title: Extra- and intrathoracic access.
abstract: The most complex patients requiring vascular access are those with bilateral central vein occlusions. Endovascular repair of the central lesions when feasible allow upper extremity use for access. When endovascular repair is not feasible, femoral vein transposition should be the next choice. When lower limb access sites have been exhausted or are contraindicated as in obese patients and in patients with peripheral arterial obstructive disease, a range of extrathoracic "exotic" extra-anatomic access procedures as the necklace cross-chest arteriovenous (AV) grafts, the ipsilateral axillo-axillary loops, the brachial-jugular AV grafts, the axillo-femoral AV grafts or even intra-thoracic ones as the right atrial AV bypasses represent the vascular surgeon's last resort. The selection among those extra-anatomical chest-wall procedures should be based upon each patient's anatomy or patient-specific factors.
authors.affiliation: Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis - Greece.
authors.forename: Miltos K
authors.initials: MK
authors.lastname: Lazarides
authors.forename: Efstratios I
authors.initials: EI
authors.lastname: Georgakarakos
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Schoretsanitis
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000379:methods*; D001366:Axillary Artery / Q000503:physiopathology / Q000601:surgery; D001367:Axillary Vein / Q000503:physiopathology / Q000601:surgery; D001916:Brachial Artery / Q000503:physiopathology / Q000601:surgery; D002405:Catheterization, Central Venous / Q000009:adverse effects; D005268:Femoral Vein / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D007601:Jugular Veins / Q000503:physiopathology / Q000601:surgery; D018579:Patient Selection; D006435:Renal Dialysis; D012307:Risk Factors; D013909:Thorax / Q000098:blood supply*; D016896:Treatment Outcome; D056824:Upper Extremity Deep Vein Thrombosis / Q000209:etiology / Q000503:physiopathology; D014654:Vascular Patency