PROSTHETIC-VEIN COMPOSITE GRAFT WITH REMOTE POPLITEAL ARTERIOVENOUS-FISTULA

BACKGROUND: Inadequate autogenous vein is often the limiting factor in femoral-distal reconstruction. Sequential grafts, distal arteriovenou s fistulae (AVF), and autogenous cuffs have been recommended in this s etting. This paper describes a new method of composite reconstruction, enhanced with a popliteal AVF. PATIENTS AND METHODS: Data was collect ed prospectively on 13 patients (14 limbs) who presented with severe i schemia (rest pain or ulcer 6, gangrene 8). The average age was 75 yea rs. Eleven of the reconstructions were to tibial outflow tracts. The n ovelty of the technique is in the construction of a controlled AVF bet ween the upper end of an autogenous vein graft and the popliteal vein. An uncomplicated autogenous anastomosis is created distally. The synt hetic graft is placed between the common femoral artery and the vein g raft distal to the AVF. The flow is balanced between the fistula and t he outflow tract by narrowing the fistula while monitoring the pressur e in the graft system. RESULTS: Patency was assessed by color duplex s can. Two grafts occluded (at 5 and 7 months) and 1 was revised at 12 m onths. Mean peak systolic velocity in the synthetic portion was 130 cm /s. Limb edema has not been a problem. There were 2 perioperative card iac deaths. Mean follow up is 15 months (range 6 to 36). CONCLUSION: T he addition of a controlled AVF below the synthetic portion of a compo site graft appears promising when vein is in limited supply.