Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: Our initial experience

Purpose: The National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines favor autogenous vein for arteriovenous fistulas (AVFs). This report describes our experience constructing AVFs in the lower extremities of selected patients with the superficial femoral vein (SFV). Patients and Methods: This is a retrospective analysis of 25 patients who had AVP construction with SFV from March 1998 to July 2000. In all patients upper extremity access had been exhausted. Eighteen (72%) patients were female, 15 (60%) had diabetes, and 14 (56%) were obese (body mass index > 30 kg/m(2)). The SFV was freed from the supragenicular popliteal level to the profunda femoris vein and divided distally, Eighteen (72%) patients had SFV transposition and distal superficial femoral artery reimplantation; 10 veins were banded to reduce the incidence of postoperative steal syndrome. In seven patients (28%) a composite loop fistula was constructed with a deeply buried 4- to 7-mm polytetrafluoroethylene (PTFE) graft proximally and with superficially transposed SFV distally. One of these seven patients had a PTFE above-knee femoral-popliteal bypass graft with banding of the vein at its takeoff from the distal PTFE graft. Results: Mean follow-up was 9.1 months. One patient died before the fistula could be used. Seven patients (28%) experienced major wound complications. Mean ankle/brachial index before operation was 1.03, and after operation it was 0.81 (paired difference [n = 16] = -0.26,) Mean ankle circumference before operation was 19.5 cm, and after operation it was 20.7 cm (paired difference [n = 17] = +0.87.) Cumulative primary fistula patency at 6 and 12 months was 78% and 73%, respectively. Cumulative secondary fistula patency at 6 and 12 months was 91% and 86%, respectively. There were no fistula infections. One patient eventually had an above knee amputation after experiencing an acute compartment syndrome. Eight patients required a second operation to alleviate a symptomatic steal syndrome. Conclusions: The SFV is an excellent conduit for vascular access, whether it is transposed or is part of a composite PTFE-SFV fistula. In this series, fistula infection was nonexistent, thrombosis rates were low and clinical evidence of venous hypertension was minimal. The major impediment to unrestricted use of SFV in constructing AVFs is a high incidence of clinically significant postoperative ischemia requiring reoperation.