Lower Extremity Arteriovenous Graft Research Articles

Comparison of Lower and Upper Extremity Arteriovenous Graft: A Retrospective Clinical Analysis with 5-Year Follow-Up

For patients in whom an upper extremity (UE) vascular access cannot be established, the lower extremity (LE) arteriovenous graft (AVG) could be selected. However, the application of LE AVG is limited owing to its high infection rate, uncertain patency time, and technical difficulties. This study aimed to compare the long-term patency rates and the incidence of vascular access complications of AVG in the LE and UE to provide a reference for the applications of AVG, especially in the LEs. This was a retrospective analysis of patients who successfully underwent LE or UE AVG placement from March 2016 to October 2021. Patient characteristics were collected and compared using parameter or nonparameter tests according to data type. Postoperative patency was evaluated using Kaplan-Meier test. Postoperative complication incidence density and intergroup comparison were estimated using the Poisson distribution. Twenty-two patients with LE AVG and 120 patients with UE AVG were included. The 1-year primary patency rate was 67.4% (±11.0% standard error [SE]) in the LE group and 30.1% (±4.5% SE) in the UE group (P=0.031). The assisted primary patency rate at postoperative months 12, 24, and 36 was respectively 78.6% (±9.6% SE), 65.5% (±14.4% SE), and 49.1% (±17.8% SE) in the LE group and 63.3% (±4.6% SE), 47.5% (±5.4% SE), and 30.4% (±6.1% SE) in the UE group (P=0.137). The secondary patency rate at postoperative months 12, 24, and 36 remains 95.5% (±4.4% SE) in the LE group and 89.3% (±2.9% SE), 83.7% (±3.9% SE), and 73.0% (±6.2% SE), respectively, in the UE group (P=0.200). Postoperative complications included stenosis, occlusion/thrombosis, infection, steal syndrome, pseudoaneurysm, severe postoperative serum swelling, and AVG exposure. The total incidence rates of postoperative complications were 0.87 (95% confidence interval [CI] 0.59-1.23) versus 1.61 (95% CI 1.45-1.79) (P=0.001) cases/person-year, the incidence rates of stenosis were 0.45 (95% CI 0.26-0.73) versus 0.92 (95% CI 0.80-1.06) (P=0.005) cases/person-year and the incidence rates of occlusion/thrombosis were 0.34 (95% CI 0.17-0.59) versus 0.62 (95% CI 0.52-0.74) cases/person-year in the LE group compared to those in the UE group (P=0.041). LE AVG had higher primary patency rate and lower postoperative complication incidence than UE AVG. With the development of interventional technology, both LE AVG and UE AVG exhibited high secondary patency rates. LE AVG can be a reliable and long-term alternative for appropriately selected patients with unusable UE vessels.

SS14. Outcomes Comparison of Chest Wall Arteriovenous Grafts and Lower Extremity Arteriovenous Grafts in Patients With Long-Standing Renal Failure

SS14. Outcomes Comparison of Chest Wall Arteriovenous Grafts and Lower Extremity Arteriovenous Grafts in Patients With Long-Standing Renal Failure

Long Term Outcomes of Arteriovenous Grafts for Hemodialysis in Lower Extremities.

Purpose:The lower extremity has received its fair share of attention as a vascular access site in patients who have exhausted their upper arm vessels. However, experiences with lower extremity arteriovenous grafts (AVGs) have so far been disappointing because of high infection rates and severe limb ischemia. We report our experience with hemodialysis access from the lower extremity.Materials and Methods:A retrospective review of 60 lower extremity AVGs created between January 2003 and December 2011 was performed. Age, sex, etiology of end-stage renal disease and complications were tabulated. Primary and secondary patency rates were determined.Results:The average age of the study population was 56 years and 38 patients were female. Renal failure was associated with hypertension in 40 (66.7%) patients, diabetes in 28 (46.7%) patients and cardiovascular disease in 9 (15.0%) patients. The follow-up period was 8–108 months. Fifty-four patients had bilateral central vein stenosis. Seven (11.7%) patients had primary failure of their AVG. There was no operation-related death. Primary and secondary patency rates were: 66% and 90% at 1 year, 40% and 90% at 2 years, 27% and 87% at 3 years, and 18% and 87% at 5 years, respectively. There were 105 postoperative complications that developed in 67 patients. Postoperative complications were: thrombosis (30), proximal vein stenosis (56), infection (9), bleeding with hematoma (1), perigraft seroma (3), steal syndrome (2), and pseudoaneurysm (4).Conclusion:A lower extremity AVG seems to be a viable option in patients with unusable upper extremity veins.

Outcomes comparison of HeRO and lower extremity arteriovenous grafts in patients with long-standing renal failure

The Hemodialysis Reliable Outflow (HeRO) graft is becoming a recognized alternative to lower extremity arteriovenous grafts (LEAVGs) as an option for patients who have exhausted traditional upper extremity access; however, which should be applied preferentially is unclear. A retrospective review of LEAVG and HeRO implants from January 2004 to August 2010 was performed. Patient demographics, medical history, procedural data, and outcomes were evaluated. Within the time periods, 60 HeROs were placed in 59 patients and 22 LEAVGs were placed in 21 patients. Demographics were similar between the two groups for many factors; however, the patients who underwent HeRO placement had significantly higher body mass index compared with the LEAVG group. Mean follow-up was 13.9 months for the HeRO group and 11.9 months for the LEAVG group. The HeRO patients underwent a mean of 6.3 previous tunneled dialysis catheter insertions and 3.1 previous AVG/arteriovenous fistula placements. The LEAVG patients underwent placement of a mean of 4.1 previous tunneled dialysis catheters and 2.6 previous AVG/arteriovenous fistulas. The principal difference was the number of interventions to maintain patency, which was 2.21 per year in the HeRO group and 1.17 per year in the AVG group (P = .003) Secondary patency at 6 months was 77% for the HeRO patients and 83% for the LEAVG patients (P = .14). The HeRO and LEAVG groups had no difference in infection rate per 1000 days (0.61 vs 0.71; P = .77) or mortality rate (22% vs 19% respectively; P = .22) at 6 months. In access challenged patients, LEAVG and HeRO offer similar rates of secondary patency, infection, and all-cause mortality. The LEAVG required fewer interventions to maintain patency, and the HeRO maintains the benefit of utilizing the upper extremity site of venous drainage. In our practice, we prefer the HeRO to LEAVG, especially in patients with peripheral arterial disease and in the obese population, because it preserves lower extremity access options.

SS23. Outcomes Comparison of HeRO and Lower-Extremity Arteriovenous Graft in Patients with Long-Standing Renal Failure

The HeRO (Hemodialysis Reliable Outflow) graft is becoming a recognized alternative to Lower Extremity AV Grafts (LEAVG) as an option for patients who have exhausted traditional upper extremity access; however it is unclear which should be applied preferentially. A retrospective review of LEAVG and HeRO implants from January 2006 to August 2010 was performed. Patient demographics, medical history, procedural data and outcomes were evaluated. Within the time periods, 62 HeRO's were placed in 61 patients and 23 LEAVG were placed in 21 patients. Demographics were similar between the two groups for gender, age, BMI, and race. Average follow-up was 14.6 months. The HeRO patients underwent a mean of 6.4 previous TDCs and 3.1 previous AVG/AVFs. The LEAVG patients underwent a mean of 4.1 previous TDCs and 2.8 previous AVG/AVFs. The principal difference was a 1 year primary patency of 26% for the HeRO group and 60% for the LEAVG group (P = .01). The number of interventions to maintain patency was 6.2 per year in the HeRO group and 3.7 per year in the AVG group (P = .40). Secondary patency at 1 year was 61% for the HeRO patients and 66% for the AVG patients (P = .56). The HeRO group and LEAVG had no difference in infection rate (31% vs. 30%) or mortality rate (33% vs 21% respectively) at 1 year. In access challenged patients, LEAVG and HeRO offer a higher incidence of infection, mortality and loss of patency compared to traditional upper extremity access. The LEAVG offers improved primary patency rate over the HeRO device.

Increasing Dialysis Access Options in Lower Extremity: Retroperitoneal Approach for External Iliac Artery-Vein Arteriovenous Graft

Exhaustion of upper extremity dialysis access options is becoming more prevalent due to the longer survival of this patient population. In addition, central venous occlusive disease (CVOD) increases the risk of losing access viability in the ipsilateral extremity. We describe a novel technique of lower extremity arteriovenous graft (AVG) placement in which the external iliac artery and vein are utilized, as illustrated in 2 selected cases. Two dialysis patients presented with exhausted upper extremity access options and bilateral intrathoracic CVOD. In patient 1, a venogram demonstrated complete occlusion of the left common iliac vein and severe stenosis of the right common femoral vein, rendering these unsuitable for access creation. In patient 2, with a history of peripheral arterial disease, an arteriogram revealed that the common and superficial femoral arteries were inadequate for access creation bilaterally. A retroperitoneal approach was utilized for a right external iliac artery and vein arteriovenous graft tunneled under the inguinal ligament to the anterior thigh. Adequate thrill and uneventful postoperative course were observed in both cases. At 10 months, patient 1 has done well on hemodialysis without the need for further intervention. Patient 2 has only recently had the procedure and is not yet using her graft. As the number of patients requiring lower extremity vascular access increases, new surgical techniques will become available to handle the clinical and anatomic challenges encountered in this population.

Mid-thigh Arteriovenous Graft in Lower Extremity Vascular Access Construction for Hemodialysis Patients

Patients who receive dialysis rely on vascular access. With advances in hemodialysis technique and dialysis service, the lifespan of patients has increased, but the sites of arteriovenous access in the upper extremities are exhausted after long-term use. In this situation, lower extremity arteriovenous graft is a popular choice by using the common femoral artery over the groin area. Unfortunately, the long-term patency rate is not satisfactory in lower extremity loop graft and there is a high infection rate. We investigated the feasibility of constructing arteriovenous access at the mid-thigh level when the upper extremity vessels are exhausted. [ Hong Kong J Nephrol 2007;9(2):86–8]

Axillary to Common Iliac Arteriovenous Graft for Hemodialysis Access: Case Report and Review of “Exotic” Axillary-Based Grafts

A 58-year-old Caucasian male with end-stage renal disease and peripheral arterial disease was referred to us for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. Magnetic resonance venography (MRV) of his chest revealed extensive bilateral venous occlusions due to numerous past hemodialysis access catheters. The patient was scheduled for right lower extremity arteriovenous graft placement, but intraoperatively was found to have severe peripheral arterial disease and a thromboendarterectomy was performed instead. Lower body venous imaging demonstrated patent iliac veins. Based on these anatomic considerations a right axillary artery to right common iliac vein polytetrafluoroethylene (PTFE) graft was placed. The graft required revision twice--once for graft ultrafiltration at the arterial end of the graft and once for needle stick infection--but continues to serve as sufficient access after 15 months. Grafts based off the axillary artery have become increasingly popular in recent years and several venous outflow options have been considered, each with distinct advantages. The common iliac vein offers a central location with high flow rate and low probability of infection. Axillary artery to iliac vein arteriovenous grafting may have a place in the vascular surgeon's armamentarium for complex vascular access cases.

Complications of Lower Extremity Arteriovenous Grafts in Patients With End-Stage Renal Disease

More data are needed to assess lower extremity angioaccess sites for hemodialysis. We did a retrospective review of 843 consecutive hospital records of upper and lower extremity arteriovenous (AV) fistulas from 1992 to 1996. Lower extremity grafts accounted for 16% (134/843) of patients in this series. Complications occurred in 58 of 134 patients (43%) and were more prevalent in women, blacks, diabetic, and hypertensive patients, but not of statistical significance. Dialysis was done for a mean duration of 13.3 years, with a mean graft patency rate of 13.8 months. The 12-month survival rate of lower extremity AV grafts was 62% (83/134). Complications in the lower extremity AV graft group (58 patients) included infections in 27 patients (46%), thrombosis within 30 days in 16 (28%), pseudoaneurysm in 9 (16%), and graft hemorrhage in 6 (10%). There is a decreased patency rate in lower extremity AV grafts.