1. Faisal Alam Consultant Vascular & General Surgeon Royal Hospital

2. Introduction: Number of patients with end-stage renal disease (ESRD) requiring hemodialysis is constantly rising worldwide Consequently number of ESRD patients with difficult access and comorbidities also increasing.

3. Introduction cont.. Patients are living longer and good number of them undergo many procedures for dialysis access. Increase in the number of patients whose vascular access options are exhausted keeps us vascular surgeons in dilemma regarding the next step.

4. Introduction cont.. Similarly high incidence of diabetic population in Oman ( about 11-12 %) has led to an increase in ESRD patients. In 2012, 65% of the vascular surgical load at the Royal Hospital was related to vascular access.

5. Introduction cont.. Majority of our patients refuse pre-emptive AVF creation. Pre-emptive procedures hardly reaches 5-10% of the actual load. As a consequence, we have high number of patients on central venous lines for dialysis

7. What are the options?! 1. All central accesses are occluded 2. All peripheral venous and PD options have been exhausted. 3. Heart Failure with very low ejection fraction

9. Is Arterio-Arterial Prosthetic Loop an option?

10. First proposed by Butt and Kountz in 1976 Janow et al. J Vasc Surg. 2005 June 34 patients with 36 AAPL (31 axillary / 5femoral) (Apr 1996 - Sept 2004) central vein occlusion 64%, steal sy 11%, severe peripheral arterial disease in 22%, and congestive heart failure in 3% Primary /secondary patency 73%/96% at 1yr and 54% and 87% at 3 years,

11. Bunger et al. J Vasc Surg. 2005 Aug 20 patients (May 2001 - Dec 2004). Exhausted AV access options in 14 patients (70%), central vein occlusion in 5 patients (25%), ischemia from steal sy in 12 patients (60%) High-output cardiac failure in one patient. Median f/u was 7.4 months. The 30-day peri-operative mortality rate was 5%. Access thrombosis in four patients (asymptomatic). Early post-op bleeding in four patients. Late graft infection in one after repeated thrombectomy. The primary and secondary patency rate was 90% and 93%, respectively, at 6 months.

12. Gdoura Moncef et al. Saudi Journal ofKidney diseases and transplant. 2005 Arterio-Arterial Interposition Graft in 9 patients Median period of use was 18 months No limb loss Stephenson et al. J Vasc Access. 2012 Nov Axillary-axillary inter-arterial chest loop graft Early dialysis within one day

13. Our Own experience 60 years old with severe heart failure (EF 15%) Exhausted peripheral access options and failed PD catheter. Had trans-lumbar Perm cath insertion (both iliacs and subclavian veins were occluded. Had left axillary inter-arterial PTFE loop graft under LA. Used for 14 months without any problems. Patient died from cardiac causes.

16. The basics of the AAPL compared with an AV graft: 1. A vein is not essential. 2. The distal perfusion is not decreased. 3. The cardiac load is not increased.

17. Instructions for the dialysis unit Nephrologists should be informed about the specifics of this access and position of needles. Advise to compress puncture site for 20 minutes after the removal of the needles. Refrain from infusion of medications through the AAPL

18. In conclusion AAPL is a viable option which seems to be under- utilized It should be considered more frequently, specially in cases of venous hypertension, steal phenomenon and congestive heart failure can be done under LA and has good medium term patency rate Complication rates are comparable with AVG and no reports of limb loss