Surgical Approach of an Infected Saphenofemoral Looped PTFE Graft Arteriovenous Fistula and Arterial Reconstruction with Cryopreserved Allograft

Abstract

Introduction: Autologous arteriovenous fistula is still the most popular vascular access for hemodialysis [1]. There have been few reports of saphenofemoral arteriovenous fistulas over the last 10 to 20 years because of suggestions of high morbidity, poor patencies and needling difficulties [2]. Some disadvantages of using this access are the necessity for a more extensive and deeper dissection using larger vessels and greater susceptibility to infection and steal syndrome [3, 4]. Attention should be paid to the patient's vasculature before surgery, through the "maturation" phase and chronic use [5]. Case report: A 72-year-old female with a history of arterial hypertension, diabetes mellitus and chronic renal failure requiring three-weekly hemodialysis, with a 4-day history of a painful and hot mass in the right thigh, fever, and hemoglobin decline. Physical examination: hematoma at the right inguinal region, presence of a tourniquet, femoral pulse 2/2 and not assessable distal pulses due to edema; coldness, and increased capillary refill. Aortoiliac and lower limb angiotomography showed: ruptured pseudoaneurysm of the right common femoral artery, ipsilateral superficial femoral artery injury and prosthetic femoral arteriovenous fistula infection. Open emergency approach through an infra-inguinal longitudinal incision was performed, draining a large hematoma and pus, finding an infected prosthetic PTFE graft from a saphenofemoral loop fistula with injury of the right superficial femoral artery and active bleeding at the site, plus dehiscence of saphenous anastomosis. Thrombectomy of the superficial and common femoral artery, en bloc arteriotomy of the right superficial femoral artery and arterial reconstruction with a cryopreserved arterial allograft with end-to-end anastomosis was performed. A Vacuum Assisted Therapy (VAC® ) system was created to cover the surgical site. Patient deceased from hypovolemic shock. Conclusions Unusual site AVFs (i.e., saphenofemoral loop graft AVFs) should be carefully followed-up to reduce the risk of complications and raise the awareness to diminish associated morbidity and mortality. An arterial cryopreserved allograft may be used for arterial reconstruction in the setting of an infected wound. The goal must be to spread more knowledge in this critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients' quality of life and survival rates.