Upper thigh loop prosthetic arterio-venous grafts (AVG) for dialysis access: An Indian perspective

Hemodialysis forms the most common replacement therapy for majority of Indians suffering from chronic kidney disease (CKD). Multiple access failure and central vein stenosis has become commonplace in Indian dialysis access patients and there is a burgeoning need for more advanced hemodialysis (HD) access options. Upper thigh arterio-venous grafts (AVG) are seldom inserted due to fear of infection and limb ischemia.This is a single institutional, retrospective, descriptive case study of consecutive patients who underwent upper thigh prosthetic AVG over a period of 7 years. All these patients had exhausted options of upper limb access and or had central vein stenosis. AVG from the proximal superficial femoral artery (SFA) to the proximal great saphenous vein (GSV) in a loop configuration using polytetrafluoroethylene (PTFE) was carried out in the upper thigh.A total of 24 patients had undergone upper thigh loop AVG. Their age varied from 24 to 77 years. The median follow-up period was 3 years. Five of these grafts developed infection (21%) which led to primary failure. A primary patency of 71% (17/24 patients) was achieved at 1 year. Thrombosis developed at a mean of 16.7 months after the primary procedure. Adjunctive procedures such as thrombectomy, segmental replacement of graft, patch angioplasty, balloon angioplasty, and stenting were required in 75% of patients to achieve a secondary patency of 86% at 1 year. Three grafts were explanted without limb loss.Upper thigh loop AVG forms a reliable alternate dialysis access option for patients with failed upper limb access sites or central vein occlusion. Adjunctive procedures are key to maintaining patency in these grafts. Good secondary patency is achievable, and the infection rates are similar to arm AVG. Close follow-up and timely intervention are key to long term dialysis through these grafts.