Saphenofemoral arteriovenous fistula as hemodialysis access

A comparison of arteriovenous grafts and fistulas in lower extremity hemodialysis procedures

OBJECTIVE

Although upper arm hemodialysis access is preferred due to better patency and lower complication rates, femoral access remains necessary for certain patients. This study evaluates the patency rates of femoral hemodialysis access, specifically comparing femoral vein transposition arteriovenous fistula (AVF) and arteriovenous graft (AVG), and identifying factors affecting patency.

METHODS

We conducted a retrospective review of patients who received femoral access at our institution from 2006 to 2022. Patency rates were assessed using Kaplan-Meier survival analysis. Risk factors influencing patency were examined through Cox regression modeling, and a comparative analysis between AVF and AVG was performed.

RESULTS

Ninety-one patients received femoral hemodialysis access (mean age, 63 ± 11 years; 57 males). Forty-one had AVF, and 50 had AVG. The overall 12-month and 24-month primary patency rates were 48% and 27%, assisted primary patency rates were 87% and 78%, and secondary patency rates were 90% and 89%. Subgroup analysis showed that femoral AVFs had 50% and 29% primary, 93% and 85% assisted primary, and 97% and 94% secondary patency at 12 and 24 months, respectively. Femoral AVGs demonstrated 44% and 22% primary, 82% and 73% assisted primary, and 84% and 82% secondary patency at 12 and 24 months. There was no significant difference in primary patency between femoral AVFs and AVGs (P = .858). However, the femoral AVF group had higher assisted primary patency (P < .001) and secondary patency (P = .001). Previous femoral vein catheterization on the contralateral side and infection adversely affected secondary patency (hazard ratio, 2.95; 95% confidence interval, 1.43-6.07; P = .002).

CONCLUSIONS

Lower extremity hemodialysis access yields excellent secondary patency and patient survival rates, with AVF showing superior assisted primary patency and secondary patency compared with AVG. Femoral vascular access is a viable alternative when upper extremity options are exhausted.

Femoral vein transposition fistula with short skip incisions: an optimised minimally invasive technique

OBJECTIVES

Femoral vein transposition (tFV) is a complex procedure that provides high patency rates for patients with exhausted upper-limb vascular access. Traditionally, the procedure involves a long single incision in the thigh to harvest the femoral vein, but this approach is associated with increased risks of local complications such as infections and haematomas. Skip incisions have shown to lower complication rates and shorten maturation times. We present an optimised, minimally invasive technique that transposes the femoral vein through three short skip incisions on the anterior thigh.

METHODS

We present the technical details and outcomes of three patients who underwent femoral vein transposition (tFV) for haemodialysis access. Additionally, we conducted a literature review on lower-limb vascular access options for haemodialysis.

RESULTS

Pre-operative clinical and ultrasound assessments confirmed femoral vein transposition (tFV) eligibility. The procedure involved three short skip incisions along the medial thigh to harvest the femoral vein. Subcutaneous tunnelization was performed through the anterior thigh. The arteriovenous anastomosis was sized at 3-4 mm to minimise the risk of lower-limb steal syndrome. The average procedure duration was 120 min. Postoperative recovery was uneventful, with patients discharged an average of 6 days after surgery. Wound healing was satisfactory, and the access was cannulated approximately 3 weeks post-procedure.

CONCLUSIONS

This method reduces wound complications and significantly improves the comfort of patients and dialysis nursing staff by enhancing cannulation access and increasing the availability of puncture sites, thereby improving the overall patient care experience.

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.

Straight configuration saphenous vein transposition to popliteal artery for vascular access

INTRODUCTION

The saphenous vein is commonly used as a vascular graft in peripheral artery surgery but rarely used for vascular access. The literature on straight configuration saphenous vein transposition to the popliteal artery is scarce. Here we present two cases of straight configuration saphenous vein transposition to the popliteal artery for vascular access, the surgical technique and respective follow-up.

CASE REPORT

Two young men, aged 29 and 36 years, were chosen for lower-limb vascular access for hemodialysis. The first patient was paraplegic since birth. He used his arms to move so upper extremity vascular access was avoided. The second patient presented with an infected upper extremity arteriovenous graft (AVG) and after multiple closed AVFs he had no more available arm veins. Both patients received autologous lower extremity straight configuration saphenous vein transpositions to the popliteal artery under spinal anesthesia in May and October 2012, respectively. Cannulation of the fistula was allowed after one month. There were no early complications. Slight swelling on the leg appeared in one of the patients. Both fistulas were still functional after 36 and 32 months, respectively.

CONCLUSIONS

The straight configuration saphenous vein transposition to popliteal artery is simple to perform, offers a long and straight segment for cannulation and may be a suitable autologous vascular access in selected patients.

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.

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.

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.

Small skin incision and fistula elevation for hemodialysis using the femoral vein

BACKGROUND

Wound morbidity commonly accompanies transposition of the femoral vein when used for hemodialysis access, mainly because of the length of the skin incision. A short incision may reduce wound complications but may compromise the arteriovenous (AV) function because of the shorter length of femoral vein available for puncture. This report presents our experience with a modification of the original technique, in which a smaller skin incision and fistula elevation were used.

METHODS

The clinical course of 25 AV fistulas in the thigh using the femoral vein was retrospectively analyzed. The original technique to create femoral AV access was used in 12 patients and the modified technique in 13. The procedures were performed between 2005 and 2007, and patients were monitored until January 31, 2011.

RESULTS

Three fistulas failed in each group. Five patients in the original group had wound complications. No wound complications occurred in the modified group. The fistula was first used at an average of 10.45 weeks and 6.14 weeks, respectively. Patency was similar in both groups.

CONCLUSIONS

It is possible to obtain a functional AV fistula in the thigh using the femoral vessels and limiting the extent of the incision. Long-term patency is reasonable, despite the use of a short femoral segment for puncture.

An experience of vascular access for hemodialysis in Brazil

Background

The analysis of hemodialysis services is relevant for the quality of life of patient. In this study we investigated the profile of vascular access used for hemodialysis patients in our Unit.

Methods

We evaluated 219 patients of both genders aged over 18 years old who have undergone implant or manufacture of vascular hemodialysis access. We excluded patients on renal replacement therapy by peritoneal dialysis.

Results

Associated diseases were hypertension and diabetes mellitus. 161 had arteriovenous fistula, with 153 held by the same dialysis and nine of them were still maturing. 27 patients on dialysis used central venous catheter. 148 were indigenous and five were made using polytetrafluoroethylene prosthesis (PTFE). Among the 27 patients with central venous catheters, ten used short-term catheter and 17 used long-term catheter. The most frequent type of fistula use was on the radio distal cephalic, in 85 patients (52.5%), followed by radio cephalic proximal in 26 patients (16%). The number of fistulas in dialysis patients conducted by this kind of therapy ranged from one to ten and in 64 patients (41.83%) fistula was the first and only to be made. Among the fistula for dialysis patients, the highest prevalence was radio cephalic fistula in 111 patients (72.5%) and mean duration of use was 48.1 months, ranging from two months to 17 years.

Conclusion

Our Unit of hemodialysis is above the limits established by international norms.