Background and Aims: End stage renal disease (ESRD) is the final stage of the progression of chronic kidney disease caused by various etiologies. Most patients with ESRD choose hemodialysis as a renal replacement therapy, for which maintaining the good function and satisfactory patency of the vascular access is extraordinarily critical. The upper extremity is the first choice for patients to construct hemodialysis access. However, some patients with problems such as exhaustion of upper extremity vascular or central venous resources due to various reasons, are unsuitable for upper limb vascular access creation. Therefore, creation of a lower extremity arteriovenous grafts (AVG) can be considered as a long-term hemodialysis access for patients. This study was conducted to review the clinical data and follow-up results of patients with AVG creation in lower extremity, so as to provide empirical evidence for this field.
Methods: The clinical and follow-up data of 32 ESRD patients undergoing construction of lower extremity AVG in Nanfang Hospital of Southern Medical University from March 2014 to November 2018 were reviewed. The relevant clinical variables of the patients were analyzed, and the postoperative primary and secondary patency rates were determined by Kaplan-Meier method.
Results: AVG tremor was palpable in all patients after the operation. One patient developed an acute attack of chronic cardiac insufficiency during the perioperative period, and then died due to no obvious improvement after drug administration and intensive dialysis treatment. Two patients developed graft thrombosis, and underwent incision of the catheter and thrombus removal. After that, no stenosis in the anastomotic stoma or in the outflow venous was observed in the angiography. The patency of the AVG was resumed and the dialysis was maintained. During the perioperative period, no complications such as infection, hemodialysis access-induced distal ischemia (HAIDI), or pseudoaneurysm occurred in all patients. Postoperative follow-up was conducted for 1 month to 6 months, with a median time of 14.1 months. During the follow-up period, AVG stenosis occurred in 13 patients (40.6%), and AVG occlusion occurred in 10 patients (31.3%), and AVG patency was restored after surgical or endovascular repair. Prosthetic vascular graft infection occurred in 3 patients (9.4%), of whom, one case had a local graft infection, and AVG was successfully retained for dialysis after removal of the infected part and transplantation of autologous vein; 2 patients underwent completely resection of the graft due to whole graft infection. No complications such as pseudoaneurysm and HAIDI occurred during this period. The average primary patency time was (20.4±3.32) months, and the 1-, 2- and 3-year primary patency rates were 64.6%, 44.7% and 19.6%, respectively. The average secondary patency time was (38.7±5.52) months, and the 1-, 2- and 3-year secondary patency rates were79.6%,79.6% and 54.6%, respectively.
Conclusion: The lower extremity AVG can achieve a satisfactory secondary patency rate after repairment, and is a feasible alternative for patients with exhausted options for creating an upper extremity vascular access. Standard preoperative evaluation, strict aseptic operating during surgery and puncture, and regular follow-up are important factors to ensure long-term patency.