Prosthetic-vein composite graft with remote popliteal arteriovenous fistula

Inadequate autogenous vein is often the limiting factor in femoral-distal reconstruction. Sequential grafts, distal arteriovenous fistulae (AVF), and autogenous cuffs have been recommended in this setting. This paper describes a new method of composite reconstruction, enhanced with a popliteal AVF.

Data was collected prospectively on 13 patients (14 limbs) who presented with severe ischemia (rest pain or ulcer 6, gangrene 8). The average age was 75 years. Eleven of the reconstructions were to tibial outflow tracts. The novelty of the technique is in the construction of a controlled AVF between the upper end of an autogenous vein graft and the popliteal vein. An uncomplicated autogenous anastomosis is created distally. The synthetic graft is placed between the common femoral artery and the vein graft distal to the AVF. The flow is balanced between the fistula and the outflow tract by narrowing the fistula while monitoring the pressure in the graft system.

Patency was assessed by color duplex scan. Two grafts occluded (at 5 and 7 months) and 1 was revised at 12 months. Mean peak systolic velocity in the synthetic portion was 130 cm/s. Limb edema has not been a problem. There were 2 perioperative cardiac deaths. Mean follow up is 15 months (range 6 to 36).

The addition of a controlled AVF below the synthetic portion of a composite graft appears promising when vein is in limited supply.