Lower Extremity Autologous Arteriovenous Fistulas

Lower extremity dialysis access is a second- or third-line form of permanent vascular access for a select group of patients. While prosthetic grafts are commonly the first choice in this situation (see chapter “Lower Extremity Arteriovenous Grafts for Hemodialysis Access”), autogenous arteriovenous fistulae have many advantages over synthetic grafts in the lower extremity, including reduced infection complications and better patency. The two primary types of autogenous arteriovenous fistula in the lower extremity are the femoral vein transposition and the greater saphenous vein arteriovenous fistula. This chapter will review the relevant anatomy, surgical techniques, and outcomes for each of these complex access types after providing a general introduction to the concepts underlying lower extremity vascular access. Special attention will be given to the history of lower extremity dialysis access, the indications for such an access type, and the pre-operative planning (with focus on the “life plan” of each unique ESRD patient) that goes into a case. Additionally, anticipation and mitigation of complications including wound complications and steal will be reviewed.