The femoral artery-femoral vein polytetrafluoroethylene graft: a 14-year retrospective study

A left femoral artery to right femoral vein bypass graft for hemodialysis access: A case report

RATIONALE

As survival prospects improve for long-term patients with hemodialysis, it is common for patients to exhaust all upper extremity access options before other avenues need exploration. The purpose of this case report was to describe our experience in creating a prosthetic graft between left femoral artery and right femoral vein in a patient with history of central venous occlusion and bilateral femoral neck fracture.

PATIENT CONCERNS

A female patient with hemodialysis exhausted all upper extremity access options along with bilateral femoral neck fracture.

DIAGNOSES

Patients with end-stage renal disease exhausted all upper extremity access options.

INTERVENTIONS

We performed a left femoral artery to right femoral vein dialysis access utilizing a prosthetic graft and autologous cephalic vein.

OUTCOME

The graft was used for hemodialysis 3 weeks after the operation. There was no edema of the lower extremity through the immediate postoperative period as well as at follow up. The patient has been using the access for 9 months with no complication of thrombosis, infection, or bleeding.

LESSONS

Prosthetic graft between the left femoral artery and right femoral vein is a simple, safe and novel approach to creating lower extremity access. This method could be a viable means of hemodialysis access in selected patients.

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.

Cuffed-tunneled Femoral Catheter for Long-term Hemodialysis

Background

Hemodialysis access is a challenging problem in patients with exhausted dialysis access sites of their upper extremities. Femoral arterio-venous polytetrafluoroethylene (PTFE) graft is often necessary. The safety and efficacy of cuffed tunneled catheters at the femoral site for long-term hemodialysis has not been extensively studied.

Methods

We inserted 14 cuffed-tunneled femoral catheters in 11 hemodialysis patients with exhausted dialysis access sites of their upper extremities. Access survival and risk of infection were compared with the 11 femoral PTFE grafts in 10 patients of our center during the same period. The choice of dialysis access was determined by the individual nephrologist. Access survival was defined as the achievement of a blood flow rate of at least 180 ml/min.

Results

The median survival of tunneled femoral catheter and PTFE graft were 166 days and 560 days respectively (log-rank test, p = 0.33). Seven of the 14 tunneled femoral catheter remained in use 3 months after insertion. The incidence of catheter- or graft-related infection was 0.38 and 0.23 episodes per 100 catheter / graft days for tunneled femoral catheters and PTFE graft respectively (p = 0.6). Five tunneled catheters and one PTFE graft had to be removed because of infection. Blood flow rates achieved were comparable between tunneled femoral catheter and PTFE graft.

Conclusions

Our preliminary data suggest that the cuffed tunneled femoral catheter has reasonable access survival and an acceptable risk of infection. It may provide a safe and effective access for long-term hemodialysis patients with exhausted access in their upper extremities, especially high risk patients who are not suitable for femoral PTFE graft creation.

Haemodialysis Access: A Single Centre UK Experience

Background

The aim of this study was to determine whether the US National Kidney Foundation Disease Outcome Quality Initiative (K/DOQI) guidelines on haemodialysis access could be achieved and to examine its relevance to patients on dialysis in the UK.

Method

A cross sectional study of chronic haemodialysis patients at our institution which involved case note review and measurements of biochemical parameters and dynamic venous pressure (dVP) was performed. Patients with polytetrafluoroethylene (PTFE) grafts were followed prospectively for 18 months.

Results

262 patients were studied - 12%, 43%, 30% and 15% underwent dialysis through dialysis catheters, radial-cephalic fistulae (rAVF), brachial-cephalic fistulae (bAVF) and PTFE grafts respectively. RAVFs, bAVFs and PTFE grafts were the primary access (i.e. the first access created for the patient) in 58%, 35% and 7% respectively. Compared with patients of Caucasian origin, patients of Afro-Caribbean race were 3.80 times (95% confidence limit: 1.51 – 9.53) more likely to have a PTFE graft. Patients with higher “dry weights” were more likely to have PTFE grafts (p<0.005 by ANOVA). Dialysis adequacy was similar irrespective of type and site of access. We found that 64% of PTFE grafts, 46% of bAVFs and 13% of rAVF had dVPs greater than 150 mmHg, (p<0.0001 by χ2). This threshold recommended by DOQI predicted 12 of 13 dysfunctional grafts, but had a positive predictive value of only 50%.

Conclusion

We have demonstrated that the K/DOQI guidelines are not only achievable, but that they can be exceeded by a considerable margin. Our data also suggest that the demographic details of patients within a unit will influence the achievable proportion of AVF: PTFE grafts (the proportion of PTFE grafts in Afro-Caribbeans being 3 times higher than in Whites). Although a dVP >150 mmHg proved sensitive in predicting future graft dysfunction, it had low specificity.

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.

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.

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.

Arteriovenous grafts in the thigh: an excellent hemodialysis vascular access when arm vasculature is exhausted

The aim of our retrospective analysis with prospective collected data was to evaluate the patency of thigh expanded polytetrafluoroethylene (ePTFE) arteriovenous (AV) grafts, which were placed in chronic hemodialysis patients by the same interventional nephrologist skilled in hemodialysis access vascular surgery. From February 1991 until March 2013, 35 thigh ePTFE grafts were placed in 31 chronic hemodialysis patients. Twenty (57%) were women, mean age 58.7 ± 14.5, dialysis vintage 11.9 ± 7.3 years, mean number of previous vascular accesses 4.4 ± 1.9. Two of the 35 (5.7%) grafts were lost to follow-up, immediate failure occurred in 1/35 (2.8%) grafts, and thrombosis appeared within 30 days in 2/35 (5.7%) grafts. Four of the 31 patients died with functioning grafts, while in 9/31 patients the grafts are still patent. In the remaining 17 AV grafts that thrombosed, no surgical intervention was performed in 8/17, while 18 thrombectomies (two per graft) were performed in 9/17 to maintain graft patency. The immediate success rate was 97.1%. Primary patency was from 0-3251 days, on average 906 ± 898, median 472, cumulative patency (N = 33) was from 0-3251 days, on average 1174 ± 954, median 966. Cumulative patency of the grafts that were patent for more than 30 days (N = 30) was from 153-3251 days, on average 1298 ± 921, median 1207. The ePTFE graft survival after the 1st year was 78%, after the 2nd year 74%, after the 3rd year 66%, after the 4th year 56%, after the 5th year 52%, and after the 9th year 13 %. The longest patency was 3251 days without any intervention. Steal syndrome occurred in two patients after 2522 and 275 days after fistula placement.

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.

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.

Thigh grafts contribute significantly to patients' time on dialysis

BACKGROUND AND OBJECTIVES

Thigh grafts are placed in hemodialysis patients who have exhausted all arm access sites. The goal of this study was to compare the survival, complication rates, and overall contribution of thigh grafts with arm grafts and fistulas in patients with at least one functional thigh graft during their dialysis history.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This longitudinal review of a prospectively acquired clinical database included 85 thigh graft recipients. The rates of survival, thrombosis, infection, and other complications were determined for a total of 268 fistulas, arm grafts, and thigh grafts placed in these patients.

RESULTS

In this patient subset, thigh graft primary failure rate was lower than arm grafts and fistulas (3 versus 13 and 61%, respectively). Excluding primary failures, thigh grafts survived longer than both arm grafts and mature fistulas (53 versus 14 and 32%, at 3 years; 47 versus 3 and 11% at 5 years). Thigh grafts had a lower thrombosis rate than arm grafts (0.543 versus 1.457/patient-year) but similar rates of loss as a result of infection and surgical revision. In patients with previous arm accesses, thigh grafts contributed 51% of total dialysis time compared with 38 and 11% for arm grafts and fistulas.

CONCLUSIONS

Thigh grafts provide long-term, thrombosis- and infection-free dialysis access for patients with exhausted arm access sites. The decision for thigh graft placement should, therefore, be made as soon as there is evidence for unavailability of arm access sites so that catheter use can be minimized.

Thigh grafts: a preferable alternative to catheters when upper extremity access sites are exhausted

Hemodialysis patients with failed upper extremity (arm) access sites comprise 5-10% of the dialysis population. In these patients, arm vessels are either unsuitable for access placement due to trauma or peripheral vascular disease, or have been exhausted following dialysis usage. Synthetic grafts in the lower extremity (thigh) would benefit these patients, but surgeons are often reluctant to place them, due to concerns of infection and vascular complications. As a result, these patients receive tunneled central venous catheters as their permanent dialysis access. Recent studies have shown, however, that survival and complication rates of thigh grafts are similar to arm grafts and fistulas. Moreover, thigh grafts have lower infection and mortality rates than catheters and provide higher blood flows and dialysis adequacy. In this editorial we argue that thigh grafts are the better option in patients who have lost all arm access sites; they should be placed in preference to tunneled central venous catheters.

Single center review of femoral arteriovenous grafts for hemodialysis

INTRODUCTION

It is unclear how to manage high risk hemodialysis patients who present with an indwelling catheter. The National Kidney Foundation Practice Guidelines urge prompt removal of the catheter, but the guidelines do not specifically address the problem of patients whose only option is a femoral arteriovenous (AV) graft.

METHODS

This study was a retrospective review of all patients who underwent femoral AV graft placement for hemodialysis access between January 1, 1996 and January 1, 2003 at the University of Michigan Health System (UMHS). Graft patency is reported according to the standards developed by the Society of Vascular Surgery and the American Association of Vascular Surgeons.

RESULTS

Thirty patients were identified who had undergone femoral AV graft placement. The mean follow-up was 23 months (range 1-75 months). The patients had had significant medical co-morbidities and multiple previous access operations (mean 3; interquartile range 1-5). The 1-year secondary graft patency rate was 41%, the 2-year rate was 26%, and the 3-year rate was 21%. Infection was the cause of final graft loss in eight patients (50% of the grafts losses, 27% of the total grafts placed.) Among those who died (n=14), the mean time from femoral graft placement to death was 31.2+/-27.5 months. The patient survival was quite low: at 1 year 81%, at 2 years 68%, and at 3 years 54%.

CONCLUSIONS

These complex patients who have exhausted their upper extremity hemodialysis options do poorly following femoral AV graft placement. Consideration should be given to long-term catheter-based access in some of these patients.

Percutaneous declotting of virgin femoral hemodialysis grafts

OBJECTIVE

The objective of our study was to evaluate outcomes of percutaneous declotting procedures in patients with prosthetic femoral dialysis grafts.

MATERIALS AND METHODS

A retrospective review of all pharmacomechanical femoral dialysis graft declotting procedures performed in our hospital between May 11, 1993, and April 30, 2003, was performed. A total of 110 procedures were performed on 25 patients (nine males, 16 females; age range, 17-80 years; mean age, 49 years) with 30 grafts.

RESULTS

Technical success was 97.3%. Using life table analysis, 30-day postinterventional primary patency was 72%, 90-day primary patency was 46%, 180-day primary patency was 25%, and 365-day primary patency was 4%. The 30-day secondary postinterventional patency was 93%, 90-day secondary patency was 86%, 180-day secondary patency was 76%, and the 365-day secondary patency was 51%. An average of 1.96 declotting procedures were performed per year of dialysis.

CONCLUSION

Percutaneous declotting of femoral hemodialysis grafts has technical success and patency rates similar to those for percutaneous declotting in the upper extremities. Results of this series exceeded criteria established by the National Kidney Foundation in the "Dialysis Outcome Quality Initiative" for immediate patency and unassisted 3-month patency.

Vascular Access in Hemodialysis Patients with Central Venous Obstruction or Stenosis: One Center's Experience

The purpose of this study was to evaluate the value of complex hemodialysis access procedures among patients with central venous obstruction who were running out of access sites. Between September 2002 and December 2003 we performed a total of 640 new hemodialysis access procedures in 3 renal units. Ten of these patients presented central vein stenosis or obstruction and were not suitable for peritoneal dialysis. Each of the 10 patients had 3 or 4 previous failed access procedures and numerous infected central lines and their dialysis catheters were not functioning adequately. Nine patients presented with a severely stenosed or occluded superior vena cava and 1 had both subclavian veins occluded. Three patients were diabetics, 2 were obese and 6 had hypertension. We performed 12 procedures on these 10 patients. Saphenous veins were used 6 times, twice as a loop to the femoral artery and 4 times as a transposition to the popliteal artery above the knee. Femoral vein transposition to the popliteal artery was carried out in 2 cases. We performed 3 axillary artery to popliteal vein polytetrafluoroethylene (PTFE) bypasses, 1 on an obese woman who had no saphenous vein and was not suitable for a femoral vein transposition, 1 on a diabetic woman whose saphenous vein loop clotted after 5 months and 1 on a female patient with severe peripheral vascular disease. The patient with bilateral subclavian vein occlusion had a brachial artery to internal jugular vein PTFE graft. The PTFE graft to the jugular vein has been patent and regularly needled with a follow-up of 4 months. Four saphenous vein fistulae were regularly used for dialysis; 2 were never used. Five saphenous fistulae clotted after an average life span of 4 months (range 3 weeks-9 months) and 1 is still patent and in use (5 months). Both femoral vein transpositions have been patent and have been needled 3 times a week with a follow-up of 10 and 4 months; one had to be revised surgically after 9 months. Of the 3 axillary artery to popliteal vein grafts, 1 had to be tied off after a week because of severe steal syndrome and 2 have been patent (20 months follow-up) and have been needled regularly ever since. Seventy percent of these patients have been dialyzed line-free through their fistula despite severe central vein stenosis or obstruction for periods of 9-18 months when this review was undertaken. Although the follow-up needs to be longer, we discuss the surgical, radiologic, and dialysis features of these patients and propose a management pathway for central vein stenosis or occlusion.

Saphenous Vein Loop to Femoral Artery Arteriovenous Fistula: A Practical Alternative

Secondary to central venous stenosis or thrombosis, alternate sites for permanent hemodialysis need to be explored. The authors' experience with the greater saphenous vein to common femoral artery loop arteriovenous fistula (GSV-CFA AVF) is presented. A retrospective review was performed of 4 women and 3 men with a mean age of 52.7 (range, 44-68) years. The mean number of prior access procedures was 3.85 (range, 1-5). Duplex ultrasound showed the greater saphenous vein (GSV) to be at least 3 mm in diameter. Perioperatively, no acute occlusion or significant steal syndrome developed. Groin wound complications (57.1%) resolved with local wound care and selectively antibiotic administration. Six patients developed mild to moderate edema, which required knee-high compression stockings. The mean follow-up was 15 (range, 9-24) months. Mean primary patency was 7 months, primary assisted patency was 15 months, and secondary patency was 16 months. The fistula was functional for hemodialysis in 71.4% (5/7). All patients developed stenoses within the GSV loop, with a mean of 3.0 balloon angioplasties per fistula. Three secondary surgical procedures were performed (two pseudoaneurysm repairs, one vein patch angioplasty). The GSV did not increase significantly in diameter. Use of a GSV-CFA AVF for dialysis access has acceptable results for alternate-site hemodialysis access. Secondary procedures were common. Factors recognized to be important for success were an adequate-sized GSV preoperatively, positioning of the GSV loop, and patient body habitus.