovenous prosthesis infection.[5] Graft preservation techniques, first introduced by Bhat et al.[6] at Montefiore Medical Center, remain controversial but may be ideally suited in the hemodialysis population, in which localized infection often occurs. A strategy of partial graft excision relies on the presence of localized infection and a good portion of the remaining incorporated graft for bypass.[5] In case of severe infection of the graft with systemic complications, we must remove the entire prosthesis.[5] The type of graft for replacing the infected prosthesis is habitually a segment of vein because it is resistant to infection. In general, we use a great saphenous vein.[5] The use of the superficial femoral vein graft was as already experienced by our service in the treatment of a pseudoaneurysm of AVF for hemodialysis [7] and Huber et al.[8]

We can also use cryopreserved arterial allografts as a vascular substitute in the setting of prosthetic material infection.[9] Unfortunately, we do not have this option in our department.

Unfortunately, sometimes, we opted for brachial artery ligation, in some cases, to reduce the operative time significantly and to avoid complex revascularization and anastomotic dehiscence.[10]

In our cases, we chose three ways to treat the infection of arteriovenous prosthesis for hemodialysis. They depend on importance of local and general signs of the infection.


  Conclusion Top


Infection of arteriovenous prosthesis for hemodialysis is a serious complication. Management of this complication depends especially to local or general signs of the infection. We prefer, if possible, to preserve the access because it is very precious for the patient, but it is not always possible. Prevention passes by the adoption of extreme rigor concerning monitoring of access, their care and punctures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Padberg FT Jr., Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg 2008;48:55S-80S.  Back to cited text no. 1
    
2.
Ready AR, Buckels JA, Wilson SE. Infection in vascular access procedures. In: Wilson SE, editor. Vascular Access: Principles and Practice. St Louis: CV Mosby; 2002. p. 189-203.  Back to cited text no. 2
    
3.
Engemann JJ, Friedman JY, Reed SD, Griffiths RI, Szczech LA, Kaye KS, et al. Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis. Infect Control Hosp Epidemiol 2005;26:534-9.  Back to cited text no. 3
[PUBMED]    
4.
Beathard GA. Physical examination of the dialysis vascular access. Seminars in dialysis 1998;11:231-6.  Back to cited text no. 4
    
5.
Ryan SV, Calligaro KD, Scharff J, Dougherty MJ. Management of infected prosthetic dialysis arteriovenous grafts. J Vasc Surg 2004;39:73-8.  Back to cited text no. 5
[PUBMED]    
6.
Bhat DJ, Tellis VA, Kohlberg WI, Driscoll B, Veith FJ. Management of sepsis involving expanded polytetrafluoroethylene grafts for hemodialysis access. Surgery 1980;87:445-50.  Back to cited text no. 6
[PUBMED]    
7.
Sedki N, Jiber H, Zrihni Y, Zaghloul R, Bouarhroum A. Successful repair of a ruptured arterio-venous fistula aneurysm with femoral vein autograft. J Vasc asc Access 2012;13:267.  Back to cited text no. 7
    
8.
Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: A systematic review. J Vasc Surg 2003;38:1005-11.  Back to cited text no. 8
[PUBMED]    
9.
Lejay A, Delay C, Girsowicz E, Chenesseau B, Bonnin E, Ghariani MZ, et al. Cryopreserved cadaveric arterial allograft for arterial reconstruction in patients with prosthetic infection. Eur J Vasc Endovasc Surg 2017;54:636-44.  Back to cited text no. 9
[PUBMED]    
10.
Chandrashekar CA, Hoskatti CR, Desai SC, Prasad RB. Role of brachial artery ligation in management of prosthetic arteriovenous graft infections. Ann Vasc Surg 2017;48:75-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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