Primary Arteriovenous Fistula at the Ankle for Patients Undegoing Hemodialysis with an Inadequate Upper Extremity Vascular Condition

Abstract

A native arteriovenous fistula (AVF) and an arteriovenous graft (AVG) in the upper extremity are generally accepted as the first and second choice, respectively, for chronic hemodialysis access. However, the number of patients whose upper extremity vessels are not suitable for vascular access (VA) has been increasing. For such patients, we created the dorsalis pedis artery-great saphenous vein fistula in the lower extremity. A 50-year-old woman with chronic kidney disease due to diabetic nephropathy initially underwent creation of an ulnar-cephalic AVG using an autologous vein graft at the left wrist joint. However, maturation of the cephalic vein was poor, and the vein was insufficient as VA for hemodialysis. Next, an AVG was created using a polytetrafluoroethylene graft in the left forearm, but it caused dialysis access-associated steal syndrome. An AVF was then created at the contralateral wrist joint, but it was insufficient due to poor blood flow. Finally, we selected the ankle and created a dorsalis pedis artery-great saphenous vein fistula. An AVF at the ankles is more advantageous than an AVG in terms of the low risk of infection and technically it is not difficult for vascular surgeons. The AVF in this patient has been working well for more than 1 year. The dorsalis pedis artery-great saphenous vein fistula is one option for VA for patients in whom conventional VA has failed.