| Abstract|| |
After years of hemodialysis we happen to be dealing with the unusable veins and requiring a vascular access. Two solutions can be proposed: the arterioarterial graft interposition or the superficial repositioning of the superficial femoral vein (SFV). We carry out 350 to 400 hemodialysis vascular accesses per year. Only 16 exceptional accesses have been realised. 7 patients have had superficial transposition of SFV. Complications observed: 1 low debit by obliteration of femoral artery treated by femoral bypass and 3 cases of thromboses (1,4 and 5 years). They either had a simple thrombectomy or one with prosthesis interposition. 9 patients had arterioarterial graft (3 brachial arteries and 6 Subclavian arteries); postoperative complications consisted of necroses skin and prosthesis infection, two precocious two thromboses of the graft (6 and 10 days) they made the subject of a thrombectomy and bleeding in the 5 th month, which required a suture. Patients had hemodialysis for 5 to 132 months. The middle length of permeability of the access was of 57 months for the superficialization of the SFV and 18 months for the arterioarterial graft. The exceptional accesses are an alternative for patients that do not have the possibility of a conventional vascular access.
Keywords: Hemodialysis fistula, Superficial femoral vein fistula, Arterioarterial jump graft.
|How to cite this article:|
Moncef G. Arterio-Arterial Graft Interposition and Superficial Femoral Vein Transposition: An Unusual Vascular Access. Saudi J Kidney Dis Transpl 2005;16:171-5
|How to cite this URL:|
Moncef G. Arterio-Arterial Graft Interposition and Superficial Femoral Vein Transposition: An Unusual Vascular Access. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2014 Mar 10];16:171-5. Available from: http://www.sjkdt.org/text.asp?2005/16/2/171/32937
| Introduction|| |
The ideal and most commonly used vascular access for hemodialysis (HD) is an arteriovenous fistula (AVF) described by Cimino and Brescia in 1966. The quality of the treatment by periodic HD largely depends on the presence of a good vascular access. However, we face many patients these days requiring a vascular access having unusable veins thus making construction of an AVF difficult.
We present our experience with two possible alternative vascular access procedures namely the arterio-arterial jump graft and the superficialization of the superficial femoral vein (SFV).
| Techniques|| |
Superficialization of the Superficial Femoral Vein:
The main indications for attempting this procedure are the presence of venous lesions and/or obstructive arterial lesions (thromboses, ligature, atherosclerosis, etc.).
The femoral vein is first evaluated by Doppler Ultrasound. The harvesting technique consists of an incision on the antero-medial surface of the thigh, beginning under the groin and extending upto four cm above the knee joint. The sartorius muscle is moved aside during preparation. The superficial femoral vein is exposed and is dissected carefully with ligature of the collaterals. The dissected superficial vein is placed in a subcutaneous canal on the anterior surface of the thigh. The vein is then anastomosed end-to-side to the artery in standard fashion. ,,,,,,
The above procedure can be performed in another fashion. A femoral AVF is first created by performing an end-to-side anastomosis between the popliteal vein and the SFV. Two months later, the vein is superficialized. This technique is not justified considering that it prolongs the usage of central catheters for dialysis by about two months.
Arterio-arterial Graft Interposition
The arterio-arterial jump graft consists of lengthening an artery using expanded polytetrafluoroethylene (PTFE) graft (bypass in loop or in buckle) [Figure - 1]. Usually, we use the subclavian artery or the superficial femoral artery, rarely the brachial artery. ,,,
The subclavian artery jump graft may be performed under local anesthesia, but light general anesthesia is preferable. This gives better airway control and ventilation and is usually well tolerated even by debilitated patients. The incision is made about three cm below the clavicle and is 10 cm long. The pectoralis major muscle is spli and the pectoralis minor muscle is divided. The axillary vein is now exposed. Ligation of branches to the vein, particularly those crossing in front of the axillary artery, is necessary for adequate mobilization. About 5-6 cm of the axillary vein should be mobilized. An end-to-end anastomosis is made between the proximal artery and a PTFE prosthesis having a diameter of at least eight mm. A circular tunnel is then made on the previous face of the thorax in which the prosthesis is placed and an end-to-end anastomosis with the distal artery is performed. The clamp on the proximal part of artery is then removed following which a good thrill is felt at the anastomosis. Used of heparinized saline followed with oral anti-coagulant (Warfarin) is obligatory. In the immediate postoperative period, small to moderate hematoma can occur in the tunnel caused by the collateral circulation and aggravated by anticoagulants. The graft can be used the following day.
The brachial arterio-arterial interposition can be achieved under local anesthesia but the skin is often of a bad quality (multiple scars) and the surface, to make the buckle, is reduced.
| Patients and Methods|| |
A total of 16 patients underwent these two vascular access procedures. Of them 15 were females and there was one male patient. The details of the demographic features of these patients are given in [Table - 1].
| Results|| |
Since 1993, out of a total 350 to 400 angioaccess procedures performed per year, only 16 unusual accesses were performed.
Superficialization of the Superficial Femoral Vein
Seven patients underwent this access procedure. Hemodialysis was commenced within three weeks after creating the access in all these patients. Access thromboses occurred in three cases (1, 4 and 5 years respectively after the procedure was performed). Two patients were treated with thrombectomy while one needed repair by interposition of a graft.
Arterio-arterial Prosthetic Graft
Nine patients had arterio-arterial prosthetic grafts (3 brachial arteries and 6 subclavian arteries). The PTFE Grafts were used for HD very early following the surgery, very often on the day following the intervention. Early thrombosis of the graft during treatment with warfarin, occurred in two cases on the sixth and tenth days respectively; both underwent thrombectomy successfully. Bleeding from the prosthesis occurred in the fifth month in one patient, and was controlled with a simple suture. Pseudoaneurysms formed after 52 months, at sites of repetitive needle puncture, and were treated by segmental replacement.
The study patients have been receiving HD treatment for periods ranging from 5 to 132 months. The median duration of use of the access was 57 months for the superficialization of the superficial femoral vein and 18 months for the arterio-arterial prosthetic graft.
| Discussion|| |
Superficialization of the Superficial Femoral Vein
The superficial femoral vein is a good vessel for use in HD. The diameter ranges from 6 to 8 mm for an adult, and the wall is thick. This vein has been used extensively as a conduit for aortic reconstructions, venous reconstructions, and infra-inguinal revascularizations and as arteriovenous fistula for HD with good long term results. ,, Jackson  reported that the superficial femoral vein is an ideal material for angioaccess in the lower extremities. The technique adapted permits avoiding a venous anastomosis and to have a large junction with the common femoral vein, with should help prevent stenosis of the venous outflow. Thomas et al  have reported that the incision used allows harvesting of both the SFV and saphenous vein which minimal skin flaps. We constructed a composite saphenous and SFV access for two reasons. First, the composite configuration increased the overall length of the access. This was particularly important for the patient with the thigh fistula where the distance from the superficial femoral artery to the subcutaneous tissue was several centimetres. Second, the smaller diameter of the saphenous vein potentially limited the quantity of blood flow through the graft and thereby avoided ischemic complications. Complications reported: ,, include thromboses, cardiac failure, symptomatic distal leg ischemia (steal syndrome), aneurysm, edema of the limb and infection.
Arterio-arterial Prosthetic Graft
The arterio-arterial transposition is an old idea. Butt and Kountz proposed it for the first time in 1976.  In 1977 Zingraffs et al  did a femoro-popliteal by-pass with a carotid bovin graft on a girl on HD who developed thrombosis of the superficial femoral artery. Over a period of 38 months Zanow et al 18 performed this procedure on 16 patients, at the femoral site (n= 3) or the subclavian site (n=13) without any post-operative complications. More than 2900 dialytic treatments via arterio-arterial graft interposition were performed. We encountered the usual complications of any prostheses including infection, rip, pseudoaneurysm and thrombosis. However, we did not note neo-intimal hyperplasia in polytetrafluoroethylene grafts which indicated good function in the long run.
These unusual vascular access procedures are to be considered only for patients who have no suitable superficial vein for arteriovenous fistula. This may result from:
a) Occlusion or unsuitability of six peripheral veins.
b) Distal ischemia caused by diabetic or arteriosclerotic angiopathy.
c) Cardiac failure with intolerable additional cardiac load, when creation of potentially high flow shunt is necessary.
| Summary|| |
The arterio-arterial jump graft and superficialization of femoral superficial vein are some exceptional angioaccesses. It is an alternative for patients who do not have the possibility of creation of a conventional vascular access. Results of these procedures are satisfactory with good flow rates even in the long run.
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[Figure - 1]
[Table - 1]