Endovascular obliteration of in situ saphenous vein arteriovenous fistulas during tibial bypass.

Current methods of ligating venous branches during in situ vein tibial bypass are associated with significant wound complications, especially in diabetics. Making only proximal and distal wound incisions could avoid these wound problems. We report the use of endovascular techniques with coils and balloons guided by intraoperative arteriography and angioscopy to obliterate arteriovenous (AV) fistulas in three elderly diabetic patients undergoing tibial bypass. In all cases the proximal and distal vessels were first isolated and deemed suitable for bypass. The greater saphenous vein was prepared for the proximal and distal anastomosis, and angioscopically guided valvulotomy was performed. An introducer sheath was placed through a large proximal saphenous side branch for vascular access. With the use of fluoroscopy, AV fistulas were serially identified and cannulated with a guidewire. A guide catheter, passed over the wire into the side branch, served as the conduit through which coils and balloons were placed. Proximal and distal anastomoses were completed and arteriography performed. We were successful in obliterating AV fistulas in all three patients, but completion arteriography revealed additional AV fistulas requiring surgical ligation in two patients. Furthermore, operative time was increased by 1 1/2 to 5 hours. Two of three patients had wound infections, one at the proximal and one at the distal incision. All patients were discharged with a functioning bypass and no AV fistulas were seen on duplex scans. Endovascular obliteration of AV fistulas is feasible but is currently limited by prolonged operative time and incomplete obliteration.