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

ORIGINAL ARTICLE

J Vasc Access 2011; 12 ( 3): 253-257 DOI: 10.5301/JVA.2011.6387

Composite PTFE-transposed superficial femoral vein for lower limb arteriovenous access Efstratios I. Georgakarakos, George S. Georgiadis, Nikolaos G. Schoretsanitis, Konstantinos C. Kapoulas, Miltos K. Lazarides Department of Vascular Surgery, University Hospital of Alexandroupolis, Demokritos University, Alexandroupolis Greece Department of Vascular Surgery, University Hospital of Alexandroupolis, Demokritos University, Alexandroupolis - Greece Department of Vascular Surgery, University Hospital of Alexandroupolis, Demokritos University, Alexandroupolis - Greece Department of Vascular Surgery, University Hospital of Alexandroupolis, Demokritos University, Alexandroupolis - Greece Department of Vascular Surgery, University Hospital of Alexandroupolis, Demokritos University, Alexandroupolis - Greece

ABSTRACT 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. Key words: Arteriovenous fistula, Composite graft, Hemodialysis, Superficial femoral vein, Transposition

JVA_10_1101_GEORGAKARAKOS

Accepted: December 22, 2010

INTRODUCTION

MATERIAL AND METHODS

Angioaccess in the lower limb is currently gaining increased attention, since an increasing number of end-stage renal disease patients need a reliable and durable arteriovenous (AV) access after failure or exhaustion of multiple upper extremity vascular access sites. Several methods for lower-extremity AV access for hemodialysis have been described, ranging from placement of permanent femoral catheters to the construction of autologous and prosthetic AV fistulas (AVFs) (1, 2). Among these, superficial femoral vein transposition (tSFV) is associated with better primary and secondary patency rates than femoral synthetic grafts, as well as lower infection and consequent access loss rates, at the expense of more frequent postoperative ischemia, due to steal syndrome (1). The aim of this paper is to present our primary experience with 3 cases of composite tSFV-polytetrafluoroethylene (PTFE) loop grafts for lower limb access, focusing on the pathophysiology of flow due to the interposition of a PTFE segment.

Patient 1 A 79-year-old male patient with end-stage renal disease had required hemodialysis for 8 years. The patient was neither diabetic nor obese. Past history revealed several AVF access operations in both upper arms. On physical examination, he had palpable pulses over the dorsalis pedis arteries, and his ankle-brachial index (ABI) was estimated to be 1.0 bilaterally. Two longitudinal, tandem incisions separated by a skin bridge were performed parallel to the medial border of the sartorius muscle, and the SFV segment was mobilized up to the adductor canal, with ligation of all small tributary branches, up to the level of the common femoral vein (CFV), sparing the profunda femoral vein representing the main collateral leg outflow. A 6-mm PTFE (Gore Intering Vascular Graft) was anastomosed end-to-side to the common femoral artery and positioned laterally, superficial to the sartorius muscle and lying deep in the

© 2011 Wichtig Editore - ISSN 1129-7298

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Composite femoral vein-synthetic graft for dialysis access

Fig. 2 - Peak systolic velocity (PSV) and end diastolic velocity (EDV) values along the different segments of the polytetrafluoroethylene (PTFE)transposed superficial femoral vein (SFV) loop.

Fig. 1 - The different segments of the polytetrafluoroethylene (PTFE)transposed superficial femoral vein (SFV) loop (schematic drawing of the operation in insert above right).

subcutaneous plane (Fig. 1). The SFV was divided distally and tunneled to the skin subcutaneously in the medial aspect of the thigh. The anastomosis between the PTFE and the transposed vein was created with a running 6-0 Prolene suture in a beveled end-to-end fashion rather than in perpendicular end-to-end fashion, to minimize the risk of anastomotic narrowing. A drainage closed system was put in the thigh and was removed at the first postoperative day, and the patient was fully mobilized. The patient was treated with low-molecular-weight heparin at a therapeutic dose for 10 days with additional application of compression stockings. The entire loop was examined in the sixth postoperative month, with color duplex Doppler ultrasound (L25e/13-6 MHz; Micromaxx; Sonosite, Bothell, WA, USA). The values of peak systolic velocity (PSV) and end diastolic velocity (EDV) in the feeding common femoral artery (CFA) just prior to the central anastomosis (site 1) and 4 sites in the PTFE segment along its course (sites 2-5) with its last site being just proximal to the PTFE-vein anastomosis (site 5) were recorded. The location of the anastomosis was referred to as site 6. Accordingly, the PSV and 254

EDV along the venous segment of the loop (sites 7-10), up to the transposed SFV-CFV conjugation were recorded. Finally, the maximum diameter (mm) in 6 different sites along the vein segment (from just distal to the anastomotic site, to a few centimeters before the confluence to the CFV) was estimated. Values were compared according to t-test (2-tailed), and a p value