© 2011 Wichtig Editore - ISSN 1129-7298 J Vasc Access ( 2012; 1): 132 13 132 LETTER TO EDITOR great saphenous vein (VSM). After four weeks of matura- tion, AVF was punctured for the first time and it still oper- ates successfully. During the last 8 years, the patient un- derwent abdominal surgery (left nephrectomy because of adenoma), and had a melena followed by an episode of hypotension. The patient is dialyzed 4 hours three times per week, blood pump is 280-300mL/min and Kt/V is 1.4. Color Doppler ultrasound measured flow volume is 810 mL/ min. VSM is dilated to 18mm. For the last 8 years neither access complications nor puncture problems occurred. Native AVF is by far the best vascular access option. Guidelines recommend creating AVF as distally as possible, and in the upper extremity (4, 5). Sometimes, the upper ex- tremity AVF cannot be created, because of the specific condi- tions and characteristics of the patient. There is the possibility to successfully opt for an AVF instead of a AVG is weaker in patients who are elderly, female, obese, have peripheral vas- cular disease, ischemic cardiac disease or diabetes mellitus (DM). Lower extremity vascular access should be taken into consideration as it is able to provide sufficient flow volume, and, indeed, is “as distal as possible”. Financial support: None. Conflict of interest: None. Informed consent: The patient’s formal consent to publish this report, including a photograph of his lower extremity, was obtained. Tamara K. Jemcov, 1 Marko Z. Bumbasirevic, 2 Sanja P. Simic-Ogrizovic 1 1 Nephrology Clinic, Clinical Center of Serbia, Belgrade 2 Institute for Orthopaedic Surgery and Traumatology, Clinical Center of Serbia, Belgrade - Serbia tjemcov@gmail.com REFERENCES 1. Pisoni RL, Young EW, Dykstra DM et al. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int. 2002;61:305–316. 2. Dixon BS, Novak L, Fangman J. Hemodialysis vascular access survival: upper-arm native arteriovenous fistula. Am J Kidney Dis. 2002;39:92–101. 3. Huber TS, Carter JW, Carter RL et al. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg. 2003;38:1005–1011. 4. Tordoir J, Canaud B, Haage P et al. European best practice guidelines (EBPG) on vascular access. Nephrol Dial Transplant 2007;22:(Suppl 2): ii92. 5. NKF-KDOQI. Clinical practice guidelines for vascular access. Am J Kidney Dis. 2006;48(Suppl 1):S249. Challenging lower extremity dialysis access: long-term use of a leg AV-fistula Editor, A well functioning vascular access (VA), which can pro- vide efficient hemodialysis, has been one of the main goals of every nephrologist and vascular access surgeon for years. There are three main types of VA: native arteriovenous fis- tula (AVF), arteriovenous prosthetic graft (AVG), and central vein catheter (CVC). Their use varies widely between differ- ent countries in Europe and the United States (1). The use of AVF ensures the lowest morbidity and mortality rates, as well as the best longevity, patency, and low health care costs, in comparison to other VA options (1-3) The EBPG for Vascular Access and the KDOQI guide- lines recommend upper extremity native AVF as the best vascular access solution for patients on chronic hemodi- alysis therapy (4, 5). Unfortunately, in some cases a native AVF cannot be created on the upper extremity, and as a second best choice the vascular surgeon or/and nephrologist decide to apply an AVG or a permanent tunnel CVC. However, one should sometimes consider a “lower” native AVF as an option, in- stead of immediately opting for a graft or tunnel catheter. One subject in our dialysis unit has had a lower ex- tremity AVF for the last 8 years. He was hospitalized aged 34 because of spontaneous hematoma right intracerebra- lis artery, with consecutive left hemiparesis. Laboratory analyses and echosonography examination of the kid- neys revealed advanced chronic renal failure. Malignant hypertension was the cause of the neurologic and renal complications. Initially, peritoneal dialysis was selected as renal replacement therapy option. After three months of continuous ambulatory peritoneal dialyses (CAPD), and three episodes of peritonitis, CAPD was discontinued. Peritoneal catheter was removed and temporary CVC was inserted. An attempt to create a native AVF on the left hand side failed. As the patient had left hemiparesis, another attempt to create a native AVF was made, but this time on their right leg (Fig. 1), with a latero-terminal anas- tomosis between the right posterior tibial artery and the JVA_11_L1005 DOI:10.5301/JVA.2011.8445 Fig. 1 - Distal lower extremity AVF and punctu- re sites during a hemodialysis ses- sion. View publication stats View publication stats