title: Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia.
abstract: OBJECTIVE
  Construction of prosthetic arteriovenous access for hemodialysis in the thigh results in a high incidence of graft failure and infection. Autogenous femoral artery-common femoral thigh transposition (transposed femoral vein [tFV]) arteriovenous accesses have superior patency, but our previous report documented a high incidence of ischemic events requiring secondary surgical intervention. Recent results of improved patient selection and intraoperative maneuvers to reduce ischemia are unknown.
  
  
  METHODS
  During a 6-year period eight children (mean age, 13.3 years) and 46 adults (mean age, 52.3 years; 27 female, 19 male) underwent construction of 55 tFV thigh accesses for hemodialysis access. Adult patients were divided into groups I and II on the basis of the introduction of specific strategies to reduce the incidence of ischemic complications. In the cohort of children, steal prophylaxis included one banded femoral vein, three tapered femoral veins, two distal femoral artery pressure measurements taken before and after access construction (mean ratio, 0.70), and two closed anterior and superficial posterior compartment fasciotomies. Of the first 25 accesses in adults (group I, mean age, 55.9 years), 10 had access banding (six at the initial procedure and four in the immediate postoperative period to treat ischemia). Of the second 22 accesses (group II, mean age, 48.2 years), steal prophylaxis included 14 tapered femoral veins, 6 distal femoral artery pressure measurements (mean ratio, 0.76; range, 0.62 to 0.86), and 1 fasciotomy. Patients with significant distal occlusive disease were not offered a tFV access in the time frame of group II.
  
  
  RESULTS
  Eight accesses in children had 100% primary functional patency at 2 years, with no reoperations for ischemia. Nine group I adult patients underwent remedial procedures to correct distal ischemia. No adult patient in group II required a remedial procedure to correct ischemia. Groups I and II 2-year secondary functional access patency was 87% and 94%, respectively. There were no access infections in either group. Femoral vein tapering significantly reduced the need for remedial correction of ischemia ( P = .03).
  
  
  CONCLUSIONS
  Improved patient selection and selective intraoperative femoral vein tapering eliminated remedial procedures to correct ischemia in patients undergoing tFV access. Patency rates were excellent despite the liberal use of vein tapering. Transposed FV access should be considered for good risk individuals undergoing their first lower extremity access.
authors.affiliation: Department of Surgery, Cedars Sinai Medical Center, USA. wayne.gradman@cshs.org
authors.forename: Wayne S
authors.initials: WS
authors.lastname: Gradman
authors.forename: Judith
authors.initials: J
authors.lastname: Laub
authors.forename: William
authors.initials: W
authors.lastname: Cohen
mesh_terms: D000293:Adolescent; D000328:Adult; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000379:methods*; D002648:Child; D005260:Female; D005268:Femoral Vein / Q000601:surgery*; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D006435:Renal Dialysis / Q000379:methods; D013848:Thigh / Q000098:blood supply*; D014654:Vascular Patency