Adjunctive Arteriovenous Fistula With Tibia1 and

Peroneal Reconstruction for Limb Salvage

lbrahim M. Ibrahim, MD, Englewood, New Jersey

Barry Sussman, MD, Englewood, New Jersey

Irving Dardik, MD, Englewood, New Jersey

Mark Kahn, MD, Englewood, New Jersey

Michael Israel, MD, Englewood, New Jersey

Maryann Kenny, RN, Englewood, New Jersey

Herbert Dardik, MD, Englewood, New Jersey

The creation of an arteriovenous fistula for treating arterial insufficiency has interested surgeons for al- most a century [I]. This concept was investigated extensively in both experimental and clinical settings during the late 19th and early 20th centuries. The results were unsatisfactory, and the procedure fell into disrepute until revived by Jordan [2,3] in 1949. Since then certain types of arteriovenous fistulas were shown to maintain viability of ischemic ex- tremities in the experimental animal [4-81. Others investigated the use of arteriovenous fistulas as a means of enhancing flow in synthetic or biologic grafts in the venous or the arterial system [S-14]. The clinical experience, however, with these “reversal of flow” operations has been disappointing if not dele- terious [I]. Blaisdell et al [15] reported good results in the femoropopliteal region in four cases but noted subsequent failure in three of them.

Vascular reconstruction to the tibia1 and peroneal arteries will yield good patency rates if the runoff is good including an intact pedal arch [16-191. Bypass into a tibia1 or peroneal artery with poor runoff and a deficient or absent pedal arch will most likely fail. The runoff system in such instances is incapable of maintaining graft flow. Creating an arteriovenous fistula at the site of the distal anastomosis will maintain high graft flow rates while preserving flow

From the Vascular Surgical Service, Englewood Hospital, Englewood. New Jersey.

Requests for reprints should be addressed to Herbert Dardik, MD, De- partment of Vascular Surgery, Englewood Hospital, 350 Engle Street, En- glewood, New Jersey 07631.

Presented at the Eighth Annual Meeting of The Society for Clinical Vas- cular Surgery, Palm Springs, California, March 19-23, 1980.

into the markedly diseased distal circulation. This report documents preliminary experience with this procedure in association with tibia1 or peroneal re- vascularization when an inadequate runoff system precluded reliable and durable graft patency.

Material and Methods

Thirteen patients underwent creation of an adjunctive arteriovenous fistula to crural bypass during a 5 month trial period beginning in November 1979. Eleven bypasses were performed to the peroneal artery; 1 was performed to the posterior tibia1 artery and the other to the anterior tibia1 artery. Ages ranged from 53 to 84 years (mean 71). There were six men and seven women. Eleven patients (85 per- cent) had diabetes mellitus. Nine of the patients (69 per- cent) had had one or more previous revascularization procedures, with an average for the whole group of one procedure per patient. Five patients had undergone mul- tiple revascularization attempts. All of the patients had one or more of the usual risk factors including previous myo- cardial infarction, hypertension, cerebral vascular disease, chronic obstructive pulmonary disease and renal insuffi- ciency. The mean follow-up period was 3 months, with a range of 1 to 6 months.

Each patient in this series was threatened with imminent limb loss without successful revascularization. The indi- cations for surgery were rest pain in 13 patients, pregan- grene in 2, frank gangrene in 11 patients (of the forefoot in 8 and the foot in 1) and a nonhealing transmetatarsal stump in 2 patients. All patients had cold feet with areas of cyanosis and mottling. Preoperative arteriography was performed in all cases to evaluate the feasibility of recon- struction by delineating the distal runoff and, if possible, the pedal arch. If the latter was not visualized, operative

246 The American Journal of Surgery

Adjunctive Arteriovenous Fistula

Ftgure 7. Left, posterior tibia/ artery wtth considerable disease distally ( large arrow) and absent arch (small arrow). Center, diminutive peroneal artery (arrow) with inadequate communication to the posterior tibia/ artery at the malleolar level. No pedal arch is present. Right, small and calcified peroneal artery (arrows) with inadequate communications to the major pedal vessels.

maneuvers such as sounding, fluid injection and arteriog- raphy were employed. The runoff in each case was classi- fied as poor or inadequate because of multifocal areas of stenosis, extensive calcification and small vessel caliber associated with a deficient, inadequate or absent pedal arch (Figure 1). The indication for adjunctive arteriovenous fistula was inadequate runoff and pedal arch in all 13 pa- tients, calcification in 9, multifocal stenosis in 3, small caliber of the crural artery in 4 and previous surgery in 9.

Attempts at peroneal bypass without arteriovenous fistula in three patients resulted in failure intraoperatively, 1 hour postoperatively and 10 days postoperatively. There were no technical errors in any of these cases. Immediate revision of the bypass to include an arteriovenous fistula was performed. A fourth patient had undergone two pre- vious femoroperoneal bypasses that lasted 6 and 30 months. At that time only a diminutive peroneal artery was present that was clearly inadequate for bypass alone. The remaining seven peroneal arteries were either markedly calcified, small or had no communication to a pedal arch (absent or deficient). The two tibia1 artery reconstructions had no continuity of the leg artery into the foot. These ar- teries were moderately calcified. According to criteria previously established [16,18], conventional bypasses in all of these patients would have resulted in immediate or early failure. Intraoperative electromagnetic flow meter recordings were obtained in four cases. Flow characteristics

Figure 2. Diagram of the technique for composite side- to-side arteriovenous fistula with simultaneous distal end- to-side anastomosis of bypass to fistula.

were also studied by local intraarterial injection of papa- verine hydrochloride, 20 mg. Cardiac output determina- tions were performed immediately before, during and after surgery in three cases. Follow-up was complete for this series. Postoperative observations were made of graft patency, reversal of ischemic signs and symptoms, and healing of lesions and amputation stumps. Doppler re-

Volume 140, August 1980

lbrahim et al

Figure 3. lntraoperative angiogram showing femorafpero- neat bypass with supptementaty atferiovenous fish&a. Note the small distal peroneal artery ( arrow). There is an ex- cellent venous network that permits continued grafl pat- ency.

cordings of ankle and segmental limb pressures and phle- borheography were performed routinely to define the status of the arterial and deep venous systems.

Technique: The exposure of the peroneal artery by the lateral approach with fibulectomy has been described previously [20]. When an arteriovenous fistula is to be constructed, great care must be taken to avoid injury to the adjacent veins. These vessels are generally quite small (less than 2 mm in diameter) and very delicate. Both artery and vein are meticulously dissected for comparable lengths (25 to 30 mm). Equal arteriotomy and venotomy incisions are established. The adjacent walls of the artery and vein are sutured with a running 7-O polypropylene suture to create a common posterior wall. The graft is then anastomosed to the artery and the vein concomitantly (Figure 2). We used the glutaraldehyde-stabilized unbilical vein (Bio- graftTM, Meadox Medicals, Oakland, New Jersey) for bypass material in all cases. Ordinarily the proximal anastomosis is performed first. The graft is placed in a subcutaneous tunnel passing lateral to the knee. Intraoperative arteri- ography is performed routinely to evaluate the technical performance of the anastomosis and the quality of the runoff [19] (Figure 3). In the absence of an adequate vein, the saphenous vein can be transsected distally and passed pretibially, in the case of peroneal and anterior tibia1 anastomosis, for use as the venous side of the fistula. Care must be taken to ensure proper positioning of the saphe- nous vein in the subcutaneous position (Figure 4).

Figure 4. tntraoperative arteriogram of femoral anterior tibia1 bypass. There is an inadequate distal anterior tibia/ artery wfth a deficient arch. The saphenous vein was used to create an atteriovenous fistula and forms part of the anterior tibia/ artery anastomosis (large arrow). It then passes prettbtal/y to its normal course on the media/ aspect of the leg (arrows).

Results

There was no operative mortality (less than 30 days postoperatively). Morbidity was limited to two patients. One patient with a history of a stroke had another stroke from which she subsequently recov- ered. Another patient with a history of renal and cardiac failure developed congestive heart failure and pulmonary complications that required long-term respiratory assistance. Limbs were saved in 10 pa- tients (77 percent). One below-knee amputation was required in spite of graft patency because of the ex- tent of gangrene. This patient probably should have undergone amputation as a primary procedure. Two other patients, who had undergone successful in- terval thrombectomy at 1 and 2 weeks postopera- tively, also required amputations at the above-knee level. In the former patient, an ilioperoneal Dacron@ umbilical vein composite failed 2 weeks after the original surgery. This was the longest graft in the series, there being no profunda femoris to provide additional runoff into the thigh. The other above-

248 The American Journal of Surgery

Adjunctive Arteriovenous Fistula

knee amputation was required after the site of pre-

vious thrombectomy became infected. An interpo-

sition graft was performed as well as a muscle flap. However, during this procedure a large number of venous collaterals were sacrificed and the fistula

failed soon thereafter. Ancillary toe and transmetatarsal amputations

and stump revisions were performed in 6 of the limbs salvaged. These included two transmetatarsal am- putations with split-thickness skin grafts, three toe

amputations and one revision including skin grafting of a necrotid transmetatarsal amputation stump. One

patient developed a steal phenomenon characterized

by coolness and pallor of the forefoot. This patient also developed mild tachycardia, perhaps secondary

to increased cardiac output. Both conditions re-

sponded well to ligation of the popliteal vein. Patent grafts were characterized by a soft pulse,

a palpable thrill and an audible bruit. Functional grafts resulted in reversal of the ischemic signs and symptoms and healing of ulcers and amputation stumps. Doppler pressures and indexes improved in

the patients that had low values preoperatively. Two patients with markedly sclerotic arteries had elevated preoperative pressure due to incompressibility.

Phleborheography disclosed deep venous thrombosis

in two patients, one of whom required thrombectomy of the vein employed for arteriovenous fistula. Both patients were treated postoperatively with antico- agulants and maintained graft patency, and neither had significant leg edema.

Comments

Surgeons have for many years attempted highly unconventional modes of revascularization of the legs when faced with inoperable end-stage vascular dis-

ease. There have, however, been no substantial

clinical successes. Among the more creative proce- dures were direct muscle revascularization [21], omental transfer [22] and arteriobone fistula [23]. Others used arteriovenous fistulas to augment blood flow in diverse conditions such as bone length dis- crepancy [24], myocardial insufficiency [25] and neurologic disorders [26]. The use of arteriovenous fistula to maintain flow in prosthetic grafts in small artery and venous reconstructive surgery has been studied predominantly in the laboratory [g-14].

The use of arteriovenous fistulas in ischemic states is based on several considerations, some proven and others hypothetical. Arteriovenous fistula is a potent stimulus to the development of collateral circulation [4,6,27]. Arteriovenous fistula results in the hyper- trophy of small vessels and the development of an intense collateral network. Total blood flow thus increases. However, these events take time and

therefore cannot be relied on when the need for in-

creased blood flow is acute. A second consideration in the use of arteriovenous

fistula for extremity ischemia is the reversal of flow that these fistulas produce in the distal venous circuit [4,6,7]. The extent to which this occurs is limited by the venous valves. Incompetence of the valve may occur progressively with time but is probably quite

limited since the gradient decreases with increasing distance from the site of the arteriovenous fistula.

This is undoubtedly a major cause of the failures that

have occurred with the construction of adjunctive arteriovenous fistulas at the femoral and popliteal

level as well as with “total reversal” procedures

[Il. The most critical factor in maintaining a patent

graft in instances of inadequate runoff is the ability to shunt an adequate volume from the arterial circuit into the low resistance venous circuit. The mainte-

nance of flow over the minimum threshold by the arteriovenous fistula prevents stagnation and even- tual thrombosis. Arterial and venous graft patency

can thus be dramatically improved by the augmen- tation of flow with a distal arteriovenous fistula [9,10,12,14,28-311.

A theoretical objection to the use of arteriovenous fistula is the possible increase in blood volume and

cardiac output. The amount of blood shunted de- pends on the size of the fistula [32]. Fistulas placed in medium-sized vessels are well tolerated if they are less than 1 cm in diameter and carry less than 20

percent of the cardiac output [33-351. Arteriovenous fistulas constructed for hemodialysis are well toler- ated in spite of slight increases in cardiac output and

pulse rate [32]. The arteriovenous fistulas con- structed in this bypass series were all to small veins with an average diameter of less than 2 mm. The

largest was to a saphenous vein 3 mm in diameter. Venous resistance and collaterals can influence the

amount of blood shunted through the arteriovenous fistula. Electromagnetic flow meter recordings per- formed during surgery showed an average flow of 350 ml/min through the graft with the arteriovenous fistula open. Although it is possible that this flow might increase, it is unlikely that it will exceed 20

percent of the cardiac output. One patient had mild tachycardia and after ligation of the popliteal vein because of a steal phenomenon, the pulse rate re- turned to normal. This fistula remained functional through smaller collateral veins.

A second major concern in the construction of an arteriovenous fistula is the possible development of venous hypertension and edema. This did not occur in this series, presumably because of the small size of the veins and the low venous resistance. Arterio-

Volume140,August1980 249

lbrahim et al

venous fistulas do not ordinarily create venous hy- pertension [35].

Steal of blood from the distal arterial bed, although a potential complication, has in fact not been a sig- nificant problem. Thi; phenomenon occurred in one patient and was successfully managed by popliteal vein ligation. Transient steal phenomena were sus- pected in two other patients who had mottling of the feet. This receded slowly, perhaps due to the subse- quent development of distal venous valvular in- competence.

In 1966 Blaisdell et al [15] suggested that creation of an arteriovenous fistula at the distal anastomosis “may permit reconstruction of almost any peripheral artery of the leg.” However, interest in this approach waned as advances and success were achieved in various types of reconstructions. Because our expe- rience with tibia1 and peroneal bypass has demon- strated the inadequacy of reconstruction into a markedly diseased artery in the face of a deficient or absent arch, interest in adjunctive arteriovenous fistula has escalated. Survival of the limb still de- pends on the arterial inflow to the foot. It is possible that retrograde arterial flow into the distal vein in- creases with time by eventual incompetence of the venous valves, but we believe that this is of secondary importance, as demonstrated by the saphenous vein arteriovenous fistula where the distal end of the vein was simply ligated.

The patients in this series were all threatened with imminent loss of limb due to end-stage vascular oc- clusive disease. Conventional bypasses had either failed or were considered contraindicated because of the probability of graft closure. Using the adjunctive arteriovenous fistula technique, the early patency rate in these desparate bases is excellent (11 of 13). These results clearly show that an arteriovenous fistula can maintain graft patency with augmentation of flow. It is also clear that long-term results with regard to graft patency, limb salvage and aberrations in local and systemic hemodynamics are essential in order to elucidate the role of adjunctive arteriovenous fistulas in peripheral vascular reconstruction.

Summary

Arteriovenous fistulas were constructed as an ad- junct to femoral peroneal and tibia1 bypasses in 13 patients threatened by imminent limb amputation. Previous attempts at conventional vascular recons- tructive procedures had failed in nine patients. De- ficient or absent pedal arches were noted in all pa- tients, as were poor quality or small crural arteries. Graft patency was achieved in 11 cases and limb salvage in 10. There wis no mortality. A steal phe-

nomenon occurred in one patient and was success- fully treated by secondary popliteal vein ligation. These preliminary results clearly indicate that an adjunctive arteriovenous fistula can maintain pat- ency in a femoral tibia1 or peroneal bypass graft while preserving flow into the markedly diseased distal circulation.

References

1. Szilagyi DE, Jay GD, Murrel ED. Femoral arteriovenous anas- tomosis in the treatment of occlusive arterial disease. Arch Surg 1951;63:435.

2. Jordan P. At-teriovenous shunts for revascularization of isch- emit limbs. J Michigan M Sot 1949;48:1011.

3. Johnston CG, Jordan P Jr, Cloud T. Arteriovenous anastomosis in traumatic vascular lesions. Am J Surg 1950;80:809.

4. Root HD, Cruz HB. Effects of arteriovenous fistula on the de- vascularized limb. JAMA 1965;191:645.

5. Amir-Jahid AK. Revascularization of lower extremities by re- versal of blood flow with and without lumbar sympathectomy: an experimental study. Surgery 1966;59:243.

6. Matalo NM, Cohen SE, Wolfman EF. Use of an arteriovenous fistula for treatment of the severely ischemic extremity: experimental evaluation. Ann Surg 1976;184:822.

7. Johansen K, Bernstein EF. Revascularization of the ischemic canine hindlimb by arteriovenous reversal. Ann Surg 1979; 190:243.

8. Gausewitz S, Berard DF, Dilley RB, Bernstein EF. Arteriovenous anastomosis and arteriovenous fistula in revascularizing the ischemic canine limb. Surg Forum 1978;29:211.

9. Dean RE. Read RC. The influence of increased blood flow on thrombosis in prosthetic grafts. Surgery 1964;55:581.

10. Blaisdell FW, Lim RC, Hall AD Thomas AN. Reconstruction of small arteries with an arteriovenous fistula. Arch Surg 1966;92:206.

11. Steinman C, Atpert J, Haimovici H. Inferior vena cava bypass grafts: an experimental evaluation of a temporary arterio- venous fistula on their long-term patency. Arch Surg 1966;93:747.

12. Scheiner TM, Jude JR. Experimental replacement of the su- perior vena cava: effect of temporary increases in blood flow. J Thorac Cardiovasc Surg 1964;48:781.

13. Hobson RW, Wright CB. Peripheral side-to-side arteriovenous fistula. Hemodynamics and, application in venous recon- struction. Am J Surg 1973;126:411.

14. Wilson SE, Johaur A, Stone RT. Stanley TM. Patency of biologic and prosthetic inferior vena cava grafts with distal limb fis- tula. Arch Surg 1978;113:1174.

15. Blaisdell FW, Lim RC, Hall AD, Thomas AN. Revascularization of severely ischemic extremities with an arteriovenous fis- tula. Am J Surg 1966;112:166.

16. Dardik H. Dardik I, Sprayregen S, lbrahim IM, Veith FJ. Patient selection and improved technical aspects in small-vessel bypass procedures of the lower extremity. Surgery 1975; 77:249.

17. Dardik H, lbrahim IM, Dardik I. The role of the peroneal artery for limb salvage. Ann Surg 1979;189:189.

18. Dardik H, lbrahim IM. Sussman B, Greweldinger J, Adler J, Dardik I. The pedal arch: morphology and relationship to patency of crural reconstructions. Submitted for publica- tion.

19. Dardik H, lbrahim IM, Koslow A. Dardik I. Evaluation of intra- operative arteriography as a routine for vascular recon- struction. Surg Gynecol Obstet 1978;147:853.

20. Dardik H, Dardik I, Veith FJ. Exposure of the tibial-peroneal arteries by a single lateral approach. Surgery 1974;75: 377.

2 1. Shinoya S, Ban I, Nakata Y. Skeletal muscle revascularization by vascular implantation. J Cardiovasc Surg 1973;14:208.

250 The American Journal of Surgery

Adjunctive Arteriovenous Fistula

22. Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol Obstet 1971;132:301.

23. Vetto RM, Belzer FO. Use of an arteriobone fistula in advanced ischemia. Surg Forum 1965: 16: 13 1.

24. Hiertonn T. Arteriovenous fistula for discrepancy in length of lower extremities. Acta Orthop Stand 1961;31:25.

25. Chatterjee KN, Warren R. Effect of internal mammary arterio- venous fistula on myocardial blood flow. Surgery 1963; 53505.

26. McKhann CF. Bleknap WD, Beck CS. Cervical arteriovenous anastomosis in treatment of mental retardation, convulsive disorders and cerebral spasticity. Ann Surg 1950;132: 162.

27. Robertson RL, Dennis EW, Elkin DC. Collateral circulation in the presence of experimental arteriovenous fistula: deter- mination by direct measurement of extremity blood flow. Surgery 1950;27: 1.

28. Johnson Y, Eiseman B. Evaluation of arteriovenous shunt to maintain patency of venous autograft. Am J Surg 1969; 118:915.

29. Sauvage LR. Factors contributing to long-term failures in human vascular prosthetic grafts. J Cardiovasc Surg 1964;5:544.

30. Stansel HC. Synthetic inferior vena cava grafts: influence of increased flow. Arch Surg 1964;89:1096.

31. Levin PM, Rich NM, Hutton JE Jr, Barker WF, Zeller JA. Role of arteriovenous shunts in venous reconstructions. Am J Surg 1971;122:183.

32. Johnson G Jr, Blythe WB. Hemodynamic effects of arteriove- nous shunts used for hemodialysis. Ann Surg 1950;171: 715.

33. Reid MR. The effect of arteriovenous fistula upon the heart and blood vessels. A special and clinical study. Bull Johns Hop- kins Hosp 1920;31:43.

34. Frank CW, Wang HH, Lammerant J, Miller R, Wegria R. An experimental study of the immediate hemodynamic adjust- ment to acute arteriovenous fistulae of various sizes. J Clin Invest 1955;34:722.

35. Schenk WG, Martin JW, Leslie MB, Partin AB. The regional hemodynamics of chronic experimental arteriovenous fis- tulae. Surg Gynecol Obstet 1960;110:44.

Volume 140, August 1980 251