Liposuction used to treat deep vascular accesses for hemodialysis

1. Introduction
In the incident ESRD (end stage renal disease) population, the
prevalence of obesity, defined as a BMI (body mass index)
of above 30 kg/m2, is higher than in the general population,
30% in 2002 when last reported.1

2. obese ESRD patients have an increased survival on hemodialysis
compared with non-obese patients and that they receive less renal
transplants due to obesity US have a large population that will need
hemodialysis for an extended period of time.
it is not uncommon for the arteriovenous fistulas to properly mature
after their creation, but to be too deep to be accessed due to a thick layer
of overlying adipose
tissue.
In some cases, the entire fistula cannot be accessed, and the patient
needs a tunneled catheter.
In other cases, only 4–5 cm of the fistula length is superficial enough to
be
accessed, the rest of it being too deep for cannulation.

3. In the case of brachiocephalic and brachiobasilic AVF, the more
superficial parts are located close to the elbow and AVF is deeper in the
upper two-thirds of the arm.
In these cases the repeated needles sticks in a short segment of AVF
will lead to premature deterioration of AVF due to aneurysms formation
and skin thinning.
AVGs, Sometimes they are tunneled too deep in the adipose layer,
sometimes the patient gains weight after AVG placement and the graft
becomes too deep to access or only a short segment can be cannulated
leading to early AVG damage and early loss due to overuse.

4. The usual approach:
• surgical elevation
• transposition of the access
• surgical lipectomy.
!!! large incisions !!!

5. Liposuction
In this article, authors present their experience with using liposuction to
superficialize deep AVF and AVG in 14 patients.

6. METHOD
prospective, observational, nonrandomized, single
center study conducted between December 2015 and
February 2019 at the University of Nebraska Medical
Center (UNMC).

7. Inclusion Criteria
1. AVF or AVG that is deeper than 6 mm in the
cannulation zone. Included accesses that could not be
cannulated at all and accesses in which only a short
segment was superficial enough for cannulation.
2. AVF diameter of at least 6 mm.
3. Mature access: surgical creation more than 6
weeks
prior to liposuction procedure.

8. Inclusion Criteria
4. All accesses had angiogram prior to liposuction to ensure a
viable access that will work for a reasonably long time after
superficialization, no significant collaterals, central vein stenosis,
or venous hypertension.
5. Patient age above 18 years old.
6. Life expectancy of more than 1 year.
7. Ability to provide informed consent for the surgery

9. Exclusion Criteria
1. Lack of access maturation.
2. Uncorrected central vein stenosis.
3. Access limb swelling.
4. Presence of distal hypo perfusion syndrome.
5. Life expectancy less than 1 year.

10. The primary outcome was successful
superficialization defined as:
1. For patients- could not use the deep
access at all: removal of the tunneled hemodialysis
catheter.
2. For patients- only short segments of their
access was used: the ability to continue to use the
access after surgery and the total length of the
access that could be cannulated after healing.

11. Secondary outcomes included
• access depth at the end of surgery
• access depth after complete healing (4 weeks)
• early and late postoperative complications,
• access primary and secondary patency,
• time from surgery started using parts of the
access.

12. Ultrasound
• duplex ultrasound B mode to measure the
access depth prior, during and after surgeries and
after healing.
• Measured depth in five places located at
equal distances along the access length

13. Anesthesia
● general intravenous anesthesia with
monitored anesthesia care but no intubation in
most of the patients
● general endotracheal anesthesia
● axillary block

14. Surgical procedure
There is no need to superficialize a marginal access.
The angiogram would also map the access and possible
collaterals that
could be treated and their location accurately mapped in
order to avoid them during the surgery.
Immediately prior to surgery-2d ultrasound probe

16. Marking on the skin the access location and dividing the
length of the access to be liposuctioned in 5 segments.

17. Preparation
chlorhexidine and draped with sterile towels
liposuction solution (composition: 1 liter
normal saline with 1 mg of epinephrine and 50
cc of 1% lidocaine)
15 cm long, 18G needle

18. (c) Injection of the liposuction solution.
(d) Liposuction cannula is inserted and liposuction begins.

19. Preparation
● Two 5 mm long incisions - on each side of the access
● The fat overlying the access but also the fat located lateral and
medial to the access was liposuctioned using 3 and 3.5 mm
diameter cannulas

20. (e and f) Different types of cannulas used for
liposuction.

21. The surgery was completed when the fat layer over the access
disappeared.
The stab incisions were sutured.
The area liposuctioned was dressed in multiple layers of fluff gauze and
surgical netting or coban.
in hospital operation rooms and the primary operator
was a professor of plastic surgery.

22. ● Patients were followed at their hemodialysis units and
by the plastic surgeon to ensure proper healing.
● The operated-on parts of the access were cannulated 4 weeks after
surgery.
● The decision to cannulate was made after consulting
the interventional nephrologist

23. Result

24. Result

25. Result
● The mean access depth at the end of surgery was 7 mm.
● The mean access depth 4 weeks post-surgery was 5.3 mm
(range 4–8 mm).
● Two out of three patients to remove the catheters.
● The usable access length increased from a mean of 5–12.7 cm
(range 10–15 cm).

26. Result

27. Complication
only one surgical complication: excessive bleeding requiring
stopping the liposuction sooner than planned.
manual pressure and the patient was discharged to home the same
day.
In this patient, despite having to stop prematurely, still gained access to
extra 6 cm of AVF making a total of 12 cm accessible for cannulation.

28. DISCUSSION
- The challenge of this technique is that the liposuction is performed in
close proximity of a large vessel with very high blood flow and
perforating the vessel can cause severe consequences.
- In this cohort, the liposuction was very safe and well tolerated.
- There were no infections, skin necrosis, or late hematomas. All the
patients were discharged to home the same day.
- Only one patient had intraoperative bleeding that was easily controlled
with digital pressure.
- Postoperative pain was mild.

29. DISCUSSION
- Future studies are needed to evaluate if avoiding access manipulation
leads to improved access patency.
- selection bias
- given the low number of cases, the outcomes should be regarded with
caution
- liposuction seems to work well on accesses up to 12–13 mm deep

30. CONCLUSION
- Liposuction seems to be an effective, minimally invasive, well-tolerated
surgical procedure to superficialize deep hemodialysis vascular access.
- Compared studies necessary
- IN ACH:

31. 1. How do we manage
2. Possibility to do liposuction
3. How often do lipoectomy
4. Cost of the procedure