Annals of Vascular Surgery - Brief Reports and Innovations (Jun 2023)
Management of limb threatening ischemia following lower extremity hemodialysis access
Abstract
Introduction: Lower extremity arteriovenous (LE-AV) access is uncommon and is often reserved for patients who have exhausted upper extremity options. The development of limb threatening ischemia (LTI) ipsilateral to LE-AV access is a challenging problem with scant literature to guide treatment. This case series highlights the presentation and management of LTI after LE-AV access placement. Methods: In this single surgeon series, five patients presented after LE-AV access with clinical symptoms of LTI, characterized by rest pain and/or tissue loss. A chart review of their outcomes including long term follow up and management strategy was performed. Results: Of the five patients identified, three (60%) were female and all five (100%) had exhausted their upper extremity dialysis options. The patients had a mean age of 46 years (range 27–58), with a mean dialysis duration of 18 years (range 9–32). Three patients presented on postoperative day 0, 64, and 280 with rest pain. Two patients presented with diabetic foot gangrene with ischemia, 2 and 39 months after thigh access placement. Treatment in the rest pain group consisted of emergent plication of a femoral vein transposition on the day of placement and the other two had distal revascularization with interval ligation (DRIL). The two patients who presented with diabetic gangrene had open partial foot amputations followed by revision of the AV access inflow to the deep femoral artery in combination with popliteal pedal bypasses. Mean amputation free survival was 66 months (range 44–110) and the accesses had a mean secondary patency of 55 months (range 36–72). Four patients had preoperative and postoperative noninvasive testing, all with marked improvement in ankle brachial indices and digital pressures after revascularization. Conclusions: LE-AV access remains an important option for patients with limited hemodialysis access choices; however, the arteriovenous shunting induced by LE-AV access placement can cause a steal and can easily unmask lower extremity peripheral arterial disease, resulting in LTI. For those patients presenting with isolated rest pain, treatment should be primarily focused on arteriovenous steal, while patients with tissue loss warrant further intervention on pre-existing atherosclerotic disease. Appropriate treatment of lower limb ischemia associated with patent AV access can lead to long term limb and access salvage.
