Management Of Critical Lower Extremity Ischemia Ipsilateral To Arteriovenous Access
David Patrick Stonko, MD, MS, Courtenay Holscher, MD, PhD, Thomas Reifsnyder, MD.
Johns Hopkins, Baltimore, MD, USA.
OBJECTIVE: Critical lower extremity (LE) ischemia ipsilateral to arteriovenous (AV) access is a challenging problem with scant literature to guide treatment. This small series highlights the presentation and management. METHODS: Chart review of a single surgeonís experience over fourteen years with LE AV access complicated by limb threatening ischemia. RESULTS: There were five patients, 3 women and 2 men, mean age of 46 years (range 27-58), on dialysis for a mean of 18 years (range 9-32). All five had exhausted their upper extremity dialysis options. Three patients presented on postoperative day 0, 64, and 280 with rest pain. Two patients presented with diabetic foot gangrene with ischemia, 2 and 39 months after thigh access placement. The accesses with steal included: femoral vein transposition, superficial femoral artery (SFA) to saphenofemoral junction ePTFE, and popliteal artery saphenous vein transposition. The patients presenting with gangrene had an SFA to femoral vein ePTFE, and a common femoral artery HeRO. The accesses had a mean secondary patency of 55 months (range 36-72). Treatment in the rest pain group consisted of emergent plication of the femoral vein transposition on the day of placement and the other two had distal revascularization with interval ligation (DRIL). The two patients who presented with diabetic gangrene had open partial foot amputations followed by revision of the AV access inflow to the deep femoral artery in combination with popliteal pedal bypasses. Mean amputation free survival was 66 months (range 44-110). The patient with the HeRO graft presented 45 months later with a heel infection resulting in a below knee amputation. Four patients had preoperative noninvasive testing and there was marked improvement in ankle brachial indices and digital pressures after revascularization. CONCLUSIONS: A minority of dialysis patients end up with leg access and a minority of these patients develop an ischemic limb. Treatment should address the AV steal portion of the problem when rest pain is the presenting symptom. When there is a large foot wound further intervention on any atherosclerotic disease is necessary. Appropriate treatment of lower limb ischemia associated with patent AV access can lead to long term limb and access salvage.
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