Prosthetic lower extremity hemodialysis access grafts have satisfactory patency despite a high incidence of infection

Leg Ulcer and Venous Symptoms Related to Lower Extremity Arteriovenous Access for Hemodialysis: A Retrospective Review with Emphasis on Wound Complications

Lower extremity arteriovenous (AV) access serves as a crucial alternative for hemodialysis when upper extremity options are no longer viable. While there are numerous reports on functional patency, limited information exists regarding complications related to venous insufficiency and postoperative quality of life. This study aims to assess the actual incidence of such complications and provide evidence-based insights for clinical decision-making. We retrospectively analyzed 121 end-stage renal disease patients who underwent lower extremity AV access at Maharaj Nakorn Chiang Mai Hospital from 2006 to 2023. Among them, 105 patients (86.8%) had lower extremity AV grafts, while 16 patients (13.2%) had lower extremity AVF. Primary and secondary patency rate were 69.4% and 81.8% at one year, respectively. The mortality probability was 50.4% with a mean follow-up of 58 months. Mortality predictors included age (P = .001), aspirin use (P = .022) and statin use (P = .005). Primary failure occurred in 8 patients (6.6%) and vascular graft infection is the primary cause. There were no occurrences of venous leg ulcers developed, suggesting that the risk of this complication may be lower than previously thought in the short to medium term. However, 13.3% of patients experienced leg swelling and 21.7% had hyperpigmentation. The mean revised venous clinical severity score was 1.22 and the average EQ-5D-5L quality of life score was 0.99. Our findings suggest that the risk of venous leg ulcers in patients with lower extremity AV access may be lower than previously thought, at least in the short to medium term. This should encourage surgeons to consider this technique when upper extremity options are exhausted, while maintaining vigilance for early signs of venous insufficiency. Continued research into the detrimental effects of the hyper-dynamic blood flow rate on AV access and preventive strategies will enhance the benefit of lower extremity AV access in the future.

Alternatives for exhausted dialysis access

Hemodialysis (HD) access failure is a frequent problem encountered by vascular surgeons. As treatment of end-stage renal disease improves and patients live longer on HD, eventual exhaustion of traditional upper extremity HD access is common. Efforts to preserve and maintain these accesses are essential. However, when they fail, alternative surgical access options should be pursued prior to destination-tunneled dialysis catheters. Hemodialysis Reliable Outflow grafts as well as various configurations of lower extremity arteriovenous fistulae and grafts can be utilized. For most alternative HD access options, there is a paucity of data for long-term patency, cost, and risk of infectious or ischemic complications compared to traditional options. However, smaller studies examining Hemodialysis Reliable Outflow grafts, femoral vein transposition, and lower extremity grafts show acceptable safety and efficacy. Depending on the cause of traditional access failure and patient-specific anatomic constraints, we recommend a systematic approach to alternative access creation, with destination-tunneled dialysis catheters reserved as a last resort. The most common cause of HD access failure is venous outflow obstruction. As such, we have structured this manuscript around a meta-analysis of retrospective studies describing nontraditional access options that can be utilized with escalating degrees of central venous stenosis or occlusion.

To evaluate the complication and patency rate of superficial femoral vein transposition in tertiary care center

INTRODUCTION

When all access options in the upper extremity have been exhausted, an autologous access can be created in lower extremity. The purpose of this study is to report our experience with superficial femoral vein transposition (SFVT) results in terms of postoperative complication and patency rate.

MATERIALS AND METHODS

In the time period from January 1, 2019 to April 30, 2021, thirty-five cases of SFVT performed at our large tertiary care center Sindh Institute of Urology and Transplantation (SIUT). All patients had exhausted upper arm veins or had central vein obstructions. Medical records of all patients were traced, patients were interviewed using a standard proforma and evaluated the current AVF function in the OPD clinic or by telephone calls. Data including demographics and postoperative complications were collected.

RESULTS

Thirty-nine cases of SFVT performed at our institute. Three were immediately lost to follow up so they were excluded from the study. Mean patient age was 30 ± 13.4 years. Most of our patients were females (57%) and 15 males (43%) with an average age of 29.05 years. The most common underlying renal diseasewas unknown in 16 (45%).Thirty-five patients included in the analysis; out of which primary failure observed in 4 patients, three patients were expired before fistula maturation and 3 were expired before 6 months. The remaining 25 fistulas patency rates were estimated. No any patient died due to fistulas related complication; patients died due to their primary disease.

CONCLUSION

Our study shows that with appropriate patient selection, SFVT have low infection rates and patency that is comparable with other access types.

HeRO graft-The results of the cologne single center study

OBJECTIVE

The HeRO graft is a technique for vascular access in patients with limited treatment options; however, the published results with the HeRO graft are diverging. We therefore conducted a single-center study.

METHODS

Patient records between July 2014 and February 2020 from Vascular Access Unit of the Department of Vascular and Endovascular Surgery of University Clinic of Cologne (Germany) were reviewed. Retrospective data was analysed from patients with a HeRo graft (n = 18).

RESULTS

Eighteen patients were enrolled in the study. The mean age of the patients was 62.8 ± 17.24 years. During the follow-up period, no patients died from complications related to the HeRO graft. Each patient had a mean of 1.94 concomitant diseases. The primary patency rates of the HeRO graft at 3, 6, 12, 18, and 24 months were 61.1%, 50%, 16.7%, 11.1%, and 5.6%, respectively. The secondary patency rates at the same time intervals were 77.8%, 72.8%, 55.6% 55.6%, and 55.6%, respectively. There were 44 re-operations per year, or 2.4 operations per patient. The main cause of acute complications was acute graft occlusions after HERO graft implantation. An infection after the graft implantation occurred in five (27.7%) patients, leading to graft explanation in 2 cases.

CONCLUSION

The use of the HERO graft is a valuable alternative method for providing a durable dialysis access in patients with limited access options. The secondary patency and survival are good with a low infection rate.

Straight lateral thigh femoropopliteal-femoral arteriovenous graft an alternative vascular access for patients with exhausted upper limbs dialysis access

INTRODUCTION

The durability of hemodialysis vascular access remains a troublesome issue for the patients as well as vascular surgeons that requires frequent reinterventions to maintain the access function.

AIM

This study aimed to evaluate straight thigh polytetrafluethylene (PTFE) arteriovenous graft (AVG) in patients with exhausted upper extremities dialysis access.

METHOD

Our study was a retrospective analysis of prospectively collected data of 30 patients were operated upon for straight pattern lateral thigh PTFE AVG between 2016 and 2018. The primary outcome was efficacy and patency of AVG, and secondary outcome was procedure safety, including infection, thrombosis, ligation, lower limb functional status, and mortality.

RESULTS

A 30 patients with 30 Lower Limb AVG with maximum 30-month follow-up period. The mean age was 48 years. Males were (n = 15/30). Thrombophilia patients were (n = 7/30). Primary patency at 6 months was 100%. It declined to 93% at 12 months, 73% at 18 months, 47% at 24 months, and 40% at 30 months. The secondary patency was 97% at 18 months, 83% at 24 months, and 73% at 30 months. More than half of the patients showed complications (n = 18/30), the most frequent was thrombosis (n = 16/18). A secondary procedure was needed for 17 patients, the most frequent was thrombectomy (n = 11/17), adjunctive culprit lesion repair was the key for regaining graft patency. Graft removal was necessary in six patients due to infection (n = 4) and ruptured graft aneurysm (n = 2).

CONCLUSION

Lateral straight thigh PTFE AVG is a reliable and durable alternative modality with adequate dialysis efficacy in patients with exhausted upper extremities dialysis accesses. Secondary procedures due to complications were frequent but no significant major bleeding as regard patients with ruptured graft were non-significant and no distal threatening ischemia or related deaths were observed.

Technique for a lateral approach to a superficial femoral artery-femoral vein thigh loop arteriovenous graft placement in avoidance of a traditional groin incision

INTRODUCTION

The number of patients with end stage renal disease reliant on long-term hemodialysis access continues to grow. When traditional upper extremity hemodialysis sites are exhausted, lower extremity access should be considered. Although autogenous lower extremity options are available, prosthetic lower extremity grafts are frequently used. However, infection can complicate a significant percentage of lower extremity grafts with a traditional groin incision. We present our technique and early results of a lateral approach to a superficial femoral artery-femoral vein thigh loop arteriovenous graft (lat-SFA-FV AVG) in the proximal thigh, which avoids a traditional groin incision and provides a functional access with promising patency.

METHODS

Between April 2017 and August 2019, five lat-SFA-FV AVG were placed in our institution for arteriovenous access in patients who had exhausted options in upper extremities.

RESULTS

Five patients were included in the study. Median SFA size was 8 mm. One patient had moderate SFA calcification, while the other four patients had either none or mild SFA calcification. All grafts were successfully placed with few postoperative complications, including no wound infections. One patient expired 3 weeks after the procedure due to unrelated cause. Three patients had functional grafts at a median follow-up of 499 days.

CONCLUSION

Our early experience demonstrates that the lateral approach to the SFA-FV AVG has several advantages including avoidance of groin infection and acceptable patency. Furthermore, our early experience identifies patient factors which may be important to patient selection for this procedure.

Upper thigh loop prosthetic arterio-venous grafts (AVG) for dialysis access: An Indian perspective

INTRODUCTION

Hemodialysis forms the most common replacement therapy for majority of Indians suffering from chronic kidney disease (CKD). Multiple access failure and central vein stenosis has become commonplace in Indian dialysis access patients and there is a burgeoning need for more advanced hemodialysis (HD) access options. Upper thigh arterio-venous grafts (AVG) are seldom inserted due to fear of infection and limb ischemia.

MATERIALS AND METHODS

This is a single institutional, retrospective, descriptive case study of consecutive patients who underwent upper thigh prosthetic AVG over a period of 7 years. All these patients had exhausted options of upper limb access and or had central vein stenosis. AVG from the proximal superficial femoral artery (SFA) to the proximal great saphenous vein (GSV) in a loop configuration using polytetrafluoroethylene (PTFE) was carried out in the upper thigh.

RESULTS

A total of 24 patients had undergone upper thigh loop AVG. Their age varied from 24 to 77 years. The median follow-up period was 3 years. Five of these grafts developed infection (21%) which led to primary failure. A primary patency of 71% (17/24 patients) was achieved at 1 year. Thrombosis developed at a mean of 16.7 months after the primary procedure. Adjunctive procedures such as thrombectomy, segmental replacement of graft, patch angioplasty, balloon angioplasty, and stenting were required in 75% of patients to achieve a secondary patency of 86% at 1 year. Three grafts were explanted without limb loss.

CONCLUSION

Upper thigh loop AVG forms a reliable alternate dialysis access option for patients with failed upper limb access sites or central vein occlusion. Adjunctive procedures are key to maintaining patency in these grafts. Good secondary patency is achievable, and the infection rates are similar to arm AVG. Close follow-up and timely intervention are key to long term dialysis through these grafts.

Ilio-Femoral Deep Vein Thrombosis Secondary to May-Thurner Syndrome With Ipsilateral Lower Limb Arterio-Venous Graft In-Situ

Ilio-femoral deep vein thrombosis (DVT) is rare in patients with lower limb arterio-venous grafts due to a state of high blood flow. May-Thurner syndrome (MTS) is an anomaly where the left common iliac vein is compressed by the right common iliac artery. We present a rare case of ilio-femoral deep vein thrombosis in a patient with May-Thurner Syndrome and an underlying arteriovenous graft in-situ who presented with acute lower limb swelling. The patient underwent catheter-directed thrombolysis, pharmaco-mechanical thrombectomy, venoplasty and iliac vein stenting. Follow-up surveillance duplex ultrasound showed patency of the iliac vein stent and arteriovenous graft at 1-year postoperatively.

Long-term outcomes of transposed femoral vein arteriovenous fistula for abandoned upper extremity dialysis access

BACKGROUND

The number and longevity of patients with end-stage renal disease requiring dialysis access have continued to increase, leading to challenging situations, including exhausted upper extremity access and severe central venous stenosis. This has led to an increase in the use of alternative access sites, including the lower extremities. The transposed femoral vein arteriovenous fistula for dialysis access is a previously described alternative, although limited data are available on its long-term patency.

METHODS

Patients treated with a transposed femoral vein fistula were retrospectively reviewed. A transposed femoral vein fistula was created by harvesting the femoral vein and transposing it to the distal superficial femoral artery at the level of the adductor canal. The demographic information, perioperative characteristics, complications, and long-term outcomes were recorded and analyzed.

RESULTS

A total of 21 patients had undergone transposed femoral vein fistula for dialysis access after an average of 5.3 ± 2.8 failed dialysis access procedures and a duration of 6.1 ± 4.9 years from the initiation of dialysis. The average age at the procedure was 53.5 ± 12.8 years. Ten patients (47.6%) had a history of diabetes mellitus and nine (42.9%) had a history of coronary artery disease. Technical success was achieved in 100% of cases, and 16 patients (76.2%) were discharged with anticoagulation therapy. The primary patency at 1, 3, and 5 years was 93%, 74%, and 74%, respectively. The secondary patency at 1, 3, and 5 years was 100%, 89%, and 89%, respectively. Two patients had compartment syndrome requiring fasciotomy, and six patients experienced wound complications.

CONCLUSIONS

Transposed femoral vein fistula for dialysis access is a viable alternative for patients with an exhausted upper extremity access, with good long-term patency.

Good long-term patency: 10-year follow-up using the mid-thigh adductor loop arteriovenous graft

Introduction:

Definitive access in patients requiring renal replacement therapy is an ever-increasing challenge. For those where autogenous venous access is no longer a viable option, arteriovenous grafts can be considered. This article describes long-term follow-up, complications and patency rates of the mid-thigh ‘adductor loop’ arteriovenous graft.

Methods:

50 mid-thigh loop arteriovenous grafts have been inserted into 48 patients in our unit over the past 11 years. A prospective database was collected on patients receiving an arteriovenous graft at our unit by the senior author. All remained under the care of our unit ensuring accurate follow-up data collection and database was updated at regular intervals.

Results:

Death-only censored primary patency at 1, 3 and 5 years was 76%, 44% and 23%, respectively. Patients receiving transplants were not censored as follow-up of the arteriovenous grafts was possible. Secondary patency at 1, 3 and 5 years was 95%, 63% and 45%. These rates are higher than previous studies looking at lower limb arteriovenous grafts. Graft thrombosis occurred in 14 patients (28%). Six patients were treated for an infection (12%) but only four grafts were excised; much lower than documented in previous studies.

Conclusion:

Autogenous venous access remains the perceived gold standard for patients requiring dialysis for end stage renal failure, despite some published data reporting poor outcomes. We have shown that adductor loop arteriovenous grafts can be a reliable, safe and long-term alternative in those whom fistula formation is not possible and may have a role earlier in the patient journey than previously thought, as a result of good patency and lower complications.

Long-term results of thigh arteriovenous dialysis grafts

INTRODUCTION:

A proportion of hemodialysis patients exhaust all options for arteriovenous access in upper extremities. Arteriovenous thigh grafts are a potential vascular access option in such patients.

METHODS:

We performed a retrospective study of all thigh arteriovenous access grafts placed between 1995 and 2015. The clinical, demographic patient information and patency of each thigh graft was determined from the time of surgical creation placement until abandonment, transfer to other modality, or center or end of study, and the reason for access failure documented.

RESULTS:

In total, 44 patients received 49 thigh arteriovenous accesses. The average age was 60 years (13-79 years); Half (53%) of the patients (n = 24) were female and 61% of the patients (n = 30) of arteriovenous accesses were left-sided. The cumulative proportion surviving (primary patency rates) at 12, 24, and 28 months were 43% (standard error = 9%), 33% (standard error = 9%), and 13% (standard error = 9%), respectively. The cumulative proportion of surviving grafts at 12, 24, and 48 months were 61% (standard error = 8%), 58% (standard error = 9%), and 31% (standard error = 13%), respectively. In total, 37 revisions were performed in 22 patients to maintain patency or eradicate infection. Infection occurred in 20 patients (39%) of thigh grafts requiring 16 patients (80% of those affected) to be removed; 14 patients had grafts (33.3%) that served as the lone hemodialysis arteriovenous access during the patients' lifetime on dialysis.

CONCLUSION:

Arteriovenous thigh graft access is used infrequently, but they have an acceptable patency. Some accesses require revisions and they have a high infection rate. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.

Thigh arteriovenous grafts. Quantitative comparison with alternative options: A meta-analysis

Thigh arteriovenous grafts are required in a number of patients with exhausted upper extremity veins and comprise 1%-5% of the total access procedures performed. Alternative autogenous lower extremity options are the rarely used sapheno-tibial arteriovenous fistulae, the saphenous vein transpositions, and the femoral vein transpositions. The latter have proven to be the most durable lower limb access procedures, with low infection rates and their primary patency rates ranged from 74% up to 87% at 2 years. Synthetic thigh grafts are suitable for patients who are not good candidates for any upper limb or any autogenous lower limb access and their secondary patency rates ranged from 54% up to 83% at 2 years. Thigh grafts often get infected and their average weighed infection rate in 920 such grafts included in eight large series was 22.9%. A literature search was performed to evaluate thigh grafts compared with alternative options using meta-analysis. Lower limb accesses were found superior compared to HeRO^® device regarding 1-year primary failure rate (odds ratio = 0.28, confidence interval = 0.09-0.88, p = 0.03) and additionally autogenous lower limb accesses were found superior compared to thigh grafts regarding the 1-year primary failure rate (odds ratio = 6.54, confidence interval = 2.29-18.72, p = 0.0005).

Femoral Arteriovenous Grafts for Hemodialysis: Retrospective Comparison With Upper Extremity Grafts and Fistulas

Background:

Femoral arteriovenous grafts are rarely used to provide vascular access for dialysis patients. This is likely due, in part, to historically high rates of graft loss from infection and thrombosis. However, for selected patients who have exhausted all access options in the upper extremity, femoral grafts can provide additional sites for access creation and may be preferred over central venous catheters.

Objective:

We sought to demonstrate that femoral grafts can provide a reliable and safe alternative to central venous catheters for selected patients.

Methods:

A single-center retrospective review in Vancouver, Canada, from April 1, 2008, to March 31, 2012, was conducted. All patients with new arteriovenous access (grafts and fistulas) created during the study period were included in the study population and followed for a minimum of 2 years. Comparisons of patency (primary, secondary, and functional) and complications (infectious and noninfectious) were made between the different access types.

Results:

Thirteen patients with femoral grafts were compared with 22 patients with arm grafts and 384 patients with fistulas. Femoral grafts had higher rates of thrombosis (46% with a thrombotic event) and a higher requirement for interventions (1.3 angioplasties and 0.12 thrombolytic procedures per patient per year). However, compared with arm grafts, femoral grafts had superior secondary and functional patency. No difference in patency was seen when comparing femoral grafts with upper extremity fistulas. Only 2 patients with femoral grafts required antibiotics for infection, and no grafts were lost to infection.

Conclusions:

For patients with limited access options remaining, femoral grafts may provide an additional form of vascular access before resorting to catheter use. Our study shows that with appropriate patient selection, femoral grafts have low infection rates and patency that is comparable with other access types.

Long Term Outcomes of Arteriovenous Grafts for Hemodialysis in Lower Extremities

Purpose:

The lower extremity has received its fair share of attention as a vascular access site in patients who have exhausted their upper arm vessels. However, experiences with lower extremity arteriovenous grafts (AVGs) have so far been disappointing because of high infection rates and severe limb ischemia. We report our experience with hemodialysis access from the lower extremity.

Materials and Methods:

A retrospective review of 60 lower extremity AVGs created between January 2003 and December 2011 was performed. Age, sex, etiology of end-stage renal disease and complications were tabulated. Primary and secondary patency rates were determined.

Results:

The average age of the study population was 56 years and 38 patients were female. Renal failure was associated with hypertension in 40 (66.7%) patients, diabetes in 28 (46.7%) patients and cardiovascular disease in 9 (15.0%) patients. The follow-up period was 8–108 months. Fifty-four patients had bilateral central vein stenosis. Seven (11.7%) patients had primary failure of their AVG. There was no operation-related death. Primary and secondary patency rates were: 66% and 90% at 1 year, 40% and 90% at 2 years, 27% and 87% at 3 years, and 18% and 87% at 5 years, respectively. There were 105 postoperative complications that developed in 67 patients. Postoperative complications were: thrombosis (30), proximal vein stenosis (56), infection (9), bleeding with hematoma (1), perigraft seroma (3), steal syndrome (2), and pseudoaneurysm (4).

Conclusion:

A lower extremity AVG seems to be a viable option in patients with unusable upper extremity veins.

Arteriovenous Access: Infection, Neuropathy, and Other Complications

Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.

Lower Extremity Permanent Dialysis Vascular Access

Hemodialysis remains the most commonly used RRT option around the world. Technological advances, superior access to care, and better quality of care have led to overall improvement in survival of patients on long-term hemodialysis. Maintaining a functioning upper extremity vascular access for a prolonged duration continues to remain a challenge for dialysis providers. Frequently encountered difficulties in clinical practice include (1) a high incidence of central venous catheter-related central vein stenosis and (2) limited options for creating a functioning upper extremity permanent arteriovenous access. Lack of surgical skills, fear of complications, and limited involvement of the treating nephrologists in the decision-making process are some of the reasons why lower extremity permanent dialysis access remains an infrequently used option. Similar to upper extremity vascular access options, lower extremity arteriovenous fistula remains a preferred access over arteriovenous synthetic graft. The use of femoral tunneled catheter as a long-term access should be avoided as far as possible, especially with the availability of newer graft-catheter hybrid devices. Our review provides a summary of clinical evidence published in surgical, radiology, and nephrology literature highlighting the pros and cons of different types of lower extremity permanent dialysis access.

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.

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.

Long-term outcomes of arteriovenous thigh grafts in hemodialysis patients: a comparison with tunneled dialysis catheters

BACKGROUND AND OBJECTIVE

Arteriovenous thigh grafts are a potential vascular access option in hemodialysis patients who have exhausted all upper-limb sites. This study compared the outcomes of thigh grafts with outcomes obtained with dialysis catheters.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A prospective vascular access database was queried to identify 209 thigh grafts placed from January 1, 2003, to June 30, 2011. The following were calculated: secondary graft survival (from graft creation to permanent failure), assisted primary graft survival (from graft creation to first thrombosis), and infection-free graft survival (from graft creation to first graft infection). Graft outcomes were compared with those observed with 472 tunneled internal jugular dialysis catheters.

RESULTS

The median duration of patient follow-up was 340 days for grafts and 91 days for catheters. The surgical technical failure rate of thigh grafts was 8.1% and was higher in patients with vascular disease (hazard ratio [HR], 2.94; 95% confidence interval [CI], 1.07-8.04; P=0.03). Secondary and assisted primary graft survival rates at 1, 2, and 5 years were 62%, 54%, and 38% and 38%, 27%, and 17%, respectively. Infection-free graft survival rates at 1, 2, and 5 years were 79%, 73%, and 61%. Secondary survival was much worse for dialysis catheters than thigh grafts (HR, 4.44; 95% CI, 3.65-5.22; P<0.001). Likewise, infection-free survival was far worse for catheters than for thigh grafts (HR, 3.77; 95% CI, 2.80-4.82; P<0.001).

CONCLUSIONS

Thigh grafts are a viable vascular option in patients who have exhausted upper-extremity options. Outcomes with thigh grafts are superior to those obtained with dialysis catheters.

Dialysis access

Although hemodialysis access procedures are considered the most common vascular procedures performed by either general or vascular surgeons, there is a paucity of level-one evidence in the literature. Randomized controlled trials are limited, and most of these studies have small sample sizes compared with other areas of vascular surgery, that is, carotid or aneurysm studies. We summarize the results of the world's literature for arteriovenous access in table format as a tool for those specialists managing patients with arteriovenous access procedures.

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.