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Staged ultrasound-guided liposuction for hidden arteriovenous fistulas in
obese patients
Article  in  VASA · July 2018
DOI: 10.1024/0301-1526/a000719
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Gabor Cs.Nagy
St. Bernward Krankenhaus in Hildesheim
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© 2018 Hogrefe Vasa (2018), 47 (5), 403–407
 https://doi.org/10.1024/0301-1526/a000719
 403
Original communication
Staged ultrasound-guided 
liposuction for hidden arteriovenous 
fi stulas in obese patients
Gabor Cs.Nagy1, Reiner Verwiebe2, and Matthias Wunsch3
1 Department of Vascular Surgery, St. Bernward Hospital, Hildesheim, Germany
2 Department of Nephrology and Dialysis, St. Bernward Hospital, Hildesheim, Germany
3 Department of Vascular Surgery, Königin Elisabeth Herzberge Hospital, Berlin, Germany
Summary: Background: In obese patients with end stage renal disease, puncturing matured arteriovenous fi stulas (AVF) that 
run deep under the skin surface may prove diffi cult. To achieve reliable puncturability, there are several surgical solutions. 
Superfi cialization with mobilization is common. With some newer options (lipectomy and liposuction) subcutaneous adipose 
tissue is surgically reduced. There are only a few authors who have published their experience with liposuction and we want 
to add our own results. Patients and methods: We report our experience with ultrasound-guided liposuction (USGL). We intro-
duce liposuction cannulas via small incisions to reduce the subcutaneous adipose tissue overlying the planned cannulation 
zones under ultrasound control using tumescent anaesthesia till the prospective needle access segments become easily 
palpable. So far, we have used this technique for cephalic forearm and upper arm fi stulas only. Furthermore, we review the 
relevant literature. Results: From February 2014 through November 2016, six patients were treated using USGL. Their body 
mass indices ranged from 30.8 to 53.8 kg/m2 (mean 37.6). The mean depths of the AVFs beneath the skin surface were 13.3 
(8–20) mm before and 5.1 (3.5–6) mm after surgery. The mean time of the procedure was 15 minutes. There were no postop-
erative complications. In fi ve patients, the AVFs could reliably be punctured after three weeks. One patient is not yet on dialy-
sis. During the follow-up period of 24 (11–43) months, all six AVFs remained primarily patent. In the literature, we found nine 
reports on altogether 81 patients undergoing USGL. Almost all noteworthy complications occurred only after ultrasound-
powered liquefaction of adipose tissue, which was only used by a single investigator. Conclusions: USGL is a method that can 
be learned easily, is minimally invasive, seems to be safe, and requires only short operation times.
Keywords: Arteriovenous fi stula, vascular access, obesity, liposuction, superfi cialization, ultrasound-guided
Introduction
With an increasing prevalence of obesity in the general pop-
ulation, the same tendency can also be observed in patients 
on dialysis [1, 2]. Thus, puncturing fi stulas in obese patients 
with end stage renal disease constitutes a growing chal-
lenge. If the access site vein is located deeper than 6  mm 
beneath the skin surface, the inability to insert fi stula nee-
dles, or complications of miscannulation such as haema-
toma formation, infections, false aneurysms, and fi stula 
failures become more frequent. Apart from traditional tech-
niques for superfi cialization of the vein by mobilization or 
lipectomy, new options like USGL as well as the so-called 
minimally incision superfi cialization technique (MIST), and 
the implantation of a titanium device (venous window nee-
dle guide, VWING) for repeated, easy buttonhole punctur-
ing have emerged in the last decade. We share our own ini-
tial experience with USGL, and summarize the literature.
Combining our own results with the available data pro-
vided by the literature, we would like to draw attention 
to, and encourage the use of, the ultrasound-guided li-
posuction technique, which is simple, eff ective, and most 
minimally-invasive.
Patients and methods
Surgical technique
The intended needle access segment of the matured fi stula 
is marked under ultrasound visualization. We use tumes-
cent anaesthesia (25  ml lidocaine 1 % w/v, epinephrine 
0.1 mg, 475 ml normal saline). The liposuction cannula (di-
ameter 3–4 mm), which is connected to the surgical aspira-
tor pump (60–80 kPa), is introduced and advanced under 
ultrasound guidance via a 4 mm skin incision (ESM 1). We 
perform repetitive back-and-forth movements with simul-
taneous rotations in a space (1.5–2.5  cm wide) extending 
over the entire length of the plannedcannulation zone. 
404 G. Cs.Nagy et al., Liposuction for deep AV fi stulas
Vasa (2018), 47 (5), 403–407 © 2018 Hogrefe 
 
This procedure must be performed with care in order not to 
get too close to the matured vein and is fi nished when the 
entirety of the needle access segment becomes easily pal-
pable. We do not insert any drains. To prevent haematoma 
formation, we place a folded piece of gauze over the newly-
formed shallow fossa and wrap the arm to exert suffi cient 
elastic pressure. It is important to check for the typical thrill 
so as not to occlude the fi stula.
The literature lists technical variations. Instead of tu-
mescent anaesthesia, others prefer undiluted 1 % lido-
caine with epinephrine [3]. As an alternative to a suction 
pump, suction may also be created manually with a syringe 
[3, 4]. To protect the fi stula from surgical injury, a protec-
tive shield may be used [5]. Likewise, this procedure can 
be performed under videoscopic control [6] instead of ul-
trasound guidance. Not only superfi cial, but also lateral 
adipose tissue surrounding the fi stula may be removed [3]. 
Only Ladenheim et al. [7] mentioned the use of additional 
ultrasound-powered liquefaction, which led to a higher 
complication rate. The same authors also introduced tour-
niquets to prevent haematomas.
Patients
From February 2014 through November 2016, six pa-
tients were included in a prospective follow-up study us-
ing USGL. Their body mass indices (BMI) ranged from 
30.8 to 53.8 kg/m2 (mean 37.6). Four patients were treated 
before starting dialysis, but after their fi stulas had ma-
tured. In the remaining two patients, the suitable access 
segments proved too short for puncturing. We used USGL 
with forearm cephalic fi stulas in four cases. Two cases 
involved the upper arm cephalic vein. The mean depth of 
the needle access segments under the skin surface was 
determined pre- and postoperatively in each patient by 
ultrasound (Figure 1). Four patients underwent surgery 
under continued antiplatelet aggregation inhibitors, in-
cluding one who was also under clopidogrel and phenpro-
coumon. Follow-up ultrasound imaging was scheduled 
after one week, one month, and six months. Technical 
success meant that the needle access segments were eas-
ily palpable. Clinical success meant easy and safe cannu-
lation. Table I shows the patient data.
Figure 1. Ultrasound examination of the arteriovenous fi stula. Note the distance between the skin surface and the vein before (A) and after (B) 
liposuction.
G. Cs.Nagy et al., Liposuction for deep AV fi stulas 405
© 2018 Hogrefe Vasa (2018), 47 (5), 403–407
 
noteworthy complications originated from one single 
study [7] that used a special technique diff ering from all 
others, i. e. the additional use of ultrasound-powered liq-
uefaction of adipose tissue in the fi rst nine out of thirteen 
patients. The investigator abandoned the additional ul-
trasound-powered liquefaction during the course of the 
study after serious adverse events (large haematomas, 
wound necroses, and otherwise unobserved ultrasound 
burn) had occurred in fi ve out of eight included patients 
treated with this method. For the last four patients, he 
utilised simple liposuction only, as did the investigators 
of all other studies. So for the remaining 74 out of 87 pa-
tients (85 % of all cases) who did not belong to this par-
ticular study group, there were no serious adverse events.
Discussion
It is commonly agreed “that autogenous arteriovenous fi stu-
lae should be preferred over AV grafts, and AV grafts should 
be preferred over catheters”, as stated by the European Best 
Practice Guidelines on Haemodialysis [11]. There is a wide 
armamentarium to treat deeply located arteriovenous fi stu-
las. We summarised the diff erent methods in Figure 2.
Standard techniques, which have traditionally been used 
for the brachiobasilic fi stula with mainly single long inci-
sions, comprise elevation, tunnelled transposition, and ele-
vation transposition [12]. They all have in common that the 
outfl ow vein is freed from the surrounding tissue and that 
all side branches are ligated. Vessel wall lesions, stenoses 
caused by wrongly-placed ligatures, torsion, tortuosity, and 
increased tension may lead to early and late complications. 
The absence of small side branches may reduce the longev-
ity of the access in case of proximal stenoses. Tunnelled 
transposition can also be achieved endoscopically. A recent 
technique for tunnelled transposition of venous segments, 
named MIST (minimally incision superfi cialization tech-
nique) by the authors [13], includes two short oblique skin 
incisions over the outfl ow vein, and placing the vein in a 
subcutaneous tunnel between those two incisions.
Literature search
Our PubMed search of the literature yielded four papers 
 [4, 5, 7, 8] and one letter to the editor [9]. We also found 
three relevant congress abstracts [3, 6, 10] while searching 
the internet. The keywords were liposuction, suction-as-
sisted, vascular access, arteriovenous fi stula, superfi ciali-
zation, and obesity.
Results
Own results
There were no complications in our patients. The mean 
time required for such a procedure was 15  minutes. The 
maximum mass of adipose tissue removed during a single 
procedure was 130  g. Technical success was achieved in 
every case. The mean depths of the AV fi stulas beneath the 
skin surface were 13.3 (8–20)  mm before and 5.1 (3.5–
6) mm after surgery. After liposuction, fi ve patients could 
be punctured easily after a delay of three weeks. One pa-
tient did not need dialysis thus far. The mean follow-up 
time was 24 months (11–43). All fi stulas remained patent 
and free from stenoses during the follow-up period.
Literature
In ESM 2, we provide an overview of the literature as well 
as our data by listing complications, BMI of patients, pre-
operative mean depths of the matured veins, mean tissue 
removed, time to access after intervention, primary and 
secondary patency rates, and authors’ evaluations. Super-
fi cialization with liposuction was mainly used for cephal-
ic veins but also proved to be successful with arterio-
venous prosthetic grafts [3], which supposedly were 
placed too deep originally. We found a total of 81 cases, to 
which we added our own six patients. All patients with 
Table I. Patient data.
# Gender Age
(years)
BMI 
(kg/m2)
Cephalic AVF Preop. mean 
vein depth (mm)
Postop. mean 
vein depth (mm)
Time from AVF creation 
till USGL (weeks)
ASA Follow-up 
(months)
1 f 53 33.5 radiocephalic 12 5.5 15 yes 43
2 m 55 30.8 brachiocephalic 11.5 5.5 56 no 27
3 m 23 53.8 radiocephalic 20 5 48 yes 25
4 m 60 33.6 radiocephalic 8 5 118 yes 23
5 f 69 38.5 brachiocephalic 20 6 7 no 15
6 m 61 35.6 radiocephalic 8.5 3.5 23 yes 11
BMI: Body mass index; AVF: arteriovenous fi stula; USGL: ultrasound-guided liposuction; ASA: acetylsalicylic acid.
406 G. Cs.Nagy et al., Liposuction for deep AV fi stulas
Vasa (2018), 47 (5), 403–407 © 2018 Hogrefe 
 
Conclusions
Ultrasound-guided liposuction is a minimally invasive 
method for the superfi cialization of AVF outfl ow veins 
with the smallest possible incision. Not having to mobilize 
the vein excludes a number of complications. Without ul-
trasound-powered liquefaction, liposuction shows promis-
ing results. It requires only short operation times and can 
easily be learned. No special plastic surgery training is nec-
essary for this simple procedure. Larger studies are needed 
to determine its signifi cance and range of application.
Acknowledgement
We thank Maria Parecker for her technical help.
Electronic supplementary material
The electronic supplementary material is available with 
the online version of the article at https://doi.org/10.1024/
0301-1526/a000719.
ESM 1. Figure.
Handling of the liposuction cannula under ultrasound 
guidance.
ESM 2. Table.
Overview of the literature on liposuction for superfi cializa-
tion of deeparteriovenous fi stula outfl ow veins. 
References
 1. Kramer HJ, Saranathan A, Luke A, Durazo-Arvizu RA, Guichan 
C, Hou Susan, et al. Increasing body mass index and obesity in 
the incident ESRD population. J Am Soc Nephrol. 2006;17:
453–1459.
 2. Postorino M, Mancini E, D’Arrigo G, Marino C, Vilasi A, Tripepi G, 
et al. Body mass index trend in haemodialysis patients: the 
More recent papers present techniques without mobili-
zation of the outfl ow vein, i. e. lipectomy, liposuction, and 
the implantation of a so-called VWING (venous window 
needle guide) device [14, 15], which is a palpable titanium 
implant that facilitates buttonhole puncturing.
Staged (excisional) lipectomy also shows fair results [16] 
despite a few major complications. However, USGL is less 
invasive and more likely to be faster.
The literature on liposuction – also called suction lipec-
tomy or suction-assisted lipectomy – is limited [3–10]. We 
could not fi nd any papers published by European authors 
concerning this matter. Unlike lipectomy studies, most 
liposuction cases have only been published as congress 
abstracts. USGL avoids risks that the mobilization of the 
outfl ow vein fi stula involves. There is no denudation, no 
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saves time.
We could not confi rm concerns raised in the literature 
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The small number of patients our study on USGL is 
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[10] liposuction study with a one-year primary patency 
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Figure 2. Surgical options for deeply located 
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surgical options for
deeply located AVF
outfl ow vein
superfi cialization
with mobilization
simple
elevation
tunneled
transposition
elevation
transposition
lipectomy liposuction
venous window
needle guide
superfi cialization
without mobilization
G. Cs.Nagy et al., Liposuction for deep AV fi stulas 407
© 2018 Hogrefe Vasa (2018), 47 (5), 403–407
 
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Submitted: 03.03.2018
Accepted after revision: 20.04.2018
Published online: 19.07.2018
There are no confl icts of interest existing.
Correspondence address 
Dr. Gabor Cs.Nagy
Department of Vascular Surgery
St. Bernward Hospital
Treibestr. 9
31134 Hildesheim 
Germany 
csnagy@web.de
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