Creation and closure of temporary arteriovenous fistulas for venous reconstruction or thrombectomy: description of technique

Abstract

A temporary arteriovenous fistula (AVF) created after venous reconstructive surgery or venous thrombectomy has been shown by some investigatoars to enhance patency rates.1Plate G Hollier LH Gloviczki P Dewanjee MK Kaye MP. Overcoming failure of venous vascular prostheses.Surgery. 1984; 96: 503-510PubMed Google Scholar, 2Ijima H Kodama M Hori M. Temporary arteriovenous fistula for venous reconstruction using synthetic graft: a clinical and experimental investigation.J Cardiovasc Surg. 1985; 26: 131-136PubMed Google Scholar, 3Plate G Einarsson E Ohlin P Jensen R Qvarfordt P Eklöf B Thrombectomy with temporary arteriovenous fistula: the treatment of choice in acute iliofemoral venous thrombosis.J Vasc Surg. 1984; 1: 867-876PubMed Scopus (181) Google Scholar Construction of these fistulas is often easier than closing them because ligation of a temporary AVF can be a formidable procedure. After both saphenous vein and prosthetic material were used in a variety of configurations, it was found that a looped polytetrafluoroethylene (PTFE) graft made an excellent fistula that could be closed easily with the patient under local anesthesia. This article describes the technique and experience with such a looped PTFE fistula. Twelve patients had temporary AVFs created, five after thrombectomy and seven after venous reconstructions. The venous reconstructions included five cross-leg vein grafts, one axillojugular vein bypass, and one saphenopopliteal vein bypass. Saphenous vein was used in three patients and PTFE in nine. Six millimeter PTFE was used in six instances, 5 mm PTFE in two, and 4 to 6 mm tapered PTFE in one. Patients with iliofemoral thrombectomies or cross-leg vein grafts had a fistula placed with the following technique: an oblique incision in the inguinal skinfold is made and the primary procedure is performed. A PTFE graft is then sutured, end to side, to the common femoral vein, either at the venotomy site after thrombectomy or at a site just distal to a venous bypass. The graft, 10 to 15 cm long, is then arced up towards the skin in a gentle curve so it will lie in the subcutaneous fat, a few millimeters under the incision, and brought back down to the common femoral artery. After a 15 mm arteriotomy is done, the arterial anastomosis is completed with 6-0 polypropylene sutures (Fig. 1).Postoperatively, the patient is given heparin for a period of 5 to 7 days at a partial thromboplastin time of 1.5 to 2 times control. Oral anticoagulation with warfarin is begun postoperatively and continued for 6 months. For subclavian vein reconstruction, the AVF is placed in the arm between the brachial artery and the brachial vein. The arteriotomy in the arm is several centimeters distal to the venotomy and the PTFE graft is looped close to the skin. Alternately, a Teflon-supported PTFE graft is sewn to the axillary vein and artery, looping the graft toward the infraclavicular incision. For saphenopopliteal bypass, the arterial anastomosis to the superficial femoral artery is constructed at Hunter's canal and is tapered to 4 mm to avoid a steal. The graft is passed through the popliteal fossa. Once below the knee, the PTFE graft is looped into the subcutaneous space and then down to the popliteal vein below the saphenopopliteal anastomosis. Eight to 16 weeks later, ligation of the fistula is done with either local or general anesthetics while the patient is still anticoagulated. Through the original skin incision, the graft is localized with a sterile Doppler probe, dissected circumferentially, doubly clamped, and transected. The two ends are each dissected deep into the subcutaneous tissue, oversewn, and buried in the wound. The incision is closed with subcutaneous and subcuticular sutures. Spontaneous occlusion occurred in two of the 12 grafts—one 5 mm PTFE graft and one saphenous vein. In both cases, the repair remained open. Of the 10 patent AVFs (83%), three failed to maintain an open repair (two thrombectomies and one venous reconstruction).