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OBJECTIVES: End stage renal disease continues to significantly affect health care with nearly 400,000 patients currently on hemodialysis in the United States. While current life expectancy for patients on dialysis is 5-10 years, many are living for up to 30 years, which makes the need for long term autogenous access increasingly important. With central catheter usage, dialysis patients are at high risk for central stenosis, making the successful creation of upper extremity arteriovenous fistulas challenging. We propose the use of loop femoral vein fistulas for patients who have failed conventional access procedures. Specifically, there are two modifications to this technique that we have used in an attempt to decrease previously feared morbidities. We determine the length of usable femoral vein based on a consistently found prominent branch point near the adductor canal to maintain adequate drainage to the lower leg. Additionally, the proximal profunda femoris artery is used as inflow.
METHODS: A retrospective chart review was performed looking at patients who underwent loop femoral vein arteriovenous fistula creation between 2007 and 2015. Patients who underwent the presented modified technique were selected for further analysis including complications and functional patency.
RESULTS: There were 8 patients identified who underwent creation of the modified loop femoral vein arteriovenous fistula. All patients had previous access procedures including autologous and graft arteriovenous creation and multiple catheter placements; one patient had a poorly functioning HeRO Graft. None had prior femoral vein surgical procedures. All developed mature, functional arteriovenous fistulas with 62% of patients having continued patency (mean 440 days, range 152-641). These patients required an average of one surgical revision or balloon angioplasty. Mean follow up was 10.78 months. There was no evidence of compartment syndrome or limb ischemia in any of the patients. Three had mild lower limb edema that responded to conservative treatment and five had minor wound complications.
CONCLUSIONS: Using a modified surgical technique with profunda artery inflow and anatomic markers for femoral vein length, safe and effective loop femoral vein fistulas can be created in poor candidates for upper extremity access procedures. Compared to previously described femoral arteriovenous fistula creation, this method eliminates associated critical complications such as limb ischemia, compartment syndrome, and significant lower extremity edema with the potential for long term dialysis access.