Puncture Site Necrosis Over Hemodialysis Native and Prosthetic Vascular Accesses

Background: The aim of this study was to detail our experience in the management of skin necrosis/ulceration over hemodialysis vascular accesses. Methods: We collected demographics and operative data about patients undergoing surgery for skin necrosis over native or prosthetic vascular accesses. The different procedural techniques used and outcomes achieved were analyzed. Results: Over a six-year period (2013-2019), 593 hemodialysis accesses were created and 16 patients (50%, 8 male; median age 63.6 years, range 42-87; 12 native and 4 prosthetic accesses) were emergently/urgently treated for skin necrosis with danger of rupture (n 9), minor active bleeding (n 4) or life-threatening hemorrhage (n 3). Underlying causes were local infection, aneurysm/pseudo-aneurysm formation and venous stenosis. Most accesses were preserved. Rescue procedures consisted in excision of skin necrosis in association with aneurysmorrhaphy (n 1, 6.3%), simple closure of the venous breach (n 2, 12.5%) or resection and direct re-anastomosis (n 7, 43.8%). Concomitant endoluminal dilatation of venous outflow was needed in 7 (43.8%) cases. No intraoperative complications were observed. At a median of 13 months (range 1-39), 90% of rescued accesses were still functional. Conclusions: Skin necrosis/ulceration over vascular access requires prompt surgical intervention ahead the risk of life-threatening hemorrhage. The rescue of a functional access is possible in most patients and provides an efficient dialysis in postoperative period.