Don’t Forget the Leg - Leg Fistulae

Eric S Chemla

St George’s vascular Institute

London UK

ESRD aetiology in 2015

Total 2.5 M worldwide in 2009(VAS) 70% in HD

Diabetes is the main cause(Except for Africa and SouthAmerica, 2nd cause in far East)

1.5 Billion with HBP in 2025

Global population age world widewith greater expectation (25% inEU and 20% in USA over 65 in2030)

What can we do when all usual accesses are impossibleor exhausted?

366 M type 2 diabetic in the world in2030: so more need for complex accessand spare options

Chest wall grafts have proven theirefficacy (JVS 2008; 47: 138-43 and 48:1251-4)

HeRO compared to LEAVGs showedsimilar results: ‘In our practice, weprefer the HeRO to LEAVG, especiallyin patients with peripheral arterialdisease and in the obese population,because it preserves lower extremityaccess options’ JVS 2013; 57: 776-83

Anyway , will you even be able to propose a lower limb access?

Worldwide obesity has nearly doubledsince 1980.

In 2008, more than 1.4 billion adults, 20and older, were overweight. Of theseover 200 million men and nearly 300million women were obese.

35% of adults aged 20 and over wereoverweight in 2008, and 11% wereobese.

65% of the world’s population live incountries where overweight and obesitykills more people than underweight.

More than 40 million children under theage of five were overweight in 2011.

So far the protocol is:

All upper extremity options areexhausted

Bilateral innominate or SVCocclusion

HeRO catheter is indicated before aLEAVG

Hybrid between a PTFE graft and aCVC

The evidence shows similar resultsfor both technique (Ann Vasc Surg,JVS, EJVES largest series 164 pts)

If the HeRO fails or is notsuccessfully inserted?

Surgical technique

Femoral to femoral crossover bypassgraft

Very high inflow: rightheart catheter advised beforesurgery (risk of heartfailure)

SVC thrombosis

Severe steal syndrome

Severe body image problem

No diabetes

No obesity

Superficial femoral vein transposition

First choice if SVC obstruction

No diabetes

No obesity

Limited length

Small anastomosis on the SFA in theadductor longus fascia

12 months Primary and secondary patencyrates: 73%,86% (Gradman I)

2 year secondary patency up to 94%(Gradman II)

.© Wayne Gradman, J Vasc Surg. 2001 May;33(5):968-75

Indication extended in case of obesity:composite bypass

SFV harvested only betweengastrocmnius branches andprofunda

Limited length available

Therefore too short in caseof thick fat layer

Composite bypass feasible:GSV, Bifid SFV or PTFE

Axillary artery to popliteal vein bypass graft

SVC obstruction

Diabetes

Obesity

No FMH of DVT

Systolic BP > 90mmHg

No severe cardiacimpairment

When SFV transposition isimpossible

Results: Complex bypasses St George’sVascular Institute

Primary patency 83-64-64%

Assisted primary patency87-73-73%

Secondary patency 90-77-77%

At 6-12 and 24 months

Semin Dial. 2006 May-Jun;19(3):246-50

Secondary Patency

Assisted Primary Patency

Primary Patency

Femoral PTFE grafts

Loop or straight

I prefer to avoid the groin areaHigh infection rate: 27% J VascSurg. 2010 52:1546-50

Straight SFA to Pop vein bypassbetter but 12 month I and IIpatency are: 53.9% and 75.3%(JVS 2010, 52) so SFV betteroption

5 year patency rates: 19.3% and53.6%

This option is not preferred in myopinion

Surgical technique

Femoral artery to right atrium bypassgraft

SVC and IVCobstruction

SVC obstruction and allother lower limbsoptions exhausted

Good LVF and EFrequired

Direction of theneedles- very important

Femoral artery to right atrium bypassgraft

Conclusion

There is no hopeless cases

There is almost noindication for dialysis on along term catheter becausethere would be no otheroption

There always is anothersurgical option

Perhaps need for centres ofexcellence were numberswould be high enough toachieve good results