Salvage of Mega-fistula with Nezakatgoo Technique

Abstract

Introduction: Mega-fistula is understood as an arteriovenous fistula that is very dilated throughout its course, tortuous, sometimes aneurysmal, and that presents flows above 2L/min; this carries the risk of generating multiple complications (from aneurysmal rupture, recirculation, and heart failure due to overload, among others). Its usual treatment is ligation or prosthetic replacement. Material and methods: The technique described by Nezakatgoo et al. was performed on three patients with mega fistulas (operated between 2020 and 2023) in whom salvage surgery and recovery of the entire fistula was performed. Complete dissection of the fistula from its anastomosis to the arch of the cephalic vein is performed, the vein is calibrated with a 24-34 Fr chest tube, and the excess of the mega-fistula and aneurysms are resected. In the case of stenotic areas, these are enlarged, or new anastomoses are made, and in the case of stenosis of the arch, a new anastomosis is made in the axillary vein. Results: The first case describes a left humerocephalic fistula made in 2011, which, after the plastic surgery, required two angioplasties due to stenosis in the middle third (at 125 and 236 days after the plastic surgery). It remains patent, with a total patency of 156 months since its initial confection and 36 months since the plastic. The second patient presents a mega-fistula performed in April 2019, which, after plastic surgery, required angioplasty for stenosis at one time at 509 days and continues to be permeable to date, with a total patency of 56 months and 30 months since plastic. The third fistula was operated in the context of total fistula thrombosis and required, in the first instance, a thrombectomy prior to reconstruction. It evolved in two episodes (at months 2 and 5), with stage IIb steal treated by banding (Miller technique) on both occasions. It presents a total patency of 57 m and 18 m from the plastic. All patients remain on dialysis to date due to the reconstructed fistula. Conclusions: Salvage of mega-fistula is a valid procedure to continue the useful life of native fistulas in the short and medium term; if necessary, complementary procedures are required to solve problems similar to those of other fistulas.