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Background: Obtaining hemodialysis access after exhaustion of all sites in the upper extremities remains a significant obstacle to continued care. The lower extremity is increasingly been used as alternative access with variable outcomes. The purpose of this study is to evaluate our experience with lower extremity arteriovenous access.
Methods: A database of 34 patients, (58% females and mean age of 47 year old) that underwent lower extremity arteriovenous access from March 2006 to August 2011 was queried. A total of 35 extremity arteriovenous (AV) accesses were created,:13 the femoral vein transposition (FVt) arteriovenous fistulas (AVF) (37%) and 22 prosthetic AV grafts (63%). All patients had previously failed multiple access surgeries in the upper extremity (mean 4 for FVt and 7 for AVG).
Results: Technical success was achieved in all cases (100%)with no perioperative mortality and low perioperative morbidity. Patient’s characteristics, complications and number of reinterventions for the FVt and AVG groups are listed in table 1. In two diabetic patients a concomitant distal revascularization interval ligation (DRIL) procedure was performed with a FVt fistula to prevent steal syndrome. During a mean follow-up of 36 months, 20 (60%) accesses remained functional. (45% FVt and 55% AVG; p=ns). Average function time for FVt AVF was of 20±13 months while the AVG was 11±10 months (p=0.03). Thrombotic and infective complications were higher in the AVG compared to FVt. 4 access revisions (3 due to infection, 1 open thrombectomy) were necessary in the in the AVG group vs. 3 cases revisions (2 plication and DRIL). Primary (75% vs. 57%, FVt vs.AVG; p<0.01), Assisted Primary (87% vs. 67%; p<0.01) and Secondary Patency (90 % vs.72 %; p<0.01) were significantly better in the FVt compared to the AVG at 12 months.
Table I. Patient characteristics and complications for the AVF and AVG groups.

Access Type	FVt AVF (13)	LE AVG (22)
Mean age (yrs)	41±11	54±12 *
Females	46%	68%
Hypertension	76%	81%
Coronary Artery Disease	28%	27%
Diabetes Mellitus	38%	36%
Peripheral Artery Disease	8%	18%
Procedure related Morbidity	38%	95%**
Steal syndrome	15%	10%
Edema > 2 weeks	8%	18%
Thrombosis	14%	36%
Infection	8%	27%*
Pseudoaneurysm	8%	5%
2nd Intervention rate	23%	36% *

*p<0.05 ** P<0.01
Conclusion: Autologous hemodialysis access creation in the lower-extremity has markedly superior results than prosthetic material. Patients receiving AVG do not demonstrate a sustained benefit from the access site due to high rate complications, greater intervention rate and limited access functionality. The use of AVG in the leg should be questioned.