Lower-extremity Arteriovenous Access for Haemodialysis: A Systematic Review

Background: The lower extremity is increasingly used as an access site in end-stage renal disease patients. However, reports present conflicting results, creating confusion regarding the feasibility and outcomes. Our objective is to review the available Literature and analyse the patency rates and complications of various types of lower-extremity arteriovenous access. Methods: An Internet-based literature search was performed using MEDLINE to identify all published reports on lower-extremity vascular access. The analysis involved studies comprising at least 10 arteriovenous accesses with both inflow and outflow vessels in the lower extremity, and reporting on patency rates and access-related complications. The weighted mean patency rates were calculated, and the chi-square (chi(2)) test was used to evaluate the differences in the complication rates in the subgroups of patients identified. Results: Three main types of lower-extremity vascular access were identified: the upper thigh prosthetic, the mid-thigh prosthetic and the femoral vein transposition arteriovenous access. There are limited data on saphenous vein loop grafts, which report poor results. The weighted mean primary patency rates at 12 months were 48%, 43% and 83%, respectively. The weighted mean secondary patency rates at 12 months were 69%, 67% and 93%, respectively. Access loss as a result of infection was more common in upper thigh and mid-thigh grafts than femoral vein transposition arteriovenous access (18.40%, 18.33% vs. 1.61%; P < 0.05). Ischaemic complications rates were higher in autologous than prosthetic arteriovenous access (20.97% vs. 7.18%, P < 0.05). Conclusions: Lower-extremity vascular access has acceptable results in terms of patency, with femoral vein transposition having better patency rates than femoral grafts. Autologous access is associated with less infective complications, however, at the expense of increased ischaemic complications rates. Further research with randomised trials is required to assess the outcomes of lower-extremity vascular access. (C) 2009 Published by Elsevier Ltd on behalf of European Society for Vascular Surgery