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Comparative Outcomes Of Arteriovenous Grafts And Lower Extremity Venous Transpositions And Translocations For Patients Without Suitable Upper Extremity Superficial Vein
Alexander R. Mikhail, MD, Kap Owens, MD, Danielle Sethi, MD, Wajeeh Irfan, MD, MPH, Taylor Gwin, MD, MPH, Jon Schellack, MD, Malachi Sheahan, MD, London Guidry, MD.
Louisiana State University, New Orleans, LA, USA.
OBJECTIVES: Hemodialysis access can be very challenging in patients without adequate upper extremity superficial vein or who have exhausted traditional autogenous conduits. Prosthetic graft use is fraught with infection and reduced patency rates. Our objective was to analyze the outcomes of all access constructions in patients for whom upper extremity cephalic or basilic fistula creation was not possible.
METHODS: A retrospective review of all patients who underwent surgery at a single vascular practice were screened by CPT 36825 and 36830 from 2015-2023. Patients with upper and lower extremity prosthetic grafts, necklace grafts, femoral vein transpositions, and lower extremity venous translocations to the upper extremity (femoral and saphenous vein) were identified and included for analysis. Study variables included time to last follow up (months), primary patency, primary assisted patency, secondary patency, graft infection, and steal syndrome.
RESULTS: A total of 240 upper extremity grafts, 125 femoral vein translocations, 22 saphenous vein translocations, 23 femoral vein transpositions, 25 necklace grafts, and 13 lower extremity grafts were included for analysis. Mean length to last follow up was 49 (2-160) months. Patients were divided into autogenous access (170 patients; mean number of prior access 3.6) and non-autogenous access (278 patients; mean number of prior access 2.8) for comparative analysis. The primary, primary assisted, and secondary patency rates were 39%, 69%, 84% at 12 months; 5%, 23%, 45% at 48 months for non-autogenous access compared to 38%, 83%, and 92% at 12 months; 7%, 46%, and 71% at 48 months for autogenous access. Access infection requiring access excision was seen in 6% of autogenous access compared to 18% for non-autogenous access. Steal syndrome affected 60 patients (15% autogenous, 12% non-autogenous). Harvest site complications requiring reoperation occurred in 19% of femoral vein translocations.
CONCLUSIONS: Lower extremity venous translocations and transpositions have superior patency rates and less infectious complications when compared to non-autogenous access. This must be balanced with the wound complication rate associated with femoral vein harvest. These comparative outcomes should be included in a shared decision-making model for patients without suitable vein in the upper extremity for fistula creation.
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