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Arteriovenous Fistula(AVF) in the Upper Extremities(UE) continues to be the preferred vascular access due to its excellent results compared to other methods. With the aging of the dialysis population, UE vascular access becomes more difficult due to wall calcifications and occlusive complications, leading to search for access in the Lower Extremities(LE). The use of different techniques such as transposition of the Greater Saphenous Vein(GSV) has been proposed, this being uncommon with few reports in the last 20 years. This article describes the technique and results of the AVF between GSV and Superficial Femoral Artery(SFA) performed in two patients with exhaustion of vascular accesses in UE.
32-year-old male on hemodialysis with vascular access exhaustion due to bilateral thrombosis of brachiocephalic veins. Ultrasound of LE was performed, showing GSV of 4 mm, without occlusive arterial lesions. In the operating room, continuous epidural anesthesia is administered, with an oblique incision in the right femoral inguinal region of 7 cm. SFA is dissected and GSV is removed from its arch to the knee through discontinuous incisions. The distal venous segment is sectioned, the tunnel is created on the anterior surface of the thigh and the GSV is measured so that its distal end reaches the SFA without tension (Fig. 1A). Clamps are placed in SFA and GSV, a 6 mm longitudinal opening in SFA and an end-to-side anastomosis is performed between GSV and SFA (Fig. 1B), thrill is palpated throughout the venous tract. Closure by wound planes. The next morning a hematoma of the thigh was found, with decreased thrill, so emergency surgery was decided to remove the clots while recovering function. The second patient is 19 years old, with a history of hydrocephalus with peritoneal-ventricle shunt on hemodialysis four years ago. Using ultrasound, the right GSV was visualized with a diameter of 4 mm, without occlusive arterial lesions in LE. Surgery without regional anesthetic method due to loss of sensitivity in LE. A 7 cm oblique incision was made in the inguinal femoral region. SFA is dissected and the GSV is extracted from its arch to the knee through discontinuous incisions in the skin, the distal venous segment is sectioned (Fig. 2A) and tunneled, forming a loop on the anterior surface of the thigh. Clamps are placed in SFA and GSV, a 6 mm longitudinal opening in SFA and an end-to-side anastomosis is performed between GSV and SFA (Fig. 2B), thrill is palpated throughout the vein. Hemostasis is checked and closed in layers.
The creation of AVF in the anterior loop of the thigh constitutes an effective and valuable alternative in dialysis patients without the possibility of vascular access in the upper extremities.