|Year : 2018 | Volume
| Issue : 2 | Page : 132-133
Targeted tumescent liposuction for fistula superficialization
Nitin Abrol1, Santosh A Olakkengil2, Shantanu Bhattacharjya2
1 William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
2 Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
|Date of Web Publication||3-May-2018|
Dr. Shantanu Bhattacharjya
Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide
Source of Support: None, Conflict of Interest: None
Obesity poses problem with the cannulation of arteriovenous fistula and difficulty in establishing functional autogenous access for hemodialysis. We describe a case where we used targeted tumescent liposuction to remove subcutaneous fat over the fistula.
Keywords: Arteriovenous fistula, liposuction, obesity
|How to cite this article:|
Abrol N, Olakkengil SA, Bhattacharjya S. Targeted tumescent liposuction for fistula superficialization. Indian J Vasc Endovasc Surg 2018;5:132-3
| Introduction|| |
Obesity is a major challenge for health-care system. Nearly 63% adults in Australia are overweight or obese, and this prevalence has increased steadily from 56.3% since 1995. Likewise, approximately 27% Australian children in 5–17 years of age group are overweight or obese. The same trend is seen in end-stage renal disease (ESRD) population.
Arteriovenous fistula (AVF) is the preferred mode of providing renal replacement therapy as per the recommendations of The National Kidney Foundation-Kidney Disease Outcome Quality Initiative Clinical Practice Guidelines and Fistula First., AVF is associated with fewer complications, longer patency, and longer patient survival compared to AV grafts and central venous dialysis catheters., This makes AVF a cost-effective option for dialysis.
Although obesity does not contraindicate fistula formation there are often problems associated with successful cannulation of the fistula due to the thickness of subcutaneous tissue between skin and the fistula vein. We describe a case where we used minimally invasive targeted liposuction without any external energy source for superficialization of AVF.
| Case Report|| |
A 52-year-old female was referred to transplant surgery outpatient clinic for preemptive AVF formation. She developed ESRD due to hypertensive nephrosclerosis. She did not have diabetes mellitus, and her body mass index (BMI) was 40 kg/m 2. She was planned for left upper arm brachiocephalic fistula (BCF). Four months later, her renal disease progressed and she required dialysis. She was followed at the country dialysis unit after BCF formation. There were persistent issues with cannulating the fistula because of poorly palpable vein. Therefore, she was started on hemodialysis through central venous dialysis catheter and was referred to transplant clinic for review. On repeat ultrasound scanning, size and flow in the vein were adequate; however, vein was more than 6 mm deep from the skin. After discussing various options for superficialization, she was consented for liposuction.
Procedure was performed under general anesthesia. Vein was marked in the upper arm with the help of ultrasound [Figure 1]a. Subcutaneous tissue over the vein was infiltrated with 60 ml saline + adrenaline (500 ml saline + 1 ml of 0.001% adrenaline) to create tumescence in a radial fashion [Figure 1]b. Small stab incisions were made for introduction of Lipivage ® (Genesis biosynthesis, Inc. USA) disposable suction cannula attached to 50 ml luer lock syringe [Figure 1]c. A volume of 80 ml of subcutaneous fat was removed [Figure 1]d. Depth of vein at the end of the procedure was 4 mm at elbow, 5 mm at mid-arm, and 6 mm at proximal arm. She was discharged after 4 h of observation in the daycare surgery suite with scheduled follow-up after 2 weeks. The fistula vein in the proximal arm was 6mm deep on the follow up ultrasound [Figure 2]a. There was no bruising, hematoma, and skin necrosis; fistula could be easily seen and palpable at 2 weeks [Figure 2]b.
|Figure 1: Technical details of the targeted tumescent liposuction for fistula superficialization. (a) Preoperative marking of fistula vein with ultrasound. (b) Injection of saline-adrenaline solution to create tumescence in subcutaneous tissue. (c) Liposuction with LipiVage® cannula connected to 50 ml luer lock syringe. (d) Fat removed by liposuction|
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|Figure 2: Outcome 2 weeks after the procedure. (a) Six mm deep fistula vein at proximal arm. (b) Vein can be easily seen at distal arm (black arrow)|
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She was successfully established on hemodialysis through the BCF, and her central venous dialysis catheter was removed 3 weeks after the procedure.
| Discussion|| |
AVF is preferred access for dialysis due to its cost-effectiveness in comparison to grafts., In Australia, 80% of ESRD patients requiring dialysis are on hemodialysis (70% facility HD and 10% home HD). Due to increasing prevalence of obesity in general population, proportion of obese ESRD patient is also increasing. Recommended maximum depth of fistula for reliable and successful cannulation is 6 mm., While obese patients may have suitable vein for AVF formation, thickness of subcutaneous fat over the vein is often a major deterrent to the establishment of functional autogenous access for hemodialysis.
Options available for deep AVF in obese are elevation, cephalic transposition, lipectomy, and liposuction. Elevation and Cephalic transposition are invasive procedures that divide the side branches of fistula for mobilization that may lead to angulation or vessel trauma. Longer incisions, wound complications, and longer healing time also delay cannulation of the fistula. Lipectomy and liposuction leave all tributaries undisturbed. Krochmal et al. and Rebecca et al. described three cases of suction-assisted lipectomy in obese individuals (BMI >40 kg/m 2). Only one patient developed minor hematoma and arm swelling that did not affect timing of access. Subsequently, Ochoa et al. used protective shield over the vein during liposuction. Ladenheim et al. presented their series of 13 patients who underwent liposuction for brachiocephalic and radiocephalic fi stula superficialization. Eleven underwent successful cannulation; however, one died of endocarditis and other developed hematoma and wound necrosis.
Our case is first report from Australia. Infiltration of saline-adrenaline solution creates tumescence and helps in hemostasis from capillary oozing. Injury to transverse tributary is a potential risk, but we did not encounter any bruising or hematoma after the procedure. Use of intraoperative ultrasound identifies targeted areas for liposuction, extent of liposuction, and also helps to avoid trauma to fistula. We did not use any protective shield over the vein.
| Conclusion|| |
Targeted tumescent liposuction is technically feasible, minimally invasive, safe alternative for fistula superficialization in obese individuals. A well-designed study in larger number of patients is required to establish its safety and efficacy.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]