Lower-extremity Arteriovenous Access for Haemodialysis: A Systematic Review

Transposition, Elevation, Lipectomy and V-Wing for Easy Needling

Purpose

The purpose of this study is to report surgical techniques to facilitate cannulation of deep matured veins.

Methods and Results

1) Basilic vein tunnel superficialization with rerouting in an anterior tunnel is mandatory for brachial-basilic arteriovenous fistula (AVF), mostly performed in a second surgical stage. The elevation technique, which could necessitate cannulation of the vein through the overlying scar, is not advisable. 2) Femoral vein superficialization is a one-stage surgical operation. Complications of this high-flow AVF are distal ischemia (diabetes and occlusive arterial disease are contraindications), iliac vein stenosis due to intimal hypertrophy and cardiac issues. Nevertheless, we have achieved high long-term patency rates (N = 70). Primary patency rates at 1 and 9 years were 91% ± 4% and 45% ± 11%, respectively. Secondary patency rates at 1 and 9 years were 84% ± 5% and 56% ± 9%, respectively. 3) Lipectomy for superficialization of the forearm radial-cephalic AVF is described for obese patients. Subcutaneous tissues are resected using two transverse incisions. Mobilization of the vein is avoided. At 3 years (N = 49), we recorded 63% ± 8% and 88% ± 7% primary and secondary patency rates, respectively. Anterior transposition of the forearm basilic vein is not necessary when using microsurgery for creation of distal ulno-basilic AVF. 4) VWING is a novel surgically implanted device to help buttonhole technique cannulation. It is too early to draw any conclusion from the preliminary published reports.

Conclusions

Tunnel-transposition and lipectomy are efficient techniques to allow easy needling of deeply situated upper-arm basilic vein, and cephalic vein in obese patients, respectively.

Unusual sites for hemodialysis vascular access construction and catheter placement: A review

As more end-stage renal disease patients require hemodialysis and live longer, many will fail to develop or maintain a functioning upper extremity vascular access. When a patient exhausts vascular access sites in the upper extremities, new fistulas and grafts can be constructed in the lower extremities, thorax, and abdomen as long as a pair of proximate artery and vein provide adequate blood inflow and outflow, respectively. When only a moderate size vein with adequate blood flow provides a conduit to either a patent superior or inferior vena cava, inserting a double-lumen venous hemodialysis catheter can provide temporary or permanent access. We review the literature and report the unusual sites for hemodialysis vascular access and catheter placement.

Prophylactic distal revascularization with interval ligation and simultaneous arteriovenous fistula creation in high-risk patients

Dialysis access-related ischemic steal syndrome is a well-recognized dialysis access complication. When severe, manifestations include rest pain, hand dysfunction, and tissue loss. Dialysis access attempts on the affected extremity are usually abandoned after a diagnosis of steal syndrome, and patients are often left catheter-dependent. Prophylactic distal revascularization with interval ligation has been described in patients at high-risk for steal syndrome. We present our experience with prophylactic distal revascularization with interval ligation performed simultaneously with arteriovenous fistula creation to prevent the recurrence in five patients and review the current body of literature supporting its use.

Alternative venous outflow by brachial to jugular vein vascular access for hemodialysis in the exhausted upper extremities

BACKGROUND

A shunt is usually created from the distal arm (wrist) to the proximal arm (axillary loop) as long as no central stenosis has occurred. Creating vascular access in a patient with central vein stenosis could induce venous hypertension in the upper extremities. In such patients, an ipsilateral internal jugular vein (IJV) as an arteriovenous (AV) outflow vein should be the last option for using a particular arm.

METHODS

Thirty-two patients who had AV hemodialysis access via a jugular vein were analyzed retrospectively from 2001 to 2011. All patients had an ipsilateral subclavian or axillary vein stenosis. The preserved IJV and innominate veins were preoperatively confirmed with Doppler echocardiography and contrast venography.

RESULTS

Mean age of the patients was 57.6 ± 12.3 years, and the mean follow-up period was 43.5 ± 27.4 months. Primary patency was 74%, 54%, 32%, 15% and 5% at 6 months, 1, 2, 3 and 4 years, respectively. Secondary patency was 97%, 93%, 93%, 89%, 79% and 72% at 6 months, 1, 2, 3, 4, and 5 years, respectively. One case of steal syndrome, 2 of seroma, 1 hematoma, 3 swollen arm, 2 infections, 1 pseudoaneurysm, 1 bleeding from puncture site, 8 stenoses and 13 thrombosis cases were noted.

CONCLUSIONS

A brachial-jugular AV graft showed satisfactory results in terms of patency and complication rate. The IJV could be a good outflow vein for an AV fistula if the IJV is preserved in patients with chronic renal failure who have subclavian or axillary vein stenosis or occlusion.

Percutaneous transluminal angioplasty for dysfunctional femoral hemodialysis graft

PURPOSE

We aimed to evaluate the safety and effectiveness of percutaneous transluminal angioplasty (PTA) for dysfunctional femoral arteriovenous graft and analyze clinical or anatomic predictors of graft patency.

METHODS

The records of 45 patients who underwent PTA or thromboaspiration for dysfunctional or thrombosed femoral arteriovenous graft from 2005 to 2012 were reviewed retrospectively. Primary and secondary patency rates were determined at three, six, and 12 months after PTA. The primary patency rate was analyzed according to the presence of diabetes mellitus, graft age from the time of creation to the first intervention (<12 months or ≥12 months), presence of thrombus, shape of graft (U-shape vs. straight-shape), anastomosis type of graft (femoral-femoral vs. femoral-saphenous), location of stenosis (central vs. peripheral), length of stenosis (<2 cm vs. ≥2 cm), degree of stenosis severity (<70% vs. ≥70%), and stent insertion.

RESULTS

A total of 124 PTAs were performed in 45 patients. The primary patency rate at three, six, and 12 months was 84.8%, 63.6%, and 24.2%, respectively. The secondary patency rate at three, six, and 12 months was 95.2%, 95.2%, and 85.7%, respectively. The mean duration of primary and secondary patency was 13.2 and 35.7 months, respectively. No significant clinical or anatomical predictors of primary patency could be identified. Stent placement had a negative effect on primary patency.

CONCLUSION

PTA is a safe and effective treatment for dysfunctional femoral arteriovenous grafts. Stent placement seems to improve technical success, but does not enhance the primary patency rate of dysfunctional femoral arteriovenous grafts.

Experience with chest wall arteriovenous grafts in hemodialysis patients

BACKGROUND

Maintaining long-term hemodialysis access in end-stage renal disease patients presents a serious challenge to surgeons. Over time, patients' remaining access sites diminish while complications and comorbidities simultaneously multiply; often resulting in the use of permanent tunneled catheters, which have a well-known high rate of complications and short-term usefulness. In this study, we report the results of a dialysis graft based on the axillary artery and ipsilateral axillary vein and tunneled in the subcutaneous tissues of the chest.

METHODS

We identified patients who had a chest wall arteriovenous graft (CWAVG) placed at our institution between May 2007 and December 2012. After institutional review board approval, the patients were retrospectively and then prospectively identified and followed for 2 years to document the performance, required maintenance, and complications of the graft.

RESULTS

Sixty-seven grafts in 67 patients were reviewed, representing 0.56% of our 1,192 total dialysis access creations during the study period. The average patient was 55-year-old with an average history of 3.97 explicitly documented prior accesses. Sixty interventions were performed postoperatively including 32 for thrombosis and 28 for venous stenosis. Six documented graft infections occurred (9%). Three minor wound complications occurred, but the graft was preserved. Notably, no patient developed symptoms of steal syndrome. The primary and secondary patency rates at 1 and 2 years were 69.5% and 36.9% and 81.6% and 57.6%, respectively. Twenty-three of the 67 patients died in the 2-year follow-up period (34%).

CONCLUSIONS

CWAVGs are useful and appropriate for patients with difficult upper extremity access. The patency rates for this "exotic" procedure are at least equivalent to other upper extremity grafts. The infection rate is lower than that for femoral grafts or tunneled catheters, and there is no risk of steal syndrome. CWAVGs can even be considered for primary use in patients who have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome.

The use of Tunneled Central Venous Catheters: Inevitable or System Failure?

Purpose

To evaluate reasons for tunneled central venous catheter (TCVC) usage in our prevalent hemodialysis population and assess the impact of a surgically aggressive approach to definitive access creation.

Methods

Clinical review of all patients in the West of Scotland dialyzing via a TCVC in November 2010 was performed. Reasons for TCVC usage and TCVC complications were evaluated. Over the subsequent year, aggressive intervention was undertaken to achieve definitive access in all suitable patients and outcomes re-evaluated a year later (November 2011).

Results

There was no significant difference in the proportion of patients dialyzing via a TCVC in 2010 compared to 2011 (30.3% (n=193) vs. 31.7% (n=201), respectively; p=0.56). All patients now have a “vascular access plan.” Of patients dialyzing via a TCVC in 2010, 37% had died by 2011, 22% remained on long-term line, 20% had successful arteriovenous fistula (AVF) creation, 1% had an arteriovenous graft and 2% were transplanted; 10.4% developed complications of vascular access and required ligation of a functioning AVF. A further 6.5% died within 28 days of surgery. The incidence of culture-positive Staphylococcus aureus bacteremia was 1.6 per 1,000 catheter days.

Conclusions

Aggressive strategies of AVF creation resulted in one-fifth of patients on a long-term TCVC having successful creation of an AVF. This was offset against high failure and significant complication rate from AVF creation in this population. One-third of patients dialyzing via a TCVC died in the subsequent year. Correct patient selection for AVF creation is essential and predialysis care must be optimized to avoid the need for TCVCs entirely.

Ankle fistula as the last resort for vascular access: case report and literature review

PURPOSE

For the majority of patients with end-stage renal failure, renal replacement therapy in the form of dialysis offers the only means of life prolongation. Survival times on haemodialysis have improved, and consequently, patent vascular access is required for an increasing period of time. Upper extremity options for arteriovenous placement are increasingly being exhausted, leading to creation of fistulae in the lower extremities.

METHODS

We describe the management of a patient with superior vena cava obstruction requiring haemodialysis in whom venous access options were becoming very limited. An ankle fistula was formed by anastomosing great saphenous vein (GSV) to dorsalis pedis.

CONCLUSION

The long-term patency of lower limb fistulae remains unclear. An ankle fistula preserves precious venous capital in patients who have no remaining options in the upper extremities for haemodialysis access. Furthermore, it allows for proximal revision if necessary. This serves to prolong the time spent dialysing through native fistulae, with their reduced complications and greater cost-effectiveness.

Lower limb gigantism, lymphedema, and painful varicosities following a thigh vascular access graft

Prosthetic arteriovenous grafts (AVGs) are associated with greater morbidity than autogenous arteriovenous fistulas (AVFs), but their use is indicated when AVF formation is not possible. This report adds to the literature a case of lower limb gigantism, painful varicosities, and lymphedema following long-term use of AVG in the upper thigh. The patient's past medical history included renal transplantation on the same side well before the AVG was inserted and right leg deep vein thrombosis. Suspicion of AVG thrombosis was excluded by Doppler ultrasound, which demonstrated an access flow of 1700 mL/min. A computed tomography (CT) scan of the abdomen and pelvis did not identify the cause of her symptoms. Whereas functional incompetence of the iliac vein valve might be responsible for the varicosities, the extent of hypertrophy in this case raises the suspicion of lymphatic blockage possibly secondary to groin dissection undertaken at the time of graft insertion, in addition to the previous dissection at the time of transplantation. This case highlights the need for minimal groin dissection during AVG insertion, particularly in patients with a history of previous abdominopelvic surgery.

The end stage of dialysis access: femoral graft or HeRO vascular access device

BACKGROUND

Maintaining and establishing vascular access in end-stage renal disease (ESRD) patients is complicated when they are poor candidates for traditional upper extremity access. Our objective was to compare our experience with 2 alternative dialysis accesses, the femoral arteriovenous graft (fAVG) and the Hemodialysis Reliable Outflow (HeRO), in patients with limited remaining options.

METHODS

A single institution, retrospective review of ESRD patients with fAVG or HeRO placed between May 2009 and February 2013 was performed. Adult patients were selected by reviewing all arteriovenous grafts placed at a single institution. Patient demographics, medical history, access characteristics, and outcomes were recorded from both institutional and dialysis center databases. Data were evaluated using Fisher's exact test, unpaired t-test for continuous variables, log-rank test, and univariate analysis.

RESULTS

A total of 56 accesses in 43 unique patients met these criteria: 35 fAVG and 21 HeRO; with 1 HeRO patient lost immediately to follow-up. Clinical variables were similar except the HeRO group had more diabetic patients (60% HeRO, 22.9% fAVG; P = 0.01). The average number of years on hemodialysis was 7.0 ± 1.0 for fAVG and 5.7 ± 0.9 for HeRO (P = 0.41). Primary patency was 40.5%, 18.7%, and 14.9% for fAVG and 29.0%, 29.0%, and 0% for HeRO at 6 months, 12 months, and 2 years (P = 0.67), respectively. Assisted primary patency was also similar, with 43.8%, 29.4%, and 13.8% for fAVG and 34.8%, 34.8%, and 17.4% for HeRO at 6 months, 12 months, and 2 years (P = 0.81), respectively. Secondary patency was 62.6%, 50.6%, 19.3% for fAVG and 68.0%, 53.5%, 38.3% for HeRO at 6 months, 12 months, and 2 years (P = 0.69), respectively. Average number of interventions to maintain patency for fAVG was 1.1 ± 1.47 and 1.65 ± 2.52 for HeRO (P = 0.35). Infectious complications occurred in 29% of fAVG and 15% of HeRO (P = 0.33).

CONCLUSIONS

Patients who received either fAVG or HeRO experience poor access patency. ESRD patients who receive either of these procedures appear to be at the end stage of available access options.

Extra- and intrathoracic access

The most complex patients requiring vascular access are those with bilateral central vein occlusions. Endovascular repair of the central lesions when feasible allow upper extremity use for access. When endovascular repair is not feasible, femoral vein transposition should be the next choice. When lower limb access sites have been exhausted or are contraindicated as in obese patients and in patients with peripheral arterial obstructive disease, a range of extrathoracic "exotic" extra-anatomic access procedures as the necklace cross-chest arteriovenous (AV) grafts, the ipsilateral axillo-axillary loops, the brachial-jugular AV grafts, the axillo-femoral AV grafts or even intra-thoracic ones as the right atrial AV bypasses represent the vascular surgeon's last resort. The selection among those extra-anatomical chest-wall procedures should be based upon each patient's anatomy or patient-specific factors.

Lower limb access

Lower limb vascular access is used as an access site in patients in whom all upper limb possibilities for arteriovenous access creation are exhausted or with bilateral upper limb central vein occlusions. Autologous arteriovenous fistulae (AVF) using the greater saphenous vein have disappointing results apart from the isolated success. Autologous AVF using the femoral vein transposition have good results both in terms of long-term patency and are associated with a 10-fold reduction in infection risk compared with arteriovenous grafts (AVGs). However, a femoral vein transposition is a major undertaking and is associated with an increased risk of ischaemic complications. It is not a good option for patients with established peripheral arterial disease, but may be a good alternative for the younger patient with a high infection risk. The type of lower-extremity vascular access should be carefully tailored to the individual patient.

Which accesses should be abandoned or revised?

This review considers the factors in deciding whether to abandon a functioning access. Strong indications for ligation or excision of an access are infection or severe early-onset steal. Access ligation may also be required for central vein occlusion or high-output cardiac failure. In general, a failing or thrombosed access should be restored to function unless it is no longer required. For failing or thrombosed distal arteriovenous fistulas, it may be easiest to abandon it and create a new fistula a few centimetres proximally rather than perform angioplasty, which is likely to require repeating. Other accesses may be abandoned after repeated treatment of the same stenosis over a short period provided other options exist.

Acesso vascular para hemodialise: o que ha de novo?

O aumento da expectativa de vida dos portadores de doenças crônicas, entre as quais a insuficiência renal crônica, faz com que métodos de tratamentos estejam em constante aperfeiçoamento. O uso em longo prazo da hemodiálise torna necessário confeccionar e manter acessos vasculares de utilização duradoura. Tanto as fístulas arteriovenosas - primeira opção de acesso para os pacientes hemodialíticos - como os cateteres vêm sendo objeto de estudos na literatura, na tentativa de prolongar sua vida útil. Esta revisão tem como objetivo relatar as alternativas e soluções atuais para os acessos vasculares para hemodiálise.

Tagliatelle technique for arteriovenous fistula creation using a great saphenous vein semipanel graft

Lower limb arteriovenous (AV) access creation can be attempted in patients where upper limb options are exhausted. Utilization of the great saphenous vein as a conduit for AV access has been limited due to its small diameter and resistance to dilatation. Lower limb AV fistulas today are mostly either prosthetic grafts with high rates of infection and thrombosis or transposition of the femoral vein that can lead to limb-threatening venous hypertension. In this report, we describe an optimized technique for reconstruction of the great saphenous vein to serve as a dialysis conduit. This semipanel graft reconstruction effectively doubles the diameter of the conduit without disruption of the deep venous circulation and also mitigates the requirement for a venovenous anastomosis.

Femoro-saphenous arteriovenous access-related lower limb ischemia treated by distal arteries percutaneous angioplasty

This is the first reported case of transposed femoro-saphenous angio-access complicated after four years by distal ischemia, which was successfully treated by percutaneous transluminal angioplasty (PTA) of the distal femoral and popliteal artery. Endovascular recanalization and angioplasty of the distal vessels offers a minimally invasive approach with preservation of the angio-access in these patients with high comorbidities.

Prophylactic distal revascularization and interval ligation procedure during femoral vein transposition fistula creation in patients at high risk for ischemic complications

Femoral vein transposition arteriovenous fistula (FVt AVF) is a viable autologous option when upper extremity dialysis access sites have become compromised. High volume flow through the AVF can lead to ischemic complications, including steal syndrome (SS), and may threaten access and limb viability. Risk factors for SS include: age >60 years, female sex, diabetes, atherosclerosis, hypertension, and previous limb procedures. Two dialysis patients, who were at high risk for SS in their lower extremities as assessed during the preoperative evaluation for an elective FVt AVF, had a distal revascularization and interval ligation (DRIL) procedure concurrently performed. At 42 and 24 months from their respective surgeries, both patients are reliably using their lower extremity autologous access sites and have not developed any signs or symptoms of ischemia. DRIL may represent an effective surgical strategy that can prophylactically be used to minimize the incidence of ischemic complications during FVt AVF in carefully selected, high-risk patients.

Arm composite autogenous vascular access using the great saphenous vein and the femoral vein: results from a single-centre study

OBJECTIVES

The objective is to report our results with the arm composite autogenous vascular access (ACAVA) using the great saphenous vein (GSV) and the femoral vein (FV) in tertiary vascular access surgery.

DESIGN

Retrospective single-centre study. Prospectively collected clinical database.

METHODS

Between August 2009 and March 2011, 17 patients with no suitable upper extremity vein, repeated prosthetic access failure and/or infection underwent the construction of an ACAVA. Outcome measures included the graft patency and complication rates.

RESULTS

The median follow-up was 25 months (5-32). Thirty-day morbidity affected 10 patients (59%): four wound-healing issues, three lower limb swelling, two early thromboses and one upper limb haematoma. No postoperative death occurred. At 3 months, the primary patency rate was 88% ± 8%. At 6 months, the assisted-primary patency rate was 82.4% ± 9.2%. At 12 months, the secondary patency rate was 81.6% ± 9.6%. Twenty-four secondary interventions were performed. Steal syndrome occurred in one patient following a secondary procedure. Swelling of the lower limb remained in two patients at the end of their follow-up. Three ACAVAs developed irreversible occlusion leading to loss of access.

CONCLUSION

With a high rate of postoperative morbidity and re-intervention, the ACAVA is a useful additional technique that should be restricted to difficult cases with limited vascular access options.

Retroperitoneal approach for lower extremity arteriovenous graft as long-term vascular access in a complex case

A 76-year-old woman with stage 5 chronic kidney disease requiring hemodialysis had a long history of hypertension and diabetes. Her venous access was exhausted because of several previous access procedures including autogenous arteriovenous fistula operations and central venous catheter placements. After evaluating the function of her vessels when she was transferred to Renji hospital, we created an arteriovenous graft via a retroperitoneal approach in her right lower extremity. We inserted two grafts into her right thigh, a straight external ring and a loop graft. Twenty days after operation the patient's new access was successfully used in the treatment of hemodialysis. She has been followed up to now without occurrence of any graft-related events.

[Vascular grafts as access for hemodialysis]

Prosthetic arteriovenous grafts have an inferior patency rate and greater morbidity than those with autogenous vessels and are therefore considered as secondary or tertiary vascular access for hemodialysis in patients with fatigued or unsuitable superficial arm veins. Prior access planning in accordance of patient characteristics, careful operative procedure and appropriate revision of complications can ensure long-term functioning of a vascular access using a large variety of possible prosthetic conduits. Arteriovenous grafts remain essential in vascular access surgery and their role may be increasing with higher comorbidities of patients and should be preferred to tunnelled cuffed catheters. This article reviews the indications, alternative configurations and characteristics of arteriovenous grafts.

Successful early cannulation of a superficial femoral vein transposition angioaccess in a patient without other alternatives

Early cannulation of a native fistula is defined by Dialysis Outcomes and Practice Patterns Study and Kidney Disease Outcomes and Quality Initiative as between 2 and 12 weeks postoperatively. We present a case of a patient in whom anatomical and hematological barriers prevented early cannulation graft placement, and in whom temporary catheterization was not feasible as a result of central venous occlusion. Successful cannulation at the fifth postoperative day of a native angioaccess was performed and the reasons and challenges faced behind this choice under the circumstances were discussed.

Subclavian vein angioplasty during arteriovenous fistula surgery: case report and literature review

Patients with chronic kidney disease stage 5 are generally treated by hemodialysis, preferentially performed via an arteriovenous fistula (AVF). We report the case of a 58-year-old male patient with diabetes mellitus, hypertension and end-stage renal disease in whom hemodialysis was conducted via a long-term catheter. His medical record described numerous central venous cannulations and several AVF creations. The patient developed subclinical subclavian stenosis that required creation of a new vascular access route. The purpose of this case report is to describe treatment of subclavian vein stenosis during AVF creation.

Complications of arteriovenous fistulae: beyond venous stenosis

Vascular access is the lifeline of hemodialysis patients. Currently, arteriovenous fistulae and grafts are considered permanent options for vascular access, and they share common access problems. The successful creation of a permanent vascular access depends on patient characteristics, vessel parameters, and possibly genetic factors. Utilization of a dialysis access at least 3 times a week leads to significant wear and tear of the access. The buttonhole technique is associated with a higher incidence of infection, and evidence regarding various perceived advantages remain contradictory. Infiltration and aneurysm formation of an access are common, and the literature on its impact on vascular access outcomes is limited. A patient who undergoes hemodialysis often requires multiple accesses during his or her lifetime, and the maintenance of a persistent vascular access may require creative solutions. Intensified research is crucial to comprehending the pathophysiology and treatment options for some of the common problems of vascular accesses.

Composite PTFE-transposed superficial femoral vein for lower limb arteriovenous access

PURPOSE

We report our experience in creating a composite loop of transposed superficial femoral vein (tSFV) and polytetrafluoroethylene (PTFE) synthetic graft for lower limb access. The indication for surgery was exhaustion of access sites in both upper limbs.

METHODS

Surgery was performed on 3 male patients. All patients had an ankle brachial index =0.9. The SFV was mobilized up to adductor canal, with ligation of all small tributary branches, up to the level below the profunda femoral vein, then tunneled medially to the skin. A 6-mm PTFE graft was tunneled laterally, deep in the subcutaneous plane in loop fashion to the end of the tSFV, where a beveled end-to-end anastomosis was created.

RESULTS

The blood flow in both fistulas increased gradually to 0.7-1.3 l/min postoperatively. No clinical manifestation indicative of lower limb ischemia, lymphorrhea, or infection was documented. No signs related to chronic venous hypertension were noticed.

CONCLUSIONS

Our initial experience shows that the creation of a composite PTFE-tSFV conduit is a promising technique, since it can be constructed without compromising the distal perfusion, and without infectious complications.

Hemodialysis vascular access options after failed Brescia-Cimino arteriovenous fistula

The survival of patients on long-term hemodialysis has improved. End-stage renal disease patients now need maintenance of their vascular access for much longer periods. Arteriovenous fistulae formed at the wrist are the first choice for this purpose, but, in many patients, these fistulae fail over time or are not feasible because of thrombosed veins. We searched the Pubmed database to evaluate the various options of vascular access in this group of patients based on the published literature. It is quite evident that, whenever possible, autogenous fistulae should be preferred over prosthetic grafts. Use of upper arm cephalic and basilic veins with transpositions wherever required can enhance autogenous fistula options to a large extent. Upper arm grafts should be used when no autogenous fistula is possible. Lower limb and body wall fistula sites are to be considered at the end, when all options in both upper limbs are exhausted.

Increasing Dialysis Access Options in Lower Extremity: Retroperitoneal Approach for External Iliac Artery-Vein Arteriovenous Graft

Background

Exhaustion of upper extremity dialysis access options is becoming more prevalent due to the longer survival of this patient population. In addition, central venous occlusive disease (CVOD) increases the risk of losing access viability in the ipsilateral extremity.

Purpose

We describe a novel technique of lower extremity arteriovenous graft (AVG) placement in which the external iliac artery and vein are utilized, as illustrated in 2 selected cases.

Methods

Two dialysis patients presented with exhausted upper extremity access options and bilateral intrathoracic CVOD. In patient 1, a venogram demonstrated complete occlusion of the left common iliac vein and severe stenosis of the right common femoral vein, rendering these unsuitable for access creation. In patient 2, with a history of peripheral arterial disease, an arteriogram revealed that the common and superficial femoral arteries were inadequate for access creation bilaterally. A retroperitoneal approach was utilized for a right external iliac artery and vein arteriovenous graft tunneled under the inguinal ligament to the anterior thigh.

Results

Adequate thrill and uneventful postoperative course were observed in both cases. At 10 months, patient 1 has done well on hemodialysis without the need for further intervention. Patient 2 has only recently had the procedure and is not yet using her graft.

Conclusions

As the number of patients requiring lower extremity vascular access increases, new surgical techniques will become available to handle the clinical and anatomic challenges encountered in this population.

Latero-lateral femoro-femoral arteriovenous fistula: a new surgical approach for hemodialysis patients with no vascular access

PURPOSE

A new surgical approach for vascular access for hemodialysis using a latero-lateral arteriovenous fistula (AVF) in the thigh between the femoral artery (FA) and superficial femoral vein (SFV) transposed to the subcutaneous layer in patients with no other access options is described.

METHODS

Ten patients (mean age: 37,9 years) for whom all possible sites for execution of any other procedure had been exhausted, underwent latero-lateral AVF close to the adductor channel between the FA and the SFV. The FSV was released and sectioned 2 cm from its confluence with the deep femoral vein and transposed in the subcutaneous tissue with extensions using saphenous vein or prosthetic material (PTFE) when needed. Follow -up included patency, flow evaluation and complications.

RESULTS

Postoperative follow-up ranged from 3 to 96 months, with a mean of 38 months. The AVFs presented a flow of more than 350 ml/min and the AVFs remained patent for a mean period of 38 months. There were three failures of the procedures at 3, 5 and 7 months during postoperative follow-up due to graft infection and thrombosis (a case), anaphylactic shock and thrombosis (a case) and calf pain during dialysis (a case). Two patients developed slight inferior limb edema.

CONCLUSION

The new surgical approach for access for hemodialysis represents a feasible procedure, with acceptable patency rates in exceptional cases where no other access option is available.

Lower extremity arteriovenous hemodialysis access: an important adjunct in select patients

Given the current survival rates of patients receiving hemodialysis, it has become increasingly common for patients to exhaust their upper extremity access options. Likewise, overzealous catheter use can lead to central venous occlusion or stenosis, further limiting the upper extremity access options. In these patients, use of the lower extremities for access is often required. Fortunately, there are a number of options available that have acceptable durability and utility. The purpose of this article is to review the various techniques available for placement of hemodialysis access in the lower extremity and discuss their results.

Subsartorial Mid-thigh Graft for Hemodialysis Access in Patients with Exhausted Arm Veins A Novel Strategy

To study the value of a mid-thigh graft as an alternative in the provision of long-term vascular access in patients requiring hemodialysis 11 patients (9 females, 2 males) aged 27-71 (mean 48 years) with unsuitable arm veins underwent surgery between February 2001 and January 2004 to create an arteriovenous fistula (AVF) between the superficial femoral artery (SFA) and superficial femoral vein (SFV). There were no deaths due to the procedure, no limb losses, no technical failures and all fistulae matured satisfactorily. Complications included two cases of thrombosis (surgically thrombectomised at 15 and 24 months post-operatively), one case of graft infection at three years post-operatively (treated by graft excision), and one graft failure at five years post-operatively (replaced with a second graft at the same site). After three years 10 grafts were functional and being used for dialysis. It was concluded that a mid-thigh graft is a suitable durable procedure in patients where creation of vascular access at the upper limbs is not feasible. Adequate clinical and radiological surveillance is imperative.

Good long term patency rates associated with an alternative technique in vascular access surgery--the adductor loop arteriovenous graft

INTRODUCTION

We have modified the arteriovenous groin loop procedure and present a technique associated with good patency rates and low infection rates.

METHODS

We describe an alternative femoro-femoral arteriovenous loop technique which utilises the mid-thigh sub-sartorial Superficial Femoral Artery and Femoral Vein. We then performed a retrospective analysis of all such cases performed in our unit to date and analysed the patency and infection rates associated with the technique.

RESULTS

16 cases have been performed to date with a median follow-up of 18 months. The primary and secondary patency rates at one year were 70% and 90% respectively. The overall infection rate was only 12.5%.

CONCLUSIONS

Our technique is associated with good patency rates and low infection rates. In addition it preserves modesty whilst on dialysis and the groin vessels for further vascular access surgery if needed.

Vascular Access Using the Superficial Femoral Vein

Purpose

The superficial femoral vein (SFV) provides an alternative autologous conduit for fistula formation in patients who might otherwise require a prosthetic graft for hemodialysis (HD) access. The purpose of this study was to assess the results of this technique.

Methods

Patients who underwent formation of a SFV fistula were identified from a prospectively maintained database. Casenotes were reviewed for details of the operation, complications, subsequent interventions, and to determine whether the fistula was used for vascular access.

Results

Fifteen patients (seven males, eight females; median age 53, range 28–72 yrs) were identified. Patients had a median of four (range 2–9) previous fistulae. In three patients, the mobilized SFV was transferred to the upper limb while 12 patients had lower limb fistulae. Twelve patients (80%) used their SFV fistula for HD. Eleven patients developed a wound complication (infection, dehiscence, hematoma or bleeding), with four patients returning to theater for formal exploration and three requiring application of a vacuum dressing. Two patients developed post-operative lower limb ischemia. Two patients died during a median follow-up time of 7 (range 1–27) months.

Conclusion

In selected patients who have exhausted conventional routes for vascular access the SFV fistula can be used for the maintenance of HD. There is, however, significant associated morbidity and repeated intervention is often required.