Combined Femoral Vein Transposition and Iliac Vein to Suprarenal Vena Cava Bypass as a Last Resort Dialysis Access
Article Outline
Patients undergoing hemodialysis are known to develop central venous occlusion and exhaust all options for vascular access to upper extremity sites; therefore, creating and maintaining vascular access is paramount in such patients. The present case report describes the condition of a 34-year-old woman with failed upper extremity access, frequent catheter-related issues, and multiple central venous occlusions. As a last resort, access to the lower extremity was pursued as follows: an inferior vena cava bypass was combined with a right femoral transposition fistula and a distal revascularization interval ligation procedure. This complex procedure that was carried out for the purpose of vascular access is a unique, albeit aggressive, surgical solution that resulted in autologous vascular access with a 6-month patency and also served to improve the quality of life in the seemingly hopeless case.
Vascular access in patients treated with chronic hemodialysis leads to significant complications including thrombosis, infection, high output heart failure, steal syndrome, and aneurysm formation. Another known significant complication is central venous stenosis (CVS), which results from catheter-induced trauma to the venous endothelium, and leads to thrombin generation, platelet activation, and expression of inflammatory markers on the endothelial wall. Turbulent flow through the injured intima produces ongoing hyperplasia, which significantly hampers vascular access.1 These access-related complications are a major cause of morbidity, accounting for approximately 20-30% of the hospitalizations in the cases of patients undergoing hemodialysis.1 Because of these complications, the failure rate of vascular access increases over time and patients can quickly exhaust all options for vascular access to upper extremity sites.
In patients undergoing hemodialysis, lower extremity access is considered as a last resort; access options include upper and mid-thigh arteriovenous grafts (AVGs), femoral vein transposition (FVT) fistulas, and even femoral vein upper extremity translocation. With an improvement in patient selection methods and also a decrease in complication rates, the cumulative patency of femoral vein access has also increased.2, 3 In a recent review it was found that at 12 months, upper thigh AVG, mid-thigh AVG, and FVT fistulas had primary patencies of 48%, 43%, and 83% and secondary patencies of 69%, 67%, and 95%, respectively.4 The present case report describes the state of a woman with significant access-related complications, who had no conventional arteriovenous access option. A complex lower extremity access was created to establish functional, long-term access.
Case Report
The subject of the case study was a 34-year-old woman with a history of poorly controlled type 1 diabetes mellitus, with gastroparesis, hypertension, chronic pancreatitis, opioid dependence, and a lower extremity deep vein thrombosis (DVT) which was treated by the placement of an inferior vena cava (IVC) filter and administration of coumadin. In addition, she also had a history of end-stage renal disease (ESRD) secondary to nephrotic syndrome and had been receiving hemodialysis through femoral tunneled catheters for the past 6 months. Furthermore, she also had a left radiocephalic fistula that had thrombosed and a left brachiobrachial fistula that had failed to mature. Although she had not undergone any right upper extremity access procedures, she had undergone multiple central venous catheterization for her gastroparesis and pancreatitis, including multiple right upper extremity peripherally inserted central catheter (PICC) lines, and during the past 2 years she had been frequently hospitalized for catheter-related infections.
At a hospital outside of our facility, the patient was diagnosed with methicillin-susceptible Staphyloccus aureus bacteremia secondary to chronic infection of the right femoral tunneled catheter and right groin Port-A-Cath (Deltec, St. Paul, MN)., which had been placed because of a recurrent need for IV infusions related to diabetic gastroparesis. An ultrasound showed abscess formation and hence both catheters were removed; at this point, she was transferred to our facility so that a higher level of care could be offered to her. On arrival, interventional radiology was used to traverse an occluded left iliac vein and IVC and also in the placement of a left femoral tunneled catheter. Subsequent venography revealed occlusions of bilateral axillary, innominate, and internal jugular veins, the right common iliac vein, and the infrarenal IVC with an occluded IVC filter. Our patient had no conventional options for vascular access because of the extensive central venous occlusions, a left upper extremity arteriovenous fistula (AVF) that failed to mature, and poor AVF options in the right upper extremity secondary to recurrent PICC use. Although vein mapping with ultrasound demonstrated no good fistula options in the arms and showed a thrombosed left femoral vein, it did show a good sized right femoral vein. After evaluating her access options and taking into consideration her young age, we decided to create an autogenous fistula and also performed a central venous reconstruction at the same time. Because of the lack of upper extremity fistula options, lower extremity access options were pursued in conjunction with central venous bypass to achieve a stable, long-term, and functional access. Peritoneal dialysis was thought to be contraindicated because of the patient's problems with gastroparesis and pancreatitis.
After the bacteremia was adequately treated, the patient was taken to the operating room. Midline incision was made and the abdominal cavity was entered at the upper abdomen. The right colon was reflected medially and extensive Kocher maneuver was used to expose the IVC. We made a dissection down to the distal external iliac vein, identified the ureter, and then further proceeded toward the groin. Thereafter, we made a dissection at the proximal hypogastric vein. At this point, the abdomen was packed and dissection of the leg was started. A long incision was made along the length of the leg from the right anterior superior iliac spine to the knee, through which the femoral vein and artery were dissected. A 12-mm ringed polytetrafluorethylene (PTFE) graft was sewn end-to-side from the external iliac vein to the suprarenal IVC (Fig. 1). Next, the superficial femoral vein was transposed to a superficial, lateral position and anastomosed to the superficial femoral artery (SFA) (Fig. 2). The final portion of the surgery was a distal revascularization-interval ligation (DRIL) procedure, in which a 6-mm PTFE graft was sewn to the SFA 10-cm proximal to the AVF and to a distal location just beyond the fistula anastomosis, with ligation of the SFA between the fistula and the PTFE graft (Fig. 3). The procedure was successful, with a good hemostasis and good flow through the IVC bypass graft, the DRIL bypass, and the fistula. In the initial postoperative course, our patient had problems related to a lymph leak from her groin that required re-exploration, which was ultimately resolved with a wound vacuum-assisted closure (V.A.C.) device (KCL Medical San Antonio, TX.).
Fig. 1
Intraoperative view. A 12 mm ringed polytetrafluorethylene (PTFE) graft was sewn end-to-side from the right external iliac vein to the suprarenal portion of the inferior vena cava.
Fig. 2
Intraoperative view. A long incision was made along the right anterior superior iliac to the knee; the right femoral vein was transposed to a superficial and lateral position to be anastomosed to the superficial femoral artery (SFA).
Fig. 3
Schematic representation of the surgical procedure. A 12 mm PTFE graft was sewn end-to-side from the right external iliac vein to the suprarenal inferior vena cava. The right femoral vein was transposed to a superficial and lateral position and anastomosed to the R SFA. Finally, a distal revascularization interval ligation procedure was performed with a 6 mm PTFE graft from the proximal SFA to a distal location just beyond the fistula anastomosis with ligation of the SFA.
During the later postoperative period, the patient was put on lovenox for deep vein thrombosis prophylaxis; on discharge from the hospital, she was put back on coumadin. The time taken from surgery till cannulation was 6 weeks. The patient did not show any signs of leg swelling, tingling or numbness, graft or wound infection, or pseudoaneurysm; she did not require any further re-intervention. At 6 months postoperatively, she continues to receive dialysis through the fistula and has had no further hospital admissions.
Discussion
CVS in dialysis patients most commonly results from in-dwelling catheters that drain into the central veins, thereby disrupting intimal endothelium and leading to smooth muscle proliferation.1, 5 Common presenting symptoms are swelling and an increased rate of thrombus in the access arm, superior vena cava (SVC) syndrome, and an unilateral pain that is aggravated by dialysis. CVS occurs in approximately 40% of the patients with central catheters; however, stenosis rates depend on the population studied, the duration of catheterization and the type, location, and number of catheters in place.6, 7 In cases when angioplasty or endovascular stenting is unsuccessful at reducing the stenosis, surgical bypass can be performed to preserve the access. Complex bypass procedures that have been successfully described include the necklace (axillo-axillary) bypass, internal jugular vein turndown, ipsilateral and contralateral internal jugular vein bypass, axillary vein to right atrium bypass, fem-fem crossover bypass, and axillary to popliteal and femoral to right atrial appendage bypass.8, 9 Recently, subclavian vein to right atrial appendage bypass without sternotomy has been described as a means of bypassing complete central venous obstruction while maintaining upper extremity access.10 In certain cases bypass may not be feasible, then the access needs to be occluded to alleviate the venous hypertension; this is where upper extremity access sites become exhausted and lower extremity access becomes indicated.
Lower extremity access is divided into three categories; upper-thigh prosthetic, mid-thigh prosthetic, and femoral vein transposition fistula. Although there are conflicting reports on the feasibility and success of lower extremity access, recent studies have shown acceptable results,11, 12 with femoral transposition fistula having better patency rates as compared with the mid- and upper-thigh prosthetic grafts.4 Saphenous vein loop grafts have also been described but are associated with poor outcomes, including high stenosis and re-intervention rates.4, 8, 12
In our patient, who had a failed upper extremity access, central venous occlusion, and recurrent catheter-related infections, we aimed to bypass the occlusion and to create a functional autologous fistula so that she could be no longer dependent on the catheter, and be free from its recurrent infections. Left upper extremity options in our patient were exhausted because of failed AVFs, also there were no good options for AVF in the right upper extremity because of recurrent PICC use. As a result of the lack of AVF options in the upper extremities, and because bilateral axillary, innominate and jugular veins were occluded, the patient was not a good candidate for other reconstruction options, such as ipsilateral vein turndown, axillary-jugular vein bypass, or central venous reconstruction. Therefore, we chose to proceed with an aggressive combination of a central venous bypass, FVT, AVF, and DRIL procedure. The decision to perform a DRIL procedure at the same time was based on a relatively high incidence (up to 16%) of ischemic complications of lower extremity vascular access, particularly in diabetic women.2, 11, 13, 14 To reduce the chance of persistent steal syndrome, we routinely place the proximal anastomosis of the DRIL PTFE 10 cm above the AVF. Although this was a complex procedure in a relatively high-risk patient, her access has remained patent and is functioning well. The concurrent placement of lower extremity fistulas with central venous bypass may become increasingly important as the ever growing dialysis population develops and continues to have access-related complications.
Conclusion
This report illustrates a unique, albeit aggressive, surgical solution in a seemingly hopeless case. Though it was considered a last resort, the autologous vascular access of our patient has been patent for 6 months and she has not required any re-intervention. With appropriate imaging and planning, arteriovenous access can almost always be achieved in highly challenging dialysis access patients.
References
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PII: S0890-5096(10)00220-7
doi:10.1016/j.avsg.2010.03.029
© 2011 Published by Elsevier Inc.
