The Transposed Femoral Vein Fistula: The Native Choice in Desperate Vascular Access

The Transposed Femoral Vein Fistula: The Native Choice in Desperate Vascular Access

Accepted Manuscript The Transposed Femoral Vein Fistula - The Native Choice in Desperate Vascular Access Rebecca Lefroy, Nikesh Dattani, Mariane Reyes...

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Accepted Manuscript The Transposed Femoral Vein Fistula - The Native Choice in Desperate Vascular Access Rebecca Lefroy, Nikesh Dattani, Mariane Reyes, Sriram Rajagopalan, Jack Fairhead, Anthony Jaipersad, Lorraine Corfield, John Asquith, Michael W. Greenway, Arun Pherwani PII:

S0890-5096(18)30600-9

DOI:

10.1016/j.avsg.2018.07.035

Reference:

AVSG 3999

To appear in:

Annals of Vascular Surgery

Received Date: 31 May 2018 Revised Date:

25 June 2018

Accepted Date: 9 July 2018

Please cite this article as: Lefroy R, Dattani N, Reyes M, Rajagopalan S, Fairhead J, Jaipersad A, Corfield L, Asquith J, Greenway MW, Pherwani A, The Transposed Femoral Vein Fistula - The Native Choice in Desperate Vascular Access, Annals of Vascular Surgery (2018), doi: 10.1016/ j.avsg.2018.07.035. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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The Transposed Femoral Vein Fistula - The Native Choice in Desperate Vascular Access

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Rebecca Lefroy 1, Nikesh Dattani1, Mariane Reyes2, Sriram Rajagopalan1, Jack Fairhead1, Anthony Jaipersad1,

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Lorraine Corfield1, John Asquith3, Michael W Greenway4, Arun Pherwani1

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University Hospital of North Midlands NHS Trust

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Royal Stoke University Hospital

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Newcastle Road

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Stoke-on-Trent

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ST4 6QG

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Staffordshire and South Cheshire Vascular Network

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University Hospital of North Midlands NHS Trust

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Royal Stoke University Hospital

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Newcastle Road

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Stoke-on-Trent

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ST4 6QG

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Staffordshire and South Cheshire Vascular Network

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University Hospital of North Midlands NHS Trust

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Royal Stoke University Hospital

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Newcastle Road

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Stoke-on-Trent

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ST4 6QG

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University Hospital of North Midlands NHS Trust

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Royal Stoke University Hospital

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Newcastle Road

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The Regional Nephrology and Dialysis Unit

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Vascular Radiology

Department of Anaesthesia

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ST4 6QG

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Corresponding Author:

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Rebecca Lefroy MbChB

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Foundation Doctor

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University Hospital of the North Midlands

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Newcastle Road

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Stoke-on-Trent

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ST4 6QG

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Email: [email protected]

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Tel. 01782 715 444

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Stoke-on-Trent

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Word Count: 3439 including references

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Keywords: Fistula, Femoral Vein, Leg, Renal Replacement Therapy

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Abstract

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Background: A review of our experience in creating transposed femoral vein (TFV) fistulas and some of the

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lessons we have learnt whilst performing this challenging procedure over the last 5 years.

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Methods: A retrospective review of patients who underwent TFV fistula formation between January 2013 -

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December 2017.

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Results: 15 patients underwent FV fistula formation with four cases being excluded from analysis. Median

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follow-up was 1.17 years (interquartile range 0.19 – 3.59 years). Primary and primary assisted patency rates

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were 75% and 100% at 6 months respectively and 66.7% and 100% at 1 year.

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Conclusions: Our patient group showed good fistula patency at one year and did not experience any

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incidence of ischaemic steal syndrome. We believe this to be due to careful pre-operative patient assessment

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and meticulous surgical technique. Our experience suggests that such procedures should be performed by

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surgeons with vascular expertise wherever possible to reduce the incidence of complications.

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1.1 Introduction

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Creation of native arterio-venous fistulae (AVF) is the preferred route of vascular access for patients with

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end-stage renal failure (ESRF) requiring haemodialysis. Compared to other forms of vascular access,

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autogenous AVFs are associated with better patency and lower rates of infection and mortality rates at 2

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years(1). The National Kidney Foundation produced Disease Outcomes Quality Initiative guidelines in 2006

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which preferentially detail the type and anatomical location for creating AVFs and AV grafts (see Table

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I.)(2). In these guidelines, native lower limb fistulas and grafts, including the use of transposed femoral vein

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(TFV), are listed as fifth choice for vascular access, which may reflect the paucity of evidence about the use

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of this conduit in the published literature. This aim of this study was to perform a retrospective review of all

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TFV fistula procedures performed in our unit, review the current literature and detail the lessons learnt from

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our experience.

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2.1 Methods

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This study included the review all cases of TFV fistula formation supervised by a single vascular surgeon

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(A.P.) at our unit. A prospective record of patients undergoing this procedure had been kept. Patient

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demographics and outcome data were collected from generic paper and electronic medical records as well as

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from a specific renal unit electronic database (Cyberen ®). IBM SPSS Statistics 25 was used for analysis.

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The demographics and outcomes of interest included: 1) age, gender and comorbidities, 2) number and type

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of previous vascular access and adjunctive procedures, 3) date of TFV surgery, indication for access, length

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of operating time and hospital stay, 4) AVF post-operative complication, 5) whether the TFV fistula was

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working at latest follow-up, and 6) date and cause of patient death. We used this data to calculate the patency

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and assisted patency rates in our cohort.

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2.2 Technical and anatomical considerations

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Compared to using the great saphenous vein (GSV), leg fistulas created using TFV are technically more

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challenging. The GSV is frequently found superficially and is therefore easy to harvest. However, the

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muscular structure of GSV results in the development of concentric rings of stenosis along the venous length

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when exposed to arterial pressure. As a result, the GSV matures poorly and commonly results in hypertrophy

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of the valve at the superficial femoral junction, causing outflow obstruction(3,4).

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In comparison, the Femoral vein (FV) is situated deep in the thigh and therefore harvesting this vein requires

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greater surgical experience and is a more complex dissection. Furthermore the FV has to be transposed into

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a superficial plane to enable it to be needled. However, there are a number of advantages of using the FV.

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Since the FV is a deep vein, it is invariably of good calibre and has universally avoided previous needling

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making it of good quality. In addition, the structure of the FV is distinct to that of the GSV and significantly

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less muscular. Moreover there is evidence that the use of FV results in a leg fistula with significantly

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improved long-term patency and a 10-fold lower risk of infective complications compared to using leg

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grafts(3–9).

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92 2.3 Preoperative

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It is quintessential that preoperatively each patient has a full arterial assessment. Not only does this involve a

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full access history, but it will require full external limb examination, checking all lower limb pulses and

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performing ankle brachial pressure indices (ABPIs). Formal duplex to confirm patency of the GSV, common

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and femoral vein and ipsilateral iliac veins is necessary. Duplex arterial assessment or CT angiography may

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also be required to review the proximal and distal arterial supply and assess for stenosis or aneurysmal

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changes.

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An important consideration when selecting patients for this procedure is the previous access history. These

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are often patients who have a long and complex access course and will invariably have had numerous lines.

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It is preferable that lower limbs where the outflow iliac veins have previously housed lines are avoided as

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this can potentially compromise the maturation and functioning of the TFV or may require future

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interventions to maintain patency, as we will demonstrate later in this paper.

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Considering the potential complications of this procedure, it is preferable that patients with intact saphenous

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systems are selected. The nature of this procedure will inevitably compromise the venous return from the

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leg, this precaution minimises the degree of lower limb oedema.

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In certain diabetics with amputations (below knee) we have elected to perform the TFV fistula within the

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amputated leg. This is provided that the FV is patent and the superficial femoral artery (SFA), or a section of

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it, is patent distal to a patent common femoral and profunda femoral artery (so the fistula does not jeopardise

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the stump). This scenario is unique and does not apply to patients in whom both limbs are intact where one

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cannot accept any preoperative narrowing or occlusion of SFA, as this would risk ischaemic steal.

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2.4 Anaesthesia

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Pre-operative assessment in our unit is provided using our dedicated Pre-Anaesthesia Management Service,

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which thoroughly assesses patients for surgery, minimising on-the-day cancellations, and optimises patients.

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Pre-operative investigations as recommended by the Association of Anaesthetists of Great Britain and

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Northern Ireland (AAGBI) are done as a minimum, with targeted cardiorespiratory investigations as needed.

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Special attention is made to peri-operative diabetes and anti-coagulation management, along with the timing

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of surgery to suit regular haemodialysis sessions(10).

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Our preference has been to use a neuraxial regional anaesthetic technique combined with general

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anaesthesia; these patients are often judged to be American Society of Anaesthesiologists score 3-4, and this

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technique has been felt to be more cardiostable, and also provides vasodilatation at the operative site. The

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relatively extensive deep wound requires strong analgesia postoperatively, which is well provided by lumbar

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epidural(11).

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Intra-operative patient monitoring is based on the AAGBI routine monitoring standard, with optional intra-

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arterial blood pressure monitoring when cardiovascular instability is predicted. Central venous access is not

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normally required, but can be used in high-risk cases. In our centre, peri-operative normotension is targeted

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(baseline blood pressure +/- 20%), with judicious use of crystalloid fluid and vasopressor infusions. As with

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AVF formation at other anatomical sites, intra-operative heparinisation is mandated.

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The post-operative disposition of patients is usually to a specialist vascular ward environment capable of

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safely managing epidural analgesia, with follow-up by our acute pain team on a regular basis. High-risk

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patients are cared for post-operatively in a Surgical Special Care Unit, which provides specialised

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monitoring at the High-Dependency Unit level(12).

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2.5 Operative Procedure

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The operative steps needed to harvest the FV have been previously well documented in the literature

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particularly since the FV is increasingly being used as the conduit of choice in infected aortic surgery(13). 7

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There are a few important technical considerations to note, however. The most cephalad point of dissection

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should be the confluence between the deep and FV. The junction between the deep femoral vein and

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common femoral vein should remain free of flow disturbance to avoid the formation of deep venous

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thrombosis. The geniculate vessels should define the most caudal point of dissection. Between these points

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the course of the FV should be carefully and completely dissected, following its route medial, posterior and

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then lateral to the SFA, beneath the Sartorius muscle and through the Adductor hiatus.

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For fistula formation, the SFA must also be dissected and an anastomosis created between the distal end of

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the FV and distal SFA if tunnelled longitudinally in the thigh or proximally if tunnelled into a loop.

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Importantly, the arteriotomy used to create the anastomosis should be considerably smaller than the diameter

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of the vein (no more than 5-6mm), in order to reduce the incidence of ischaemic steal syndrome. This is a

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key step in the creation of these fistulae. Finally, there is a high rate of post-operative haematoma formation

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following the procedure mandating the placement of surgical drains for at least three to five days post-

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operatively to reduce the rate of compartment syndrome and/or haematoma formation. Our practice is to

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place two drains; one in the upper part of the wound near the groin; the second in the lower part of the leg.

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Customarily the upper drain is left in for longer. More recently, we have changed our practice to close the

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wound using interrupted non-absorbable sutures, particularly in diabetic patients where the incidence of

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wound-related complications is higher. The leg is kept elevated in the post-operative period and a standard

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below knee thromboembolic stocking (TED®) applied, along with administration of prophylactic dose low-

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molecular-weight heparin.

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Figures 1, 2 and 3 show the steps of the procedure and examples of the fistulas created.

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3.1 Results

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In total, we have performed fifteen cases of native FV transposition. Four patients had to be excluded from

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the present analysis. Two because their fistulas were created in other countries (voluntary charity work) so

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could not be followed up, one patient in whom a fistula was created pre-emptively and so has not yet been

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used, and the final patient who has had a fistula created only recently hence has no significant follow up.

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Therefore this study describes the experience of TFV for vascular access in 11 patients performed between

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January 2013 and December 2017. All patients were discussed in a renovascular multidisciplinary team

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meeting prior to FV fistula formation.

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The demographics of these 11 patients are detailed in Table II. The indications for TFV fistula formation

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were as follows:

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1. ESRF in nine patients.

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2. Refractory hypocalcaemia in one patient. Daily calcium infusions were required in this patient who

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had suffered from multiple fractured lines. They were unable to manage infusions via upper limb

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fistulae.

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3. Inflammatory bowel disease in one patient. They required thrice weekly magnesium infusions and

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definitive access due to numerous clotted Hickman® lines, recurrent portacath infections and failed

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upper limb fistulae.

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Table III summarises access in these patients prior to creation of the TFV, indicating that leg fistulas are not

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a first or even third line of access for these patients.

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Our patients’ ages ranged from 35-74 years. There were eight men and three women. In all, five right and six

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left leg fistulae were created. Ten of these were configured longitudinally and one, a loop. The median

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operating time for patients was 211 minutes (interquartile range [IQR] 178 – 222 minutes). Two patients

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suffered superficial post-operative wound infections, both on a background of diabetes. One patient received

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a blood transfusion following their procedure, although anaemia was apparent pre-operatively. 9

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The median length of hospital stay was 6 days post-operatively (IQR 5-9 days). Long term, all 11 patients’

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fistulas have been utilised and functioned well. Over time a number of interventions have been performed to

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maintain fistula patency.

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reaching one year follow-up thus far. Our data revealed a primary patency rate at 1 month of 100%. At 6

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months our primary patency and primary assisted patency rates were 75% and 100% respectively. By one

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year, these were 66.7% and 100%. These are shown graphically in Figures 4 and 5.

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listed in Table IV.) -

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Two patients have subsequently undergone renal transplantation but still have functioning fistulas, now used for venous access.

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Three patients use their fistula regularly, one for calcium infusions and two for dialysis.

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One patient was lost to follow-up having moved location, last known three months postoperatively with a functioning fistula, receiving haemodialysis.

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Five patients had died, all with fistulas working at last appointment (time and causes of death

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As of December 2017;

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There were four patients who suffered complications necessitating surgical intervention; one patient

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developed a high output fistula requiring two surgical procedures to prevent systemic complications (Figure

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6). Two patients developed superficial wound infections, both of whom suffered from diabetes. Two of our

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cohort developed necrotic changes in their toes. In both cases this resulted in transmetatarsal amputations,

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with one ultimately resulting in below knee amputation and the other requiring further debridement. These

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are all summarised in Table V.

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During subsequent fistula use, four patients were noted to have episodes of bleeding post dialysis. In each

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case, bleeding was minimal requiring conservative management with pressure and needling technique

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education only.

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4.1 Discussion

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This study describes our experience with TFV leg fistulas and to our knowledge is the largest from any UK

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centre. There are a number of lessons that can be learnt from our experience with this technique. The most

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important aspect in the process of creating TFV fistulas is careful patient selection. Patients should undergo

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proper assessment of their lower limb arterial and venous vasculature, including peripheral pulses and

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ABPIs, prior to fistula formation to reduce the incidence of complications such as ischaemic steal. This

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assessment combined with experience in harvesting the FV makes vascular surgeons ideally placed to

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perform such procedures. In addition, there are a number of important technical considerations when

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creating these fistulas. These include performing adequate length of venous dissection proximally and

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distally, the use of very small arteriotomies for the anastomosis, graded closure of wounds to allow for the

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transposed and tunnelled FV, the placement of surgical drains for longer than normally expected and careful

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post-operative management.

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The importance of conducting a thorough pre-operative vascular assessment is illustrated by noting that the

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patient in our case series who underwent the highest number of endovascular procedures for stenosis (n=8)

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also was the patient who had undergone the highest number of line insertions prior to leg fistula formation

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(n=12), including historically placed femoral lines in the ipsilateral iliac venous segment that subsequently

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required venous outflow intervention to maintain patency.

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We also looked at that those patients who required further operations following fistula creation. Those

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patients who underwent transmetatarsal and leg amputations developed necrosis requiring definitive

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management at 21 months and 13 months following fistula creation. Due to the time periods between the

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operation and the symptoms, it is unlikely these complications can be solely attributed to the fistula creation,

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particularly as both patients suffered type 2 diabetes mellitus and long standing ESRF with one patient

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demonstrated poor compliance to their medical and dialysis treatment.

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Internationally, there have been only two significant case series published regarding the use of TFV fistulas.

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Gradman et al published a case series of 25 FV fistulas and reported primary and secondary fistula patency

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rates of 73% and 86% respectively at 12 months post-operatively with no cases of fistula infection. They

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found however that >30% of patients required a second operation to treat ischaemic steal syndrome which

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they felt was the major drawback with the procedure(14). This has not been our experience, which we may

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cautiously attribute to the short arteriotomies employed at our centre. More recently, Bourquelot et al has

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published the largest case series in this area based on the experience from 2 centers in France (n=70) and is

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the only series with true long-term follow-up. They reported primary patency rates of 91% at 1 year reducing

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to 45% at 9 years post-op. In addition they found a relatively high complication rate with this technique;

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14% ‘minor’ complications, 42% ‘mild’ complications and 18% ‘major’ complications, the latter requiring

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fistula ligation (all graded according to their own system). The authors concluded that careful patient

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selection is essential to avoid ischaemic complications, this is a sentiment we echo(15).

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5.1 Conclusion

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Although our experience is still small in absolute terms, we have learnt that with careful patient selection

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and meticulous surgical technique, the TFV fistula can be formed using a good calibre, virgin vein and will

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provide reliable vascular access for patients where upper limb options are lacking. Given the high rate of

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ischaemic and other complications in the literature, we recommend that these procedures are best performed

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by surgeons with vascular expertise so that a thorough pre-operative vascular assessment can be performed

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and that technical factors such as the use of small arteriotomies and adherence to basic vascular principles

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are followed.

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We must acknowledge that the procedure undertaken here is a major one, with significant complication rates

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demonstrated in the literature. The cohort of patients requiring such procedures may also be considered high

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risk with significant comorbidity, access history and therefore failures. Never the less, the outcomes we have

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demonstrated show promise that the use of the TFV does hold its place in the management of this difficult

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patient group.

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In conclusion, this experience has shown that the TFV fistula can provide a reliable, long-term option for

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vascular access even in the most challenging patients and should be considered more often in the desperate

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vascular access patient. Our preference is to use the native TFV over AV grafts wherever possible(7).

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6.1 References

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1.

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Almasri J, Alsawas M, Mainou M, Mustafa RA, Wang Z, Woo K, et al. Outcomes of vascular access for hemodialysis:systematic review and meta-analysis. J Vasc Surg 2018;64(1):236–43.

2.

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National Kidney Foundation. Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis 2006;48:487–8.

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3.

Wilmink T. Lower limb access. The journal of vascular access 2014;15(7):130-135.

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4.

Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, Giannoukas AD. Lower-extremity Arteriovenous Access for Haemodialysis: A Systematic Review. Eur J Vasc

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Endovasc Surg 2009;38(3):365–72.

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Surg 2017;18(2):130–5. 6.

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Caco G, Golemi D, Likaj E. Straight configuration saphenous vein transposition to popliteal artery for vascular access. J Vasc Access 2017;18(2):15-17.

7.

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Almasri J, Alsawas M, Mainou M, Mustafa RA, Wang Z, Woo K, et al. Lower limb access. J Vasc

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Ladenheim ED, Lulic D, Lum C, Agrawal S. Primary and secondary patencies of transposed femoral vein fistulas are significantly greater than with the hero graft. J Vasc Access 2017;18(3):232–7.

8.

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Krasiński Z, Biskupski P, Dzieciuchowicz Ł, Kaczmarek E, Krasińska B, Staniszewski R, et al. The Influence of Elastic Components of the Venous Wall on the Biomechanical Properties of Different

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Veins Used for Arterial Reconstruction. Eur J Vasc Endovasc Surg 2010;40(2):224–9. 9.

Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP, et al. Editor’s Choice –

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Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery

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(ESVS). Eur J Vasc Endovasc Surg 2018;55(6):757–818.

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10.

Ireland A of A of GB and. Aagbi Safety Guideline 2009;(January):1–20.

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11.

Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth

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2011;55(2):111–5. 12.

Intensive Care Society. The Intensive Care Society A Guide for Critical Care Settings Standards for critical incident reporting in critical care 2005;37. 15

13.

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Gefasschirurgie 2016 Aug 1;21(Suppl 2):45–54. 14.

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Neufang A, Savvidis S. Operative technique and morbidity of superficial femoral vein harvest.

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 May;33(5):968–75.

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Bourquelot P, Rawa M, Van Laere O, Franco G. Long-term results of femoral vein transposition for

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autogenous arteriovenous hemodialysis access. J Vasc Surg 2012;56(2):440–5.

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7.1 Figure Legends

309 Figure 1. a) Dissection of the Femoral Vein (FV) and femoral artery showing their path under the Sartorius.

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b) Dilated FV with perforating vessels tied off. c) Picture of the vein before tunneling showing its path

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superficially through the subcutaneous fat. d) Anastomosis of the vein onto the artery showing the small

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arteriotomy. (Supplementary Material)

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Figure 2. a) Final fistula showing the transposed Femoral Vein’s path in longitudinal fashion. b) Cannulated

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thigh fistula. c) Leg fistula in situ showing procedural scar and needling technique. (Supplementary

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Material)

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Figure 3. a) & b) Further examples of out patient’s leg fistulas. (Supplementary Material)

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Figure 4. Survival plot showing patient follow up in years.

Figure 5. Survival plot depicting primary patency of fistulas.

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Figure 6. Imaging showing one patient’s high outflow fistula. Venous portion dilation is evident along with

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iliac arterial remodeling. (Supplementary Material)

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New nomenclature

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Traditional Nomenclature

Autogenous radial-cephalic direct wrist access

Brescia-Cimino fistula

Choice

Autogenous posterior radial brachiocephalic direct access

Snuffbox fistula

Second

Autogenous radial-basilic forearm transposition

Superficial forearm vein transposition

Choice

Autogenous ulnar-basilic forearm transposition

Superficial forearm vein transposition

Autogenous radial-cephalic forearm transposition

Superficial forearm vein transposition

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First

Autogenous ulnar-cephalic forearm transposition

Superficial forearm vein transposition

Autogenous brachial-cephalic direct access

Brachiocephalic fistula

Third

Prosthetic radial-antecubital forearm access

Choice

Prosthetic brachial-antecubital forearm loop access

forearm loop bridge AV graft

Autogenous brachial-basilic upper arm transposition

Basilic vein transposition

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Forearm straight bridge AV graft

Prosthetic brachial-axillary upper arm access

Upper arm straight bridge AV graft

Choice

Prosthetic axillary-axillary upper arm access

Upper arm loop bridge AV graft

Fifth

Prosthetic popliteal-greater saphenous straight access

Thigh straight bridge AV graft

Choice

Prosthetic femoral-greater saphenous looped access

Thigh looped bridge AV graft

Autogenous popliteal superficial femoral transposition

Superficial femoral vein transposition

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Prosthetic brachial-axillary chest access

Brachioaxillary straight

Choice

Prosthetic brachial-internal jugular chest loop access

graft

Prosthetic axillary-axillary chest loop access

Brachiojugular straight bridge AV graft

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Prosthetic axillary-internal jugular chest loop access

Axilloaxillary loop bridge AV graft

Prosthetic axillary-axillary straight chest loop access

Axillojugular loop Bridge AV graft

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Seventh

bridge

Prosthetic axillary-femoral access

Axilloaxillary straight bridge AV graft Axillofemoral bridge AV graft

Choice

Table I. Reproduced from NKF guidelines showing the preference of fistula placement (2). AV-Arteriovenous.

AV

ACCEPTED MANUSCRIPT Range

Age

55.3 years

35-74 years

Number of Comorbidities

8.8

4-13

Previous Access History (number)

9

3-15

Follow Up

1 Year 2 Months

1 month – 4 years 9 months

AC C

EP

TE D

M AN U

SC

Table IV. Patient demographic summary.

RI PT

Average

ACCEPTED MANUSCRIPT Range

Number of PD catheters

0.2

0-1

Number of Lines

5.7

2-12

Number of Upper limb AVFs

2.1

0-4

Number of Upper Limb AVGs

0.6

0-2

Interventions to Previous Access

5.2

RI PT

Average

0-15

SC

Table V. Summary of previous access and interventions to upper limb access.

AC C

EP

TE D

M AN U

PD – Peritoneal Dialysis AVF – Arteriovenous Fistula AVG – Arteriovenous Graft

ACCEPTED MANUSCRIPT Fistula status at Latest Follow Up Patient 1

Cause of Death

Functional 1a Bowel Perforation b Crohn’s Disease 2 COPD ESRF

Patient 2

Functional 1a Sepsis

RI PT

b Crohn’s Disease with Abscesses

2 Recurrent DVT and Pulmonary Emboli Functional -

Patient 4

Functional -

Patient 5

Functional -

Patient 6

Functional -

Patient 7

Functional 1a Ischaemic Bowel with Perforation

M AN U

SC

Patient 3

b Atrial Fibrillation

Patient 8

Functional 1a Acute Haemorrhagic Pericarditis Functional 1a Recent Myocardial Infarction

AC C

EP

Patient 9

TE D

2 Ventricular Dysfunction, ESRF and T2DM

b Complete Occlusion of Coronary Artery c Recently Formed Thrombus 2 Severe Generalised Atherosclerosis, ESRF, Hypertension and DM

Patient 10

Functional -

Patient 11

Functional -

Table VI. Fistulas functional status at end of follow up with cause of death if applicable. COPD – Chronic Obstructive Pulmonary Disease ESRF – End Stage Renal Failure DVT – Deep Vein Thrombosis T2DM – Type 2 Diabetes Mellitus DM – Diabetes Mellitus

ACCEPTED MANUSCRIPT Length of follow

Endovascular

up years (y)

Interventions to

months (m)

Fistula

Surgical Interventions

Complications

1m -

-

-

Patient 2

3y 3.5m -

-

-

Patient 3

4y 9m -

-

-

Patient 4

2m -

-

Patient 5

4y 3m -

3y 10m 8 Fistuloplasty

Banding and ligation (T)

For high output fistula

Refashioning of fistula (T)

(see Figure 6.)

-

for stenosis (IS) 6m 2 Fistuloplasty

Patient 8

(IS) 2y 8m 2 Fistuloplasty

M AN U

Patient 7

for stenosis(IS) Patient 9

-

SC

Patient 6

RI PT

Patient 1

1y 2m 2 Fistuloplasty

TE D

for stenosis (IS)

Leg swelling linked to iliac stenosis (outflow Wound infection (DM)

Left trans metatarsal amputation (T)

Necrotic toe

Left below knee amputation (T)

(Poor compliance)

Right trans metatarsal amputation (T)

Gangrene with

Right stump debridement(T)

osteomyelitis in foot

Patient 10

3m -

-

Wound infection (DM)

Patient 11

1.5m -

-

-

leg fistulas.

EP

Table VII. Summary of patient’s length of follow up and interventions and complications to

AC C

(IS- Interventional Suite T-Theatre W-Ward CT – Computed Tomography DM – Diabetes Mellitus)

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT