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Tagliatelle technique for arteriovenous fistula creation using a great saphenous vein semipanel graft
From the Society for Vascular Surgery
Tagliatelle technique for arteriovenous fistula creation using a great saphenous vein semipanel graft Faris Alomran, MD, Benoit Boura, MD, Alexandros Mallios, MD, Romain De Blic, MD, Alessandro Costanzo, MD, and Myriam Combes, MD, Paris, France Lower limb arteriovenous (AV) access creation can be attempted in patients where upper limb options are exhausted. Utilization of the great saphenous vein as a conduit for AV access has been limited due to its small diameter and resistance to dilatation. Lower limb AV fistulas today are mostly either prosthetic grafts with high rates of infection and thrombosis or transposition of the femoral vein that can lead to limb-threatening venous hypertension. In this report, we describe an optimized technique for reconstruction of the great saphenous vein to serve as a dialysis conduit. This semipanel graft reconstruction effectively doubles the diameter of the conduit without disruption of the deep venous circulation and also mitigates the requirement for a venovenous anastomosis. (J Vasc Surg 2013;58:1705-8.)
Lower limb hemodialysis access creation can be attempted in patients where upper limb options are exhausted. Few reports exist on the utilization of the great saphenous vein (GSV) for vascular access with poor results.1,2 Most surgeons today utilize prosthetic grafts or transposition of the femoral vein (tFV) for lower limb access.3 In this report, we describe an optimized technique for GSV reconstruction in order to serve as a dialysis conduit. CASE REPORT The patient was selected to undergo the arteriovenous (AV) fistula creation using a saphenous vein semipanel graft (sPG) and first underwent computed tomography angiography and color duplex with marking of the GSV. Significant arteriopathy and diabetes are considered as contraindications for this procedure to avoid lower limb steal syndrome. Deep venous insufficiency is also considered a contraindication for this technique. The minimal length of GSV required is 40 cm with a diameter superior to 3 mm. In order to maximize the dialysis puncture site, the maximum utilizable GSV length is harvested down to the ankle if possible. The steps of the technique are as follows: (1) The maximum length of suitable GSV is harvested via interrupted skin incisions. (2) The GSV is longitudinally opened up to approximately 5 cm from the saphenofemoral junction but not vertically transected (Fig 1, a). (3) Open valvulotomy of the GSV using Pott’s scissors (Fig 1, b). (4) Folding of the single GSV panel at its center, From the Institute Mutualiste Montsouris. Author conflict of interest: none. Video presentation at the Plenary Session of the 2013 Vascular Annual Meeting of the Society for Vascular Surgery, San Francisco, Calif, May 30-June 1, 2013. Additional material for this article may be found online at www.jvascsurg.org. Reprint requests: Faris Alomran, MD, Institute Mutualiste Montsouris, 46 Blvd Jourdain, Paris 75014, France (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.06.082
creating a posterior and an anterior panel (Fig 1, c). (5) Suturing of the anterior and posterior panels onto each other starting near the saphenofemoral junction and completing the medial edge using an uninterrupted 6.0 Prolene suture. Once the medial edge suture is completed, the lateral edge is sutured in a similar fashion (Figs 1, d and 2, a). (6) A small venotomy at the distal end of the GSV is performed to enable testing of the reconstructed vein under gentle hydropressure using a syringe (Fig 2, b). (7) Lateral subcutaneous tunnelization of the sPG to ensure a puncture zone of suitable length (Fig 1, e). (8) The superficial femoral artery is dissected at the nearest point to the sPG and the AV anastomosis is conducted (Figs 1, f and 2, c). It is important to mention that an arteriotomy of no larger than 4 mm is recommended, to mitigate the risk of lower limb steal syndrome. The procedure lasted 2 hours and 40 minutes, and recovery was uneventful. The patient was discharged on day 6 following a computed tomography angiography confirming no technical anomalies and a harmonious vessel diameter. (Fig 3, a and b; Video 1). The subcutaneous tunnel is 1 to 2 cm lateral to the incision line to avoid the scarred area with attention paid to tunnel entry and exit sites (Fig 4). Wound healing was satisfactory, and the fistula was punctured successfully for dialysis 8 weeks postoperatively following a color duplex scan confirming a 1500 mL/min flow rate and remains patent at 3-month follow-up.
DISCUSSION For most authors, polytetrafluoroethylene grafts would be the first option for patients that require lower limb dialysis access.4 However, prosthetic grafts are frequently complicated by infection and venous anastomosis stenosis. Access loss as a result of infection is far more common in all thigh grafts compared with autologous thigh AV access (18.40% vs 1.61%, respectively).3 Authors have reported favorable patency results for other large-caliber autologous lower limb dialysis fistulas. In their review, Antonio et al reported better 1-year primary and secondary patency of tFV (83%/93%) than both upper- (48%/69%) and mid-thigh (43%/67%) prosthetic grafts.3 Bourquelot et al have reported impressive results with 1- and 9-year primary 1705
1706 Alomran et al
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Fig 1. a, Great saphenous vein (GSV) opened longitudinally up to 5 cm from saphenofemoral junction. b, Open valvulotomy using Pott’s scissors. c, Folding of the GSV at its center, creating anterior and posterior vein panels. d, Suturing of the medial edges, followed by the lateral edges together. e, Subcutaneous tunnelization of reconstructed graft to maximize puncture length. f, Small side-to-end arteriovenous (AV) anastomosis performed.
(91%/45%) and secondary (84%/56%) patency, respectively, in a series of 72 tFV cases.4 Similar to tFV, the described sPG technique does not involve a venovenous anastomosis, which is the most
common site for restenosis. A major advantage of sPG, however, is that it allows for the conversion of a long thin conduit into a shorter but larger-diameter autologous conduit without disruption of the deep venous circulation.
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Fig 3. Computed tomography angiography (CTA) reconstruction of the arteriovenous (AV) fistula showing subcutaneous puncture length of 13 cm (a) and harmonious vessel diameter between 7 and 8 mm thoughout (b).
Fig 2. a, The medial edge suture is complete as represented by the posterior aspect of the reconstructed vein panel in this image. The lateral edge suture can be seen to have started on the right side of the image. b, Testing of the reconstructed great saphenous vein (GSV) using gentle hydropressure through a small venotomy for the arteriovenous (AV) anastomoses. c, A maximum of 4-mm sideto-end arteriovenous (AV) anastomosis is performed.
Fig 4. Upper thigh of patient showing the lateral tunnelization of the arteriovenous (AV) fistula lateral to the surgically scarred area. A, Signifies the direction of the AV anastomosis; V, signifies the direction of the iliac vein.
tFV can result in major venous complications due to the disruption of the venous system. Bourquelot et al have reported five cases (6.9%) requiring fistula ligation due to acute venous hypertension,2 lower leg compartment syndrome,1 and major edema2 following tFV. Despite limiting tFV harvest to the segment proximal to the popliteal vein, the requirement for preventative and emergent fasciotomies and even amputations has been reported.5 High initial ischemic complication rates were observed in tFV, leading authors to advocate careful patient selection,
with some authors suggesting the exclusion of diabetic patients and individuals with significant occlusive arterial disease.4 Gradman et al have reduced the ischemic complications to zero in a series of 22 patients by selective performance of femoral vein tapering in addition to patient selection.6 In our case, we decided to limit the venotomy and arteriotomy to approximately 4 mm, leading to an acceptable 1500 mL/min flow rate and have not observed significant ischemia.
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Utilization of the nonreconstructed GSV for AV access has been the product of poor results. The largest series of GSV access has reported a 30-day access loss rate of 21 from 56 fistulas (37.5%) with 20 cases as a result of access thrombosis.2 Pierre-Paul et al reported similar findings with a primary patency of only 7 months and an average of three balloon percutaneous transluminal angioplasties per patient. In addition to two operated pseudoaneurysms, only five of seven fistulas had been successfully used for dialysis, and all patients developed vein loop stenosis. Doppler ultrasound follow-up of these patients exhibited the intrinsic resistance of the GSV to dilatation with an increase in diameter of only 1 to 2 mm, hence rarely reaching the minimum 6-mm diameter recommended by the National Kidney Foundation.7 Ex situ panel reconstruction of the GSV has previously been performed for femoral artery reconstruction and aortic bifurcation reconstruction for prosthetic graft infections.8,9 Van Zitteren et al reported some excellent results with the use of spiral vein grafts without any complications related to the longitudinal suture lines.10 This is the first report of venous panel reconstruction for AV access. Careful patient selection is imperative for the efficacy of the aforementioned technique including the presence of an adequate GSV. We suggest a minimum GSV length of 40 cm, allowing for the reconstruction of a 20-cm segment. However, this is dependent on body habitus on technical variations, and we would recommend harvesting the maximum length of adequate GSV available. We have instated a biannual echo Doppler follow-up protocol in addition to regular clinical examination to monitor for any potential complications. CONCLUSIONS This is a new technique for the utilization on the GSV as a lower limb dialysis access conduit. We believe this technique may also be applicable to other conduits where diameter may be insufficient for AV fistula creation. In our
opinion, sPG possesses various theoretical advantages that remain to be verified with long-term follow-up and further experience. REFERENCES 1. Pierre-Paul D, Williams S, Lee T, Gahtan V. Saphenous vein loop to femoral artery arteriovenous fistula: a practical alternative. Ann Vasc Surg 2004;18:223-7. 2. Correa JA, de Abreu LC, Pires AC, Breda JR, Yamazaki YR, Fioretti AC, et al. Saphenofemoral arteriovenous fistula as hemodialysis access. BMC Surg 2010;10:28. 3. Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, Giannoukas AD. Lower-extremity arteriovenous access for haemodialysis: a systematic review. Eur J Vasc Endovasc Surg 2009;38:365-72. 4. Bourquelot P, Rawa M, Van Laere O, Franco G. Long-term results of femoral vein transposition for autogenous arteriovenous hemodialysis access. J Vasc Surg 2012;56:440-5. 5. Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our initial experience. J Vasc Surg 2001;33:968-75. 6. Gradman WS, Laub J, Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia. J Vasc Surg 2005;41: 279-84. 7. Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48(Suppl 1):S248-72. 8. Mallios A, Boura B, Yankovic W, Costanzo A, Combes M. Replacement of infected prosthetic femoral graft with longitudinally vein patches. Eur J Vasc Endovasc Surg Extra 2012;23:e40-1. 9. Mallios A, Boura B, Alomran F, Combes M. A new technique for reconstruction of the aortic bifurcation with saphenous vein panel graft [published online ahead of print May 1, 2013]. J Vasc Surg doi: 10.1016/j.jvs.2013.02.245. 10. van Zitteren M, van der Steenhoven TJ, Burger DH, van Berge Henegouwen DP, Heyligers JM, Vriens PW. Spiral vein reconstruction of the infected abdominal aorta using the greater saphenous vein: preliminary results of the Tilburg experience. Eur J Vasc Endovasc Surg 2011;41:637-46. Submitted Feb 25, 2013; accepted Jun 25, 2013.
Additional material for this article may be found online at www.jvascsurg.org.
Tagliatelle technique for arteriovenous fistula creation using a great saphenous vein semipanel graft Faris Alomran, MD, Benoit Boura, MD, Alexandros Mallios, MD, Romain De Blic, MD, Alessandro Costanzo, MD, and Myriam Combes, MD, Paris, France Lower limb arteriovenous (AV) access creation can be attempted in patients where upper limb options are exhausted. Utilization of the great saphenous vein as a conduit for AV access has been limited due to its small diameter and resistance to dilatation. Lower limb AV fistulas today are mostly either prosthetic grafts with high rates of infection and thrombosis or transposition of the femoral vein that can lead to limb-threatening venous hypertension. In this report, we describe an optimized technique for reconstruction of the great saphenous vein to serve as a dialysis conduit. This semipanel graft reconstruction effectively doubles the diameter of the conduit without disruption of the deep venous circulation and also mitigates the requirement for a venovenous anastomosis. (J Vasc Surg 2013;58:1705-8.)
Lower limb hemodialysis access creation can be attempted in patients where upper limb options are exhausted. Few reports exist on the utilization of the great saphenous vein (GSV) for vascular access with poor results.1,2 Most surgeons today utilize prosthetic grafts or transposition of the femoral vein (tFV) for lower limb access.3 In this report, we describe an optimized technique for GSV reconstruction in order to serve as a dialysis conduit. CASE REPORT The patient was selected to undergo the arteriovenous (AV) fistula creation using a saphenous vein semipanel graft (sPG) and first underwent computed tomography angiography and color duplex with marking of the GSV. Significant arteriopathy and diabetes are considered as contraindications for this procedure to avoid lower limb steal syndrome. Deep venous insufficiency is also considered a contraindication for this technique. The minimal length of GSV required is 40 cm with a diameter superior to 3 mm. In order to maximize the dialysis puncture site, the maximum utilizable GSV length is harvested down to the ankle if possible. The steps of the technique are as follows: (1) The maximum length of suitable GSV is harvested via interrupted skin incisions. (2) The GSV is longitudinally opened up to approximately 5 cm from the saphenofemoral junction but not vertically transected (Fig 1, a). (3) Open valvulotomy of the GSV using Pott’s scissors (Fig 1, b). (4) Folding of the single GSV panel at its center, From the Institute Mutualiste Montsouris. Author conflict of interest: none. Video presentation at the Plenary Session of the 2013 Vascular Annual Meeting of the Society for Vascular Surgery, San Francisco, Calif, May 30-June 1, 2013. Additional material for this article may be found online at www.jvascsurg.org. Reprint requests: Faris Alomran, MD, Institute Mutualiste Montsouris, 46 Blvd Jourdain, Paris 75014, France (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.06.082
creating a posterior and an anterior panel (Fig 1, c). (5) Suturing of the anterior and posterior panels onto each other starting near the saphenofemoral junction and completing the medial edge using an uninterrupted 6.0 Prolene suture. Once the medial edge suture is completed, the lateral edge is sutured in a similar fashion (Figs 1, d and 2, a). (6) A small venotomy at the distal end of the GSV is performed to enable testing of the reconstructed vein under gentle hydropressure using a syringe (Fig 2, b). (7) Lateral subcutaneous tunnelization of the sPG to ensure a puncture zone of suitable length (Fig 1, e). (8) The superficial femoral artery is dissected at the nearest point to the sPG and the AV anastomosis is conducted (Figs 1, f and 2, c). It is important to mention that an arteriotomy of no larger than 4 mm is recommended, to mitigate the risk of lower limb steal syndrome. The procedure lasted 2 hours and 40 minutes, and recovery was uneventful. The patient was discharged on day 6 following a computed tomography angiography confirming no technical anomalies and a harmonious vessel diameter. (Fig 3, a and b; Video 1). The subcutaneous tunnel is 1 to 2 cm lateral to the incision line to avoid the scarred area with attention paid to tunnel entry and exit sites (Fig 4). Wound healing was satisfactory, and the fistula was punctured successfully for dialysis 8 weeks postoperatively following a color duplex scan confirming a 1500 mL/min flow rate and remains patent at 3-month follow-up.
DISCUSSION For most authors, polytetrafluoroethylene grafts would be the first option for patients that require lower limb dialysis access.4 However, prosthetic grafts are frequently complicated by infection and venous anastomosis stenosis. Access loss as a result of infection is far more common in all thigh grafts compared with autologous thigh AV access (18.40% vs 1.61%, respectively).3 Authors have reported favorable patency results for other large-caliber autologous lower limb dialysis fistulas. In their review, Antonio et al reported better 1-year primary and secondary patency of tFV (83%/93%) than both upper- (48%/69%) and mid-thigh (43%/67%) prosthetic grafts.3 Bourquelot et al have reported impressive results with 1- and 9-year primary 1705
1706 Alomran et al
JOURNAL OF VASCULAR SURGERY December 2013
Fig 1. a, Great saphenous vein (GSV) opened longitudinally up to 5 cm from saphenofemoral junction. b, Open valvulotomy using Pott’s scissors. c, Folding of the GSV at its center, creating anterior and posterior vein panels. d, Suturing of the medial edges, followed by the lateral edges together. e, Subcutaneous tunnelization of reconstructed graft to maximize puncture length. f, Small side-to-end arteriovenous (AV) anastomosis performed.
(91%/45%) and secondary (84%/56%) patency, respectively, in a series of 72 tFV cases.4 Similar to tFV, the described sPG technique does not involve a venovenous anastomosis, which is the most
common site for restenosis. A major advantage of sPG, however, is that it allows for the conversion of a long thin conduit into a shorter but larger-diameter autologous conduit without disruption of the deep venous circulation.
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Fig 3. Computed tomography angiography (CTA) reconstruction of the arteriovenous (AV) fistula showing subcutaneous puncture length of 13 cm (a) and harmonious vessel diameter between 7 and 8 mm thoughout (b).
Fig 2. a, The medial edge suture is complete as represented by the posterior aspect of the reconstructed vein panel in this image. The lateral edge suture can be seen to have started on the right side of the image. b, Testing of the reconstructed great saphenous vein (GSV) using gentle hydropressure through a small venotomy for the arteriovenous (AV) anastomoses. c, A maximum of 4-mm sideto-end arteriovenous (AV) anastomosis is performed.
Fig 4. Upper thigh of patient showing the lateral tunnelization of the arteriovenous (AV) fistula lateral to the surgically scarred area. A, Signifies the direction of the AV anastomosis; V, signifies the direction of the iliac vein.
tFV can result in major venous complications due to the disruption of the venous system. Bourquelot et al have reported five cases (6.9%) requiring fistula ligation due to acute venous hypertension,2 lower leg compartment syndrome,1 and major edema2 following tFV. Despite limiting tFV harvest to the segment proximal to the popliteal vein, the requirement for preventative and emergent fasciotomies and even amputations has been reported.5 High initial ischemic complication rates were observed in tFV, leading authors to advocate careful patient selection,
with some authors suggesting the exclusion of diabetic patients and individuals with significant occlusive arterial disease.4 Gradman et al have reduced the ischemic complications to zero in a series of 22 patients by selective performance of femoral vein tapering in addition to patient selection.6 In our case, we decided to limit the venotomy and arteriotomy to approximately 4 mm, leading to an acceptable 1500 mL/min flow rate and have not observed significant ischemia.
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Utilization of the nonreconstructed GSV for AV access has been the product of poor results. The largest series of GSV access has reported a 30-day access loss rate of 21 from 56 fistulas (37.5%) with 20 cases as a result of access thrombosis.2 Pierre-Paul et al reported similar findings with a primary patency of only 7 months and an average of three balloon percutaneous transluminal angioplasties per patient. In addition to two operated pseudoaneurysms, only five of seven fistulas had been successfully used for dialysis, and all patients developed vein loop stenosis. Doppler ultrasound follow-up of these patients exhibited the intrinsic resistance of the GSV to dilatation with an increase in diameter of only 1 to 2 mm, hence rarely reaching the minimum 6-mm diameter recommended by the National Kidney Foundation.7 Ex situ panel reconstruction of the GSV has previously been performed for femoral artery reconstruction and aortic bifurcation reconstruction for prosthetic graft infections.8,9 Van Zitteren et al reported some excellent results with the use of spiral vein grafts without any complications related to the longitudinal suture lines.10 This is the first report of venous panel reconstruction for AV access. Careful patient selection is imperative for the efficacy of the aforementioned technique including the presence of an adequate GSV. We suggest a minimum GSV length of 40 cm, allowing for the reconstruction of a 20-cm segment. However, this is dependent on body habitus on technical variations, and we would recommend harvesting the maximum length of adequate GSV available. We have instated a biannual echo Doppler follow-up protocol in addition to regular clinical examination to monitor for any potential complications. CONCLUSIONS This is a new technique for the utilization on the GSV as a lower limb dialysis access conduit. We believe this technique may also be applicable to other conduits where diameter may be insufficient for AV fistula creation. In our
opinion, sPG possesses various theoretical advantages that remain to be verified with long-term follow-up and further experience. REFERENCES 1. Pierre-Paul D, Williams S, Lee T, Gahtan V. Saphenous vein loop to femoral artery arteriovenous fistula: a practical alternative. Ann Vasc Surg 2004;18:223-7. 2. Correa JA, de Abreu LC, Pires AC, Breda JR, Yamazaki YR, Fioretti AC, et al. Saphenofemoral arteriovenous fistula as hemodialysis access. BMC Surg 2010;10:28. 3. Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, Giannoukas AD. Lower-extremity arteriovenous access for haemodialysis: a systematic review. Eur J Vasc Endovasc Surg 2009;38:365-72. 4. Bourquelot P, Rawa M, Van Laere O, Franco G. Long-term results of femoral vein transposition for autogenous arteriovenous hemodialysis access. J Vasc Surg 2012;56:440-5. 5. Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our initial experience. J Vasc Surg 2001;33:968-75. 6. Gradman WS, Laub J, Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia. J Vasc Surg 2005;41: 279-84. 7. Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48(Suppl 1):S248-72. 8. Mallios A, Boura B, Yankovic W, Costanzo A, Combes M. Replacement of infected prosthetic femoral graft with longitudinally vein patches. Eur J Vasc Endovasc Surg Extra 2012;23:e40-1. 9. Mallios A, Boura B, Alomran F, Combes M. A new technique for reconstruction of the aortic bifurcation with saphenous vein panel graft [published online ahead of print May 1, 2013]. J Vasc Surg doi: 10.1016/j.jvs.2013.02.245. 10. van Zitteren M, van der Steenhoven TJ, Burger DH, van Berge Henegouwen DP, Heyligers JM, Vriens PW. Spiral vein reconstruction of the infected abdominal aorta using the greater saphenous vein: preliminary results of the Tilburg experience. Eur J Vasc Endovasc Surg 2011;41:637-46. Submitted Feb 25, 2013; accepted Jun 25, 2013.
Additional material for this article may be found online at www.jvascsurg.org.