Ankle fistula as the last resort for vascular access: case report and literature review

Fourteen-Year Patency of an Anterior Tibial Artery-Saphenous Vein Fistula in an Ambulatory Patient

Background. Ankle arteriovenous fistulas are the rarest vascular access type among lower extremity fistulas for hemodialysis patients with end-stage renal disease. Here, we present a case of a tibial-saphenous fistula that remained open for a long time despite a recurrent anastomotic aneurysm. Case Presentation. A 43-year-old female patient who had been undergoing hemodialysis via a right femoral tunnel catheter for six months was referred for recurrent catheter infection and a 4 cm pulsatile mass in the anterior aspect of the ankle. While she had been undergoing hemodialysis through a right tibial-saphenous fistula for fourteen years, hemodialysis continued after the fistula’s closure due to total occlusion of the great saphenous vein through the tunneled catheter. After balloon angioplasty to the right subclavian vein, we performed right upper extremity basilic vein transposition. Later, after starting adequate dialysis from the basilic vein fistula and removing the femoral catheter, we performed a resection of the anastomotic aneurysm in the right ankle and repaired the anterior tibial artery. Because this is the only ambulatory patient and the one with the longest patency of ankle arteriovenous fistulas in the literature and the only case in which the anterior tibial artery was used, the case is presented and discussed in light of the literature. Conclusion. Despite many complications and low patency rates reported in the literature, ankle vessels should be considered for autogenous vascular access in selected patients.

Preliminary balloon dilation of both saphenous fascia and the saphenous vein increases the below-knee fistula patency, but not maturation

OBJECTIVE

There is no reliable secondary site for fistula creation in patients with preclusions for further use of upper extremity vessels as viable hemodialysis access. Below-knee vessels resemble the forearm vascular anatomy and, therefore, methods to improve the outcomes of fistula creation at this level would also help to improve the quality of life for those patients. The aim of the present study was to examine the efforts to improve the functionality of below-knee fistulas in a sample of dialysis patients.

METHODS

We retrospectively evaluated the results of ankle fistulas created following preliminary balloon dilatation of both the saphenous fascia and the saphenous vein in 11 patients who were considered eligible if they did not have concomitant venous or arterial lower extremity disease. We assessed the changes in fistula flow within 6 months as well as patency and maturation rates.

RESULTS

Though the patency rate at 6 months was 63.6% (seven patients), only three fistulas (27.3%) were used for routine dialysis. All mature fistulas were observed in patients with a preoperative posterior tibial artery flow of more than 35 mL/min.

CONCLUSION

Saphenous vein dilation throughout the below-knee promotes fistula patency, but the posterior tibial artery shows inadequate response as an inflow supplier at the ankle level. More proximal connection of saphenous vein after balloon dilation may be used in the future to achieve adequate flow from leg arteries.

Thigh arteriovenous grafts. Quantitative comparison with alternative options: A meta-analysis

Thigh arteriovenous grafts are required in a number of patients with exhausted upper extremity veins and comprise 1%-5% of the total access procedures performed. Alternative autogenous lower extremity options are the rarely used sapheno-tibial arteriovenous fistulae, the saphenous vein transpositions, and the femoral vein transpositions. The latter have proven to be the most durable lower limb access procedures, with low infection rates and their primary patency rates ranged from 74% up to 87% at 2 years. Synthetic thigh grafts are suitable for patients who are not good candidates for any upper limb or any autogenous lower limb access and their secondary patency rates ranged from 54% up to 83% at 2 years. Thigh grafts often get infected and their average weighed infection rate in 920 such grafts included in eight large series was 22.9%. A literature search was performed to evaluate thigh grafts compared with alternative options using meta-analysis. Lower limb accesses were found superior compared to HeRO^® device regarding 1-year primary failure rate (odds ratio = 0.28, confidence interval = 0.09-0.88, p = 0.03) and additionally autogenous lower limb accesses were found superior compared to thigh grafts regarding the 1-year primary failure rate (odds ratio = 6.54, confidence interval = 2.29-18.72, p = 0.0005).

Arteriovenous Access: Infection, Neuropathy, and Other Complications

Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.

Healing of venous ulcers secondary to an ankle arteriovenous fistula

Venous ulcer as a complication of ankle arteriovenous fistula for hemodialysis is rarely reported. It poses a challenge between ulcer healing and fistula preservation. We report our experience in the management of venous ulcers secondary to an ankle arteriovenous fistula in a hemodialysis patient.