Ultrasound-guided cannulation of the superficial femoral vein for central venous access

BACKGROUND

In some clinical conditions, central venous access is preferably or necessarily achieved by threading the catheter into the inferior vena cava. This can be obtained not only by puncture of the common femoral vein at the groin, but also-as suggested by few recent studies-by puncture of the superficial femoral vein at mid-thigh.

METHODS

We have retrospectively reviewed our experience with central catheters inserted by ultrasound-guided puncture and cannulation of the superficial femoral vein, focusing mainly on indications, technique of venipuncture, and incidence of immediate/early complications.

RESULTS

From June 2020 to December 2020, we have inserted 98 non-tunneled central venous catheters (tip in inferior vena cava or right atrium) by ultrasound-guided puncture of the superficial femoral vein at mid-thigh or in the lower third of the thigh, all of them secured by subcutaneous anchorage. The success of the maneuver was 100% and immediate/early complications were negligible. Follow-up of hospitalized patients (72.5% of all cases) showed only one episode of catheter dislodgment, no episode of infection and no episode of catheter related thrombosis.

CONCLUSIONS

The ultrasound approach to the superficial femoral vein is an absolutely safe technique of central venous access. In our experience, it was not associated with any risk of severe insertion-related complications, even in patients with low platelet count or coagulation disorders. Also, the exit site of the catheter at mid-thigh may have advantages if compare to the exit site in the inguinal area.

Femoral Vein Transposition Arteriovenous Fistula is a Feasible Option in "Selected" Patients as Hemodialysis Access

Introduction: Lower extremity hemodialysis access is offered to the patients who have severe central venous stenosis. Femoral vein transposition arteriovenous fistula (FV tAVF) is an alternative to lower leg arteriovenous prosthetic grafts. Its safety and patency is under observation.

Materials and Methods: This is a retrospective review of patients who had FV tAVF between January 2011 and March 2016. Preoperative clinical findings, intraoperative findings, postoperative complications, and patency of the AVF were noted and analyzed.

Results: There were 7 patients who underwent FV tAVF during this study period. Most patients were female (6 : 1), with mean age of 45.2 years (range, 33–55 years). All patients were hypertensive. Mean body mass index was 26.1 kg/m². Patient had on average previous 6 dialysis accesses. Most patients had preoperative venograms (6/7). Mean interval between initiation of dialysis and creation of the arteriovenous fistula was 1.08 years. All procedures were done under general anesthesia. Four patients required extension of FV with either the small segment of polytetrafluorethylene or vein graft. Two patients had early postoperative complications. One patient developed hematoma, whereas other had wound dehiscence. All the accesses were utilized for dialysis after a mean interval of 6 weeks. All patients had a patent fistula on average follow-up of 2 years.

Conclusion: Appropriate patient selection for FV tAVF can provide good patency with low incidence of complications. This can be considered for good risk individuals undergoing their first lower extremity access.

Unusual sites for hemodialysis vascular access construction and catheter placement: A review

As more end-stage renal disease patients require hemodialysis and live longer, many will fail to develop or maintain a functioning upper extremity vascular access. When a patient exhausts vascular access sites in the upper extremities, new fistulas and grafts can be constructed in the lower extremities, thorax, and abdomen as long as a pair of proximate artery and vein provide adequate blood inflow and outflow, respectively. When only a moderate size vein with adequate blood flow provides a conduit to either a patent superior or inferior vena cava, inserting a double-lumen venous hemodialysis catheter can provide temporary or permanent access. We review the literature and report the unusual sites for hemodialysis vascular access and catheter placement.

Arm composite autogenous vascular access using the great saphenous vein and the femoral vein: results from a single-centre study

OBJECTIVES

The objective is to report our results with the arm composite autogenous vascular access (ACAVA) using the great saphenous vein (GSV) and the femoral vein (FV) in tertiary vascular access surgery.

DESIGN

Retrospective single-centre study. Prospectively collected clinical database.

METHODS

Between August 2009 and March 2011, 17 patients with no suitable upper extremity vein, repeated prosthetic access failure and/or infection underwent the construction of an ACAVA. Outcome measures included the graft patency and complication rates.

RESULTS

The median follow-up was 25 months (5-32). Thirty-day morbidity affected 10 patients (59%): four wound-healing issues, three lower limb swelling, two early thromboses and one upper limb haematoma. No postoperative death occurred. At 3 months, the primary patency rate was 88% ± 8%. At 6 months, the assisted-primary patency rate was 82.4% ± 9.2%. At 12 months, the secondary patency rate was 81.6% ± 9.6%. Twenty-four secondary interventions were performed. Steal syndrome occurred in one patient following a secondary procedure. Swelling of the lower limb remained in two patients at the end of their follow-up. Three ACAVAs developed irreversible occlusion leading to loss of access.

CONCLUSION

With a high rate of postoperative morbidity and re-intervention, the ACAVA is a useful additional technique that should be restricted to difficult cases with limited vascular access options.

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

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.

Latero-lateral femoro-femoral arteriovenous fistula: a new surgical approach for hemodialysis patients with no vascular access

PURPOSE

A new surgical approach for vascular access for hemodialysis using a latero-lateral arteriovenous fistula (AVF) in the thigh between the femoral artery (FA) and superficial femoral vein (SFV) transposed to the subcutaneous layer in patients with no other access options is described.

METHODS

Ten patients (mean age: 37,9 years) for whom all possible sites for execution of any other procedure had been exhausted, underwent latero-lateral AVF close to the adductor channel between the FA and the SFV. The FSV was released and sectioned 2 cm from its confluence with the deep femoral vein and transposed in the subcutaneous tissue with extensions using saphenous vein or prosthetic material (PTFE) when needed. Follow -up included patency, flow evaluation and complications.

RESULTS

Postoperative follow-up ranged from 3 to 96 months, with a mean of 38 months. The AVFs presented a flow of more than 350 ml/min and the AVFs remained patent for a mean period of 38 months. There were three failures of the procedures at 3, 5 and 7 months during postoperative follow-up due to graft infection and thrombosis (a case), anaphylactic shock and thrombosis (a case) and calf pain during dialysis (a case). Two patients developed slight inferior limb edema.

CONCLUSION

The new surgical approach for access for hemodialysis represents a feasible procedure, with acceptable patency rates in exceptional cases where no other access option is available.

Vascular Access Using the Superficial Femoral Vein

Purpose

The superficial femoral vein (SFV) provides an alternative autologous conduit for fistula formation in patients who might otherwise require a prosthetic graft for hemodialysis (HD) access. The purpose of this study was to assess the results of this technique.

Methods

Patients who underwent formation of a SFV fistula were identified from a prospectively maintained database. Casenotes were reviewed for details of the operation, complications, subsequent interventions, and to determine whether the fistula was used for vascular access.

Results

Fifteen patients (seven males, eight females; median age 53, range 28–72 yrs) were identified. Patients had a median of four (range 2–9) previous fistulae. In three patients, the mobilized SFV was transferred to the upper limb while 12 patients had lower limb fistulae. Twelve patients (80%) used their SFV fistula for HD. Eleven patients developed a wound complication (infection, dehiscence, hematoma or bleeding), with four patients returning to theater for formal exploration and three requiring application of a vacuum dressing. Two patients developed post-operative lower limb ischemia. Two patients died during a median follow-up time of 7 (range 1–27) months.

Conclusion

In selected patients who have exhausted conventional routes for vascular access the SFV fistula can be used for the maintenance of HD. There is, however, significant associated morbidity and repeated intervention is often required.