Distal vein patch with an arteriovenous fistula: A viable option for the patient without autogenous conduit and severe distal occlusive disease

Background: The addition of a distal arteriovenous fistula (DAVF) to improve patency in lower extremity bypass is well described. This report describes a technique of using a distal AVF to enhance a distal vein patch (DVP) in patients without adequate autogenous conduit and who have concomitant severely disadvantaged arterial runoff. Methods: A retrospective review from May 2002 to May 2007 analyzed 270 tibial bypasses. DVP-AVF was the conduit in 30 bypass grafts. Patient demographics included 16 men, 14 women, diabetes mellitus (67%), and chronic renal failure (20%). All patients had limb-threatening ischemia manifest as rest pain or tissue loss, with 20 patients referred after failed prior revascularization: 11 failed bypasses, and nine failed endovascular interventions. In each case, the only outflow artery available was an isolated tibial segment or a diseased pedal vessel not ordinarily deemed suitable for bypass. At surgery, a common ostium AVF was created between the outflow tibial artery and corresponding tibial vein before DVP construction. Follow-up was 1 to 24 months, with graft function evaluated by pulse examination and duplex surveillance. Primary patency and limb salvage ± SE were determined by life-table analysis using Rutherford criteria. Results: The proximal anastomosis originated from the external iliac (23%), common femoral artery (43%), and superficial femoral artery (33%). Outflow arteries included the anterior tibial (40%), posterior tibial (30%), and peroneal (30%). Venous hypertension in the bypassed limb was noted, but not considered problematic in any patient. Perioperative graft failure occurred in one patient. Six graft failures led to six major amputations (1 above knee; 5 below knee). One patent graft was excised due to infection. Primary patency at 6, 12, 18, and 24 months was 78.3% ± 6.8%, 78.3% ± 10.5%, 62.6% ± 11.1%, and 62.6% ± 15.6%; limb salvage was 78.7% ± 6.7%, 78.7% ± 10.1%, 78.7% ± 10.1%, and 57.7% ± 12.5%. Conclusion: This early experience describes a modification of the DVP technique in patients with threatened limb loss and severely disadvantaged tibial runoff. The addition of an AVF may reduce outflow resistance, thereby contributing to higher flow rates and improved graft patency. Further investigation is warranted because the DVP-AVF technique may result in acceptable graft patency and limb salvage for patients with no other alternative than amputation.