Clinical Outcome of Transposed Femorofemoral Arteriovenous Fistula: Single-Center Experience

Transposed femorofemoral arteriovenous fistulae (TFFAVF) are one the last options for the creation of vascular access (VA) using autologous veins when all options for upper-limb VA fail. They are created by transposition of the femoral vein (FV), and even though their indication is limited, good long-term patency has been reported. Here, we report our preliminary experience using this technique. We retrospectively analyzed all patients that underwent creation of a TFFAVF between April 2015 and August 2023. Contraindication to the technique was an ankle brachial index (ABI) <0.85, apparent arterial occlusion or stenosis, deep vein thrombosis, occluded or dysfunctional great saphenous vein, and chronic heart failure (ejection fraction < 55%). During the study period, 2,794 VAa were created, and only 7 TFFAVFs (0.3%). The mean age was 66.6 years old, three patients (42.9%) were male, and the mean preoperative ABI was 0.96. All patients received general anesthesia, and the mean operative time was 199.7 minutes. All patients had successful cannulation, and the mean time to first puncture/mean flow volume before puncture was 19.3 days and 1291.9 ml/min, respectively. Some cases required periodic reinterventions, but secondary patency was obtained in 100% of cases, including one case that has been patent for more than eight years. As for the postoperative perfusion to the foot, the mean postoperative ABI decreased to 0.84, and there was one case of chronic limb-threatening ischemia that required subsequent revascularization. When all options for VA creation in the upper limbs are exhausted, TFFAVF may be a good durable option for VA creation using an autologous vein. It is easy to puncture, and is associated with good secondary patency due to the wide diameter of the FV. However, its indication is extremely limited, and awareness of postoperative distal ischemia will be mandatory.