Journal of Dr. NTR University of Health Sciences

: 2020  |  Volume : 9  |  Issue : 1  |  Page : 60--62

Lower limb vascular access for maintenance hemodialysis patients – A case series

T Nagalakshmi, C Mahesh, K Siva Parvathi, R Nagaraj, A Sunnesh, N Sai Sameera, K Naveen Kumar, Siva Kumar Vishnubotla 
 Department of Nephrology, Srivenkateswara Institute of Medical Sciences, Tirupathi, Andhra Pradesh, India

Correspondence Address:
Dr. K Siva Parvathi
Assistant Professor, Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupathi, Andhra Pradesh


The vascular access is considered as Achilles heel of a successful maintenance hemodialysis (MHD) program. Although it is ideal to initiate the dialysis through arteriovenous fistula (AVF), many of the patients start initiation through central venous catheters which predispose them later to multiple access complications. Also, as the elderly population has poor vasculature to support AVF, many of them end up exhausting all upper limb vascular accesses. As a result, there are a group of MHD patients with difficulty in using upper limb vascular access secondary to multiple access failure who are otherwise unable to switch to another modality of renal replacement therapy completely and have to rely on lower limb vascular access as a last resort to sustain life. We would like to share our experience on lower limb vascular access in our institute. The three types of lower limb vascular accesses include lower limb AVF, lower limb AV graft, and tunneled femoral vein catheter as illustrated in three patients with a successful utilization in sustaining life.

How to cite this article:
Nagalakshmi T, Mahesh C, Parvathi K S, Nagaraj R, Sunnesh A, Sameera N S, Kumar K N, Vishnubotla SK. Lower limb vascular access for maintenance hemodialysis patients – A case series.J NTR Univ Health Sci 2020;9:60-62

How to cite this URL:
Nagalakshmi T, Mahesh C, Parvathi K S, Nagaraj R, Sunnesh A, Sameera N S, Kumar K N, Vishnubotla SK. Lower limb vascular access for maintenance hemodialysis patients – A case series. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Jul 3 ];9:60-62
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Full Text


The maintenance hemodialysis (MHD) is the most common renal replacement modality for a majority of patients with end-stage renal disease (ESRD) across the world.[1] Dialysis population is increasing at 5% per year.[2] The National Kidney Foundation guidelines recommend arteriovenous fistula (AVF) as the vascular access of choice in these patients. Upper limb AVF from distal to proximal [radiocephalic (RC), brachiocephalic (BC)] in nondominant arm is the initial option for patients transitioning from chronic kidney disease (CKD) to ESRD.[3] However, with the improving healthcare, many of the patients entering into maintenance dialysis are elderly, with multiple comorbidities. These patients have difficulty in obtaining upper limb AVF because of poor vasculature.[4] Thus, the patients who have exhausted their peripheral venous capital need innovative approaches to create the access of last resort such as lower limb vascular access.[5]

Lower limb vascular access is indicated in patients with multiple access failure in the upper limbs, poor upper limb vasculature on preoperative vascular mapping, central venous stenosis, and not willing for peritoneal dialysis.[3]

The various types of lower limb venous accesses include semi-permanent and permanent. The semi-permanent femoral vein central venous catheter (tunneled cuffed) can be used as a bridge access while a patient requires time for maturation of upper limb AVF, and difficulty in cannulating other central veins. The permanent accesses include (1) autogenous lower extremity AVF – (a) femoral artery–femoral vein transposition, (b) femoral (superficial femoral artery)–great saphenous vein looped transposition, and (c) posterior tibial artery–greater saphenous vein and (2) synthetic lower extremity arteriovenous graft (AVG) with either an upper thigh synthetic graft or mid-thigh synthetic graft. Parekh et al. suggested an algorithm in clinical decision-making for lower extremity permanent vascular access.[3]

We present here our experience on semi-permanent and permanent lower limb venous accesses in the management of ESRD from a tertiary care center during the last 2 years. The work is presented after obtaining consent.

Patient 1

A 62-year-old gentleman with diabetic kidney disease received MHD through right internal jugular vein initially, followed by multiple upper limb vascular access failures at different intervals (primary failure of both left and right BCAVF and AVG between left axillary vein and brachial artery). He was then supported with continuous ambulatory peritoneal dialysis (CAPD) for some time before catheter removal for fungal peritonitis. In such a situation, explaining the pros and cons, right lower limb autogenous AVF type c (between posterior tibial artery and great saphenous vein) [Figure 1]a and [Figure 1]b was created, which served him for 2 years and was lost due to thrombosis. Subsequently, he was maintained on left tunneled femoral vein catheter for a period of 3 weeks, before he succumbed.{Figure 1}

Patient 2

A 59-year-old gentleman, with chronic glomerulonephritis was on MHD, with a history of multiple access failures, was contemplated for a lower limb permanent venous access with lower limb AVG (between femoral artery and femoral vein) [Figure 2]a and b] on his preference. Because of AVG thrombosis, he was supported with CAPD for 4 years till last.{Figure 2}

Thus, this patient represented an example for the use of AVG as permanent lower limb vascular access.

Patient 3

A 47-year-old gentleman, diabetic and hypertensive, with ESRD was maintained initially on CAPD. Following fungal peritonitis, he was shifted to HD. As he had bilateral hypoplastic internal jugular veins, a femoral tunneled catheter [Figure 3]a, [Figure 3]b was opted as semi-permanent access before using the left RC AVF already created and in the process of maturation.{Figure 3}

Thus, this patient represented an example for the use of femoral cuffed tunneled catheter as a semi-permanent lower limb vascular access as a bridge access awaiting the maturation of left RC AVF.


The use of lower extremity access was first attempted by Quinton, Dillard, and Scribner in 1960 at the ankle using an exteriorized silastic tube; however, successful lower limb arteriovenous shunt was designed by George I. Thomas in 1970 in the groin.[3] Since then, lower limb permanent vascular access has evolved to include autogenous AVF and femoral tunneled cuffed catheters along with AVG. Despite the availability of lower limb venous access as an option, it is not well practiced because of various reasons such as lack of awareness, fear of infections, surgical expertise, and patient preferences. Taking the cue from Parekh et al.'s clinical decision-making algorithm, we present our case series. Patient 1 exhausted all upper limb accesses with central vein stenosis and could not be continued on CAPD in view of fungal peritonitis, and he was supported with a lower limb AVF between posterior tibial artery and great saphenous vein; this sustained his life for another 2 years. The second patient though suitable for PD opted for HD after failure of upper limb vascular access; he was supported with AVG which lasted for a month and he was later shifted to PD. The third patient represented the use of tunneled femoral catheter as a bridge access. He was a patient of CAPD failure and also had hypoplastic central veins. His left upper limb AVF was in the process of maturation.

Keeping in view the fact that lower limb vascular access is an access of last resort, it is essential that the awareness of preservation of venous systems of upper limb is of paramount importance. Avoidance of usage of cephalic and antecubital veins for trivial reasons in any patient with renal failure more so in association with diabetes mellitus would preserve them for the effective utilization in creating the best upper limb vascular access of first choice in the event of a need.

In conclusion, our presentation highlights (a) the importance of lower limb vascular access for consideration in patients with multiple access failures and unsuitability for PD and (b) to preserve and perpetuate the art and skill in creation of these unusual vascular accesses in the academic surgical training to sustain patient's life. Although lower limb vascular access is not an ideal choice, in situ ations of need it is an access to be reckon with. “If you do not have the best, do the best with what you have” – Confucius.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1US Renal Data System: USRDS 2013 Annual Data Report: Atlas of End Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013. Available from: [Last accessed on 2016 May 19].
2Gibbons CP. Vascular access in the lower limb. Eur J Vasc Endovasc Surg 2009;38:373-4.
3National Kidney Foundation, 2006. Updates Clinical Practice Guidelines and Recommendations.
4Vishal BP, Vandana DN, Tushar JV. Lower extremity permanent dialysis vascular access. CJASN 2016;11:1693-702.
5Vachharajani TJ, Agarwal AK, Asif A. Vascular access of last resort. Kidney Int 2018;93:797-802.