Ankle Arteriovenous Fistula – a Rare Site of Choice for Hemodialysis

Alternatives for exhausted dialysis access

Hemodialysis (HD) access failure is a frequent problem encountered by vascular surgeons. As treatment of end-stage renal disease improves and patients live longer on HD, eventual exhaustion of traditional upper extremity HD access is common. Efforts to preserve and maintain these accesses are essential. However, when they fail, alternative surgical access options should be pursued prior to destination-tunneled dialysis catheters. Hemodialysis Reliable Outflow grafts as well as various configurations of lower extremity arteriovenous fistulae and grafts can be utilized. For most alternative HD access options, there is a paucity of data for long-term patency, cost, and risk of infectious or ischemic complications compared to traditional options. However, smaller studies examining Hemodialysis Reliable Outflow grafts, femoral vein transposition, and lower extremity grafts show acceptable safety and efficacy. Depending on the cause of traditional access failure and patient-specific anatomic constraints, we recommend a systematic approach to alternative access creation, with destination-tunneled dialysis catheters reserved as a last resort. The most common cause of HD access failure is venous outflow obstruction. As such, we have structured this manuscript around a meta-analysis of retrospective studies describing nontraditional access options that can be utilized with escalating degrees of central venous stenosis or occlusion.

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.

Outcome of tibio-saphanous arteriovenous fistula in patients with failed upper extremity dialysis access: A report of two cases

Arteriovenous fistulas (AVF) are the preferred access for hemodialysis in patient with end stage renal disease. Usually, distal vessels of upper limb are preferred. There are situations in which the upper limb cannot be a site for AVFs or graft as in cases of bilateral central venous stenosis or with exhausted sites in upper limb. In these cases, lower limb AVF can be considered. Tibial-saphanous (ankle) fistula should be the preferred site over femoral AVF/graft following the principle of distal to proximal. Also, femoral AVFs are associated with more ischemic and infective complications. The present report describes successful hemodialysis in two patients with tibial-saphanous fistula a site rarely used as an option for HD access. Hemodialysis for over 1 year in one patient and 6 months in the other portrays the success of this approach.

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).