Program Book - Keck School of Medicine of USC - University of ...

efore initiation of dialysis. It functions best in patients less than 65 years of age but stillhas significant complications such as hematoma, pseudoaneurysm, and fibrosis. Thebrachial axillary graft functions satisfactorily in the patient who has on- going dialysisand an urgent need for an access. With care, early puncture can usually be made safelyin standard wall thickness PTFE grafts within approximately 48 hours. Brachial artery toaxillary grafts form less venous myointimal hyperplasia in the older patient and canundergo outflow revision usually by short endovascular covered stents or occasionallyopen outflow revision in order to maintain patency. Whether the access is autogenousor a prosthetic construction, it is important to verify axillosubclavian vein patencypreoperatively.Fourth, it is unlikely that preemptive percutaneous transluminal angioplasty of thevenous outflow will prolong patency of the PTFE graft. In five of six randomized trials,the increased rate of PTA intervention did not result in any prolongation of graft survival.On the other hand, the AV fistula that is slow to mature or failing, will respond toaggressive PTA of strictures. PTA with or without a stent should be reserved forphysiological dysfunction in the AV graft specifically an increasing trend in venousreturn pressure, or a flow decrease to less than 600 mls/min in association with agreater than 50 % luminal diameter reduction. Remember, the median duration ofextended patency with PTA is approximately 3 months which is only half the patencythat can be obtained with open patch angioplasty although the former technique issimpler and now holds sway among most access surgeons.Fifth, central venous catheterization with a tunneled, cuffed catheter may be the onlytechnique necessary for the older patient with chronic renal failure requiring64