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The European Renal Best Practice Guidelines and National Kidney Foundation recommend using a graft to create a dialysis vascular access if an autogenous (native) arteriovenous fistula (AVF) cannot be created. Besides prosthetic graft, the greater saphenous vein translocation or cadaver/non-cadaver homologous saphenous vein graft are other possible options. In 2018, the European Society for Vascular Surgery suggested using a biological graft over a prosthetic graft, especially in case of infection. However, the guidelines did not make any specific reference to using a homologous vein graft.
The limited evidence on using saphenous vein graft is conflicting with early failures in few reports and reasonable primary patency in others. A major concern with biological vein graft is the occurrence of chronic rejection and sensitization for future kidney allograft surgery. Consequently, there are methods to reduce antigenicity by decellularization vein graft using cryopreservation solution. Heintjes reports a method to reduce antigenicity using chlorohexidine solution and storing the vessel at 4ºC, and at 1 year, a primary patency of 57%. The Berardinelli did not observe a single incidence of rejection in over 1100 homologous saphenous vein graft surgeries, including across the ABO blood group.
Case report
A 23-year-old female patient with CKD secondary to obstructive uropathy from neurogenic bladder due to myelomeningocele, hypertension, and hepatitis C is admitted to the hospital presenting a history of dysfunctional left internal jugular CVC with inadequate blood flow, which had not been exchanged as an outpatient procedure due to lidocaine allergy and anesthesiology assistance was unavailable. The renal replacement therapy was peritoneal dialysis 10 years ago for 6 months but switched over to hemodialysis due to severe peritonitis. Then, a kidney transplant was performed and lasted for 8 years. Currently, during maintenance hemodialysis have had multiple episodes of catheter-related bloodstream infection. Her vascular access history included multiple failed native arteriovenous accesses including two autogenous saphenous vein grafts. The venography revealed severe bilateral subclavian vein stenosis with multiple collateral veins. The innominate veins and superior vena cava were patent (Fig. 1).
Although the autogenous arteriovenous fistula is the preferred dialysis vascular access, innovative approaches should be considered in patients with exhausted vasculature or with central venous stenosis. A homologous saphenous vein graft is a reasonable alternative that needs to be evaluated before considering a prosthetic graft.