Femoral vein transposition arteriovenous fistula (FV tAVF) has been shown to be a “feasible and reliable” option for haemodialysis vascular access in complex patients, according to the findings of a multicentre retrospective analysis published in the Journal of Vascular Access (JVA).
The study included 32 adult patients undergoing FV tAVF creation due to exhaustion or unavailability of upper arm veins or bilateral upper central venous occlusion and lower extremity circulation at three centres in Brazil.
In their JVA paper, study author Márcio Filippo (Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil) and colleagues report that the procedure achieved primary patency rates of 90%, 84%, 60% and 18% at six, 12, 24 and 60 months respectively.
“In this publication, we revisited femoral vein transposition—an unfortunately underutilised option for challenging patients who are progressing toward vascular access failure,” Filippo comments to Renal Interventions. “Our results confirmed the safety and strong outcomes of this robust technique, which can reduce reliance on catheters and grafts, improving both life expectancy and quality of life for these patients. In our view, femoral vein transposition should be reconsidered as a technically feasible, effective, reliable, and durable solution, especially for younger patients and for centres with limited resources and high infection rates.”
Certain characteristics of the femoral vein, including its large calibre and thin walls, support its long-term tAVF functionality, the researchers write. FV tAVF emerged as an option for arteriovenous fistula (AVF) creation after 2000, and has been in use in Brazil several years.
“The technique offers advantages over prosthetic grafts, including improved patency rates and reduced risks of infection and thrombosis,” the study’s authors state. “Furthermore, innovations in surgical techniques, such as vein tapering and refined anastomosis methods, have further improved outcomes and minimised complications such as steal syndrome.”
However, despite these benefits, they not that the adoption of FV tAVFs for haemodialysis access remains heterogeneous, and complications including high rates of wound morbidity and infection have been reported in some series.
Using a sample of adult patients who underwent FV tAVF creation for haemodialysis vascular access between August 2013 and January 2023, the researchers examined primary patency, defined as the interval from access creation until the first intervention performed to maintain or restore patency. Technical success was defined as the successful maturation of the tAVF, achieved when the access allowed for effective haemodialysis with the prescribed flow for at least three consecutive session.
Complications including the incidence of wound complications, reoperation due to bleeding, deep venous thrombosis, steal syndrome and postoperative acute lower limb ischaemia requiring intervention were also evaluated.
The investigators report that patients had a mean age of 52 years at the time of tAVF creation, and 68% were female. They had been on dialysis for a median of 42 months before undergoing FV tAVF creation, and had a median of 2.5 previous dialysis accesses and five prior central venous tunnelled or non-tunnelled catheters for haemodialysis. The most frequent aetiology of chronic kidney disease (CKD) was hypertension (46.8%).
Bilateral upper central venous occlusion, which occurred in 46.8% of patients, was cited as the most common reason for FV tAVF indication, followed by exhaustion or unavailability of upper arm veins (40.6%). Before FV tAVF creation, 31 patients (96.8%) had existing dialysis accesses in the upper limbs, while one patient had an AVF in the lower limb. Of the newly created FV tAVFs, 34% were placed on the right limb and 65% on the left limb.
On outcomes, the investigators report that technical success was achieved in 29 patients, with three failure cases—one requiring ligation due to infection and another due to lower limb acute ischaemia. One patient died due to postoperative lower limb acute ischaemia.
Nine additional deaths were reported during the study period, though none of these were related to the procedure. The median time to first cannulation was 40 days, with three patients (9.3%) undergoing kidney transplant after the surgery.
Wound complications were seen in 15 patients, with 93.3% of these classified as having infection Grade 1 and 6.7% as infection Grade 2. No Grade 3 wound complications were reported. Most complications—75%—did not require surgical intervention. Six needed drainage and one required AVF ligation due to infection. Reoperation due to bleeding was performed in two patients and deep venous thrombosis was seen in four patients. Postoperative lower limb acute ischaemia requiring fistula ligation or revision occurred in two patients, while steal syndrome occurred in six patients, with one requiring reoperation.
Further to the rates of primary patency reported, the investigators note that there was no significant difference observed between sexes, although male sex was identified as a protective factor in the cohort, significantly improving secondary patency rates compared to females.
A shorter duration of haemodialysis (≤27 months) prior to FV tAVF creation was linked to an increased risk of primary patency loss. While wound complications did not significantly impact primary patency, they were a significant risk factor for secondary patency loss.
“When used in appropriately selected patients, FV tAVFs provide durable, functional haemodialysis access,” Filippo and colleagues write in their discussion of the findings. “Prioritising the timely application of this procedure can prevent prolonged reliance on suboptimal or temporary access methods, reducing complications and improving overall outcomes.
“To support broader adoption, future work should include multicentre registries to better characterise real-world performance and identify optimal patient profiles. Cost-effectiveness analyses will be important to assess the feasibility and economic impact of FV tAVF implementation across different healthcare settings. In parallel, prospective studies incorporating standardised postoperative care pathways are needed to guide the evidence-based refinement of FV tAVF protocols.”
