Iatrogenic Graft to Vein Fistula (GVF) Formation Associated with Synthetic Arteriovenous Grafts Nabil J. Haddad,* Tushar J. Vachharajani,† Sheri Van Cleef,* and Anil K. Agarwal* *The Ohio State University, Columbus, Ohio, and †Dialysis Access Group of Wake Forest University, Winston-Salem, North Carolina ABSTRACT The prevalence of fistulous connection between arteriovenous graft (AVG) and an adjacent vein resulting in graft-vein fistula (GVF) formation is not established. AVG venous outflow ste- nosis along with repeated and traumatic cannulation is likely major contributing factor of this complication. Detection and resolution of venous outflow stenosis may be the only needed intervention. We report a series of eight cases with GVF forma- tion between AVG and adjacent veins. Awareness of this com- plication and intervention to relieve stenotic lesions may result in improved AVG survival. Vascular access dysfunction is the leading cause of hospitalization in chronic hemodialysis patients. Arte- riovenous grafts (AVG) remain a prevalent and impor- tant modality of vascular access in patients maintained on hemodialysis despite the increasing incidence of arteriovenous fistula placements in the US dialysis population (1). AVGs are associated with a variety of complications that include stenosis, thrombosis, pseud- oaneurysms with risk of rupture (2), steal syndrome, and infection (3). Fistula formation between AVG and adja- cent vein is an infrequent but significant complication. We report a series of eight cases of graft to vein fistula (GVF) formation between AVG and adjacent veins. Also, we will use the terminology ‘‘GVF’’ to describe this condition and to promote the awareness and discussion of this relatively uncommon but not a rare condition. Case 1 A 73-year-old woman with end-stage renal disease (ESRD) from hypertensive nephrosclerosis had been on hemodialysis for 1½ years. She had a functioning upper arm loop polytetrafluoroethylene (PTFE) AVG for 379 days. Her previous dialysis access was an ipsilateral forearm loop PTFE AVG. The surveillance access flow monitoring using ultrasound dilution technique failed to record any blood flows despite her renal chemistry on monthly laboratory work suggesting adequate dialysis therapy with urea removal rate of 73–77%. Technical errors were ruled out by repeated testing. Doppler study of her PTFE graft revealed a large outflow venous chan- nel in the mid-portion of her AVG, distal to the venous return needle stick (Fig. 1) The anomalous venous chan- nel forming the GVF was surgically ligated, and normal flow pattern was reestablished. The access blood flow after surgery was recorded between 960 and 1100 ml / min. The graft remained patent subsequently for 3 years and was eventually lost to infection. Case 2 A 75-year-old woman with a history of hypertension and ESRD was receiving hemodialysis via a right fore- arm AVG. The patient had two open thrombectomies in the first 2 years following her AVG placement. She was referred because of decreased access flow of her AVG. A shuntogram was performed and showed a 60% intra- graft stenotic lesion, which was angioplasted. A fistulous connection between the lower part of the venous limb and an adjacent vein was detected (Fig. 2). The site of GVF formation corresponded to the site of graft cannu- lation. The access flow increased from 521 to 694 ml / min postoperatively and resulted in improved hemodialysis adequacy. The patient had no surgical intervention following her procedure. Eight months later, the patient underwent a shuntogram and percuta- neous angioplasty of two intragraft stenotic lesions, at which time there was no evidence of GVF (Fig. 3). Case 3 A 69-year-old man with ESRD from hypertensive nephrosclerosis had been on hemodialysis for 3 years. Address correspondence to: Anil K. Agarwal, Professor of Medicine, Director of Interventional Nephrology, The Ohio State University, Division of Nephrology, 395 West 12th Ave- nue, Ground Floor, Columbus, OH 43210, Tel.: 614-293-4997, Fax: 614-293-3073, or e-mail: anil.agarwal@osumc.edu. Seminars in Dialysis—Vol 23, No 6 (November–December) 2010 pp. 643–647 DOI: 10.1111/j.1525-139X.2010.00801.x ª 2010 Wiley Periodicals, Inc. 643