Femoral artery-internal iliac artery interposition graft for AV access.

Abstract

Increasing numbers of patients on long term hemodialysis become “desperate” and lose all convenient veins for constructing an AVF and even for insertion of CVSs. In the literature there are too many “exotic” AV grafting techniques. In 3 diabetic patients we performed femoral artery (end to side) - internal iliac artery (end to end) bypass grafting for VA. The first patient (56 F) had had >10 AVF-AVG operations and 6 catheter insertions. Right above knee amputation was done because of diabetic foot infection while she was being dialyzed via a femoral artery-femoral vein AVG. During her hospital stay her VA trombosed and could not be salvaged because of complete outflow tract obstruction including both common iliac veins. A 6-mm PTFE graft was interposed between the cut arterial end of the old graft and right internal iliac artery in an end to end fashion. Two weeks later she died of multiple organ failure while her VA was stil functioning. The second patient (61 F) was a left high above knee amputee and she had had 11 AVF-AVG procedures and >10 catheter insertion attempts. There was no vein available in her physical exam and on MR angiograms. Left femoral artery (end to side) - left internal iliac vein (end to end) 6-mm PTFE bypass grafting was done. The day after the operation she could be dialyzed via this VA and sent back to her own center. The third patient (76 M) came as an emergency case. There was no vein available because of multiple previous VA attempts. Thrombectomy was done to the arterial side of his previous right femoral artery-femoral vein AVG. A 6-mm PTFE graft was interpositioned between the cut end of this old graft and the right internal iliac vein. After 3 dialysis sessions his family decided to take him home. Although the fates of these patients were so disappointing, legally and ethically we must have done something for them to be dialyzed. This technique is easy to perform even under local anesthesia with sedation and we believe it should be in the armamentarium of a vascular surgeon.