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The Use of Arteriovenous Fistulae as an Adjunct to Peripheral Arterial Bypass: A Systematic Review and Meta-analysis

Open ArchivePublished:April 05, 2016DOI:https://doi.org/10.1016/j.ejvs.2016.01.014

      Background

      Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below-knee arterial segment. A number of studies have suggested that an arteriovenous fistula (AVF) sited at the distal anastomosis may reduce afterload, improve graft patency, and boost subsequent limb salvage. The aim of this study was to assess the effects of adjuvant AVF on the outcomes of peripheral arterial bypass.

      Methods

      The following databases were searched up to May 2015: Medline through Pubmed; the Cochrane Library; EMBASE; and reference lists of articles.

      Study eligibility

      All randomised controlled and observational studies that assessed the role of AVF as an adjunct to peripheral arterial bypass were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two reviewers with any disagreements adjudicated on by the senior author. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed.

      Results

      Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73–2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82–1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80–1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30–0.98).

      Conclusion

      Although adjuvant AVF is not associated with additional operative complication there is little evidence to support its use. The evidence assessing its merits is weakened by small, retrospective studies with heterogeneous cohorts.

      Keywords

      Peripheral bypass is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below knee arterial segment. Because of this challenge, a number of adjuncts to distal bypass have been assessed, with some studies suggesting that an arteriovenous fistula (AVF) sited at the distal anastomosis may improve operative outcomes. These data have not previously been systematically analysed. This review indicates that although distal AVF formation is not associated with additional morbidity compared with standard bypass, there is little evidence to support the use of adjuvant AVF in peripheral bypass.

      Introduction

      Peripheral arterial disease (PAD) is a common problem
      • Criqui M.H.
      • Franek A.
      • Barrett-Connor E.
      • Klauber M.R.
      • Gabriel S.
      • Goodman D.
      The prevalence of peripheral arterial disease in a defined population.
      • Schroll M.
      • Munck O.
      Estimation of peripheral arteriosclerotic disease by ankle blood pressure measurements in a population study of 60-year-old men and women.
      • Selvin E.
      • Erlinger T.P.
      Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000.
      with critical limb ischaemia requiring urgent surgical intervention to prevent limb loss.
      The Trans-Atlantic Inter-Society Consensus (TASC)
      • Norgren L.
      • Hiatt W.R.
      • Dormandy J.A.
      Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).
      recommends open surgical bypass for TASC type C and D lesions. Unfortunately, despite its undoubted benefits, lower limb bypass continues to be associated with high graft failure rates.
      • Veterans Administration Cooperative Study Group 141
      Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibial-peroneal revascularization.
      • SCAMICOS
      PTFE bypass to below-knee arteries: distal vein collar or not? A prospective randomised multicentre study.
      This failure is particularly apparent when the distal anastomosis is to smaller calibre infrapopliteal arteries.
      • Veith F.J.
      • Gupta S.K.
      • Ascer E.
      • White-Flores S.
      • Samson R.H.
      • Scher L.A.
      • et al.
      Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.
      • Bergan J.J.
      • Veith F.J.
      • Bernhard V.M.
      • Yao J.S.
      • Flinn W.R.
      • Gupta S.K.
      • et al.
      Randomization of autogenous vein and polytetrafluorethylene grafts in femoral-distal reconstruction.
      These smaller crural vessels are often heavily diseased and anastomosis of a bypass graft to these vessels distally is associated with lower graft patency rates. This is more pronounced the more distant the anastomosis from the tibio-peroneal trunk.
      • Veith F.J.
      • Gupta S.K.
      • Ascer E.
      • White-Flores S.
      • Samson R.H.
      • Scher L.A.
      • et al.
      Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.
      The high resistance, low flow state seen in distal bypass contributes to graft occlusion in a predictable fashion. This concept has been proposed by Sauvage et al.
      • Sauvage L.R.
      • Walker M.W.
      • Berger K.
      • Robel S.B.
      • Lischko M.M.
      • Yates S.G.
      • et al.
      Current arterial prostheses. Experimental evaluation by implantation in the carotid and circumflex coronary artery of the dog.
      The thrombotic threshold velocity described is a flow rate below that arterial thrombosis occurs predictably. The fashioning of an arteriovenous fistula (AVF) at the distal anastomosis is hypothesized to counteract this flow limiting state. It provides an alternative flow conduit through which blood can be diverted thus reducing the afterload created by the high resistance of a diseased infrapopliteal segment. This allows maintenance arterial flow above the thrombotic threshold velocity.
      Unfortunately, to date, the literature assessing the use of adjunctive AVF is characterized by small, heterogeneous studies with wide-ranging outcomes. Hence the true effect of adjunctive AVF on graft patency and limb salvage remains unclear. This systematic review aims to assess the effect of AVF on graft patency and limb salvage in peripheral arterial bypass.

      Methods

      Statement of design

      This review was carried out in accordance with the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses.”
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      for the PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

      Study eligibility

      All randomised controlled trials (RCT) and observational studies that compared the role of AVF as an adjunct to peripheral arterial bypass with peripheral arterial bypass without AVF were included. Case reports were excluded from analysis. No limitation was set as per the date, journal or language of publication.

      Population intervention comparison outcome

      The study group consisted of patients with significant peripheral arterial disease requiring bypass surgery. Who had undergone peripheral bypass with adjunctive AVF. Subjects with peripheral bypass but no adjunctive AVF were used as the control. The primary outcome was primary graft patency at 12 months.
      Secondary outcomes included:
      • secondary graft patency at 12 months
      • limb salvage rate at 12 months
      • reintervention rate: any reported graft reintervention with a view to re-establishing or maintain graft arterial flow
      • 30-day mortality rate
      • operative complication rate: any reported complication as a result of the original bypass procedure.
      Of note was significant arterial disease including debilitating claudicants and patients with critical limb ischaemia. Eligible studies were required to report on any or all outcomes including patency rates, limb salvage rates, reintervention rates, complication rates, and mortality rates of both the intervention and control group. Meta-analysis data for patency and limb salvage rates were extracted from the numbers at risk attached to Kaplan–Meier curves.

      Search methodology

      Online medical literature databases including Medline through Pubmed, EMBASE and CENTRAL were systematically searched. A comprehensive literature search was last carried out in May 2015 by two reviewers (TA/DO’N). We searched Medline through Pubmed without date or language restriction using the following search strategy: ((((fistula) OR arteriovenous fistula) OR AV fistula) OR A-V fistula) AND bypass. A total of 1961 articles were retrieved. After the filter was applied, (Comparative study, Clinical study, Observational study, Randomised controlled trial), 117 studies were identified. Both Embase and the Cochrane library were also searched in a similar fashion using the above strategy.

      Data collection

      Data were collected and assessed for inaccuracies by two reviewers (TA/DO’N) using a standardized data collection sheet. Any disagreements were discussed between both reviewers with any residual disagreements resolved by consultation with the senior author. Two studies had missing data of interest
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      but attempts to contact the corresponding authors for the raw data were unsuccessful.
      The data extracted included the following:
      • participants: age, sex, co-morbidities and indication for intervention;
      • methods: study design, methods of allocation, exclusion of participants after randomisation, and reasons for loss at follow-up;
      • interventions: graft type (vein or synthetic) (Table 1);
        Table 1Characteristics, inclusion and exclusion criteria of incorporated studies.
        Study (first author)DesignFollow-upBypassAge (mean)SexCharacteristics of patientsCompared groupsInclusion criteriaExclusion criteria
        Dardik
        • Dardik H.
        • Sussman B.
        • Ibrahim I.M.
        • Kahn M.
        • Svoboda J.J.
        • Mendes D.
        • et al.
        Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
        Cohort study24 months11066 years (AVF group)45% female (AVF group)Pre-gangrenous or gangrenous changes in 100%. No comparison of baseline patient characteristics between groupsGlutaraldehdye stabilized umbilical vein (GUV) to tibial or peroneal artery with adjuvant AVF (61) vs. distal bypass (GUV) alone (49)Patients requiring peripheral bypass with evidence of pre-gangreneprogressive frank gangreneevidence of poor crural vessel quality either pre- or intraoperativelyNon critical ischaemia

        in the intervention group alone

        A pre-op angiogram demonstrating healthy crural vessels with intact pedal archintraoperative evidencehealthy artery with good run off Not reported for comparative group
        Harris
        • Harris P.L.
        • Bakran A.
        • Enabi L.
        • Nott D.M.
        ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
        Cohort study24 months29868 years (AVF + vein cuff group) 68.6 (AVF group)

        69.9 (vein group)
        27% female (combined AVF groups)

        35% female (vein group)
        Majority had critical limb ischaemia. Groups well matched for age, sex, diabetes, smoking, previous surgery and degree of rest pain/tissue lossSynthetic femorocrural bypass with adjuvant AVF and vein cuff (43) vs. synthetic femorocrural bypass with adjuvant AVF (76) vs. vein femorocrural bypass alone (179)Patients requiring peripheral femorocrural bypass for lower limb ischaemiaNone
        Jacobs
        • Jacobs M.J.
        • Reul G.J.
        • Gregoric I.D.
        • Ubbink D.T.
        • Tordoir J.H.
        • Kitslaar P.J.
        • et al.
        Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
        Cohort study12 months2668 years (cumulative)38% female (cumulative)All patients had critical limb ischaemia and previous failed revascularization. No comparison of baseline data is providedFemorocrural PTFE bypass with AVF (14) vs. femorocrural PTFE bypass alonePatients requiring synthetic femorocrural bypass due to critical limb ischaemiaAutogenous vein available
        Kreienberg
        • Kreienberg P.B.
        • Darling 3rd, R.C.
        • Chang B.B.
        • Paty P.S.
        • Lloyd W.E.
        • Shah D.M.
        Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
        Cohort study36 months10770 years (AVF group)

        69 years (control group)
        20% female (AVF group)

        25% female (control

        group)
        Critical limb ischaemia in 100%. No significant between groups re sex, diabetes and smokersBelow knee PTFE bypass with adjuvant AVF (48) vs. below knee PTFE bypass alone (59)Patients requiring peripheral bypass with critical limb ischaemiaAutogenous vein available
        Scheltinga
        • Scheltinga M.R.
        • Poeze M.
        • de Haan M.W.
        • Tordoir J.H.
        • Kitslaar P.J.
        Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
        Cohort study24 months5669 years (AVF group)

        77 years (control group)

        Significant
        52% female (AVF group)

        50% female (control group)
        Critical limb ischaemia with no suitable vein for grafting in 100%. Reported difference between groups for age, Fontaine class and toe pressures. No difference for diabetes, smoking, hypertension, ABPI and cholesterolInfrapopliteal synthetic bypass with adjuvant AVF (44) vs. infrapopliteal synthetic bypass alone (12)Patients requiring peripheral bypass with

        critical limb ischaemia
        Autogenous vein available
        Ducasse
        • Ducasse E.
        • Chevalier J.
        • Chevier E.
        • Forzy G.
        • Speziale F.
        • Sbarigia E.
        • et al.
        Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
        Cohort study36 months6775 years (cumulative)37% female (cumulative)Critical limb ischaemia with undergoing distal bypass with synthetic graft. No difference in number of vascular risk factors for each group reported.Distal PTFE bypass with vein cuff and adjuvant AVF (35) vs. Distal PTFE bypass with vein cuff alone (32)Patients requiring synthetic peripheral bypass with critical limb ischaemiaAutogenous vein available
        Laurila
        • Laurila K.
        • Luther M.
        • Roth W.D.
        • Vilkko P.
        • Kantonen I.
        • Teittinen K.
        • et al.
        Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
        Cohort study60 months15474 years (AVF group)

        75 years (control group)
        45% female (AVF group)

        52% female (control group)
        Critical limb ischaemia with suitable vein for grafting in 100%. No reported difference between groups for age, diabetes, hypertension, ischaemic heart disease, and renal failureInfrapopliteal autogenous bypass with adjuvant AVF (77) vs. infrapopliteal autogenous bypass alone (77)Patients requiring peripheral bypass with critical limb ischaemia presence of autogenous veinSynthetic graft used
        Hamsho
        • Hamsho A.
        • Nott D.
        • Harris P.L.
        Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
        RCT24 months8971.5 years (AVF group)

        69.1 years (control group)
        42% female (AVF group)

        17% female (control group)
        Critical limb ischaemia in 100%. No reported difference between groups for age, smoking or diabetesInfrapopliteal bypass with both interposition vein cuff, patch and adjuvant AVF (48) vs. infrapopliteal bypass, vein cuff and patch alone (41)Patients requiring peripheral bypass with critical limb ischaemia patient consent synthetic graft
        • presence of autologous vein
        • venous hypertension due to deep venous obstruction
        • severely compromised cardiac function
        Laurila
        • Laurila K.
        • Lepäntalo M.
        • Teittinen K.
        • Kantonen I.
        • Forssell C.
        • Vilkko P.
        • et al.
        ScanPAC Study Group
        Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
        RCT24 months5974.3 years (AVF group)

        73 years (control group)
        51% female (AVF group)

        64% female (control group)
        Critical limb ischaemia with no suitable vein for grafting in 100%. No reported difference between groups for diabetes, hypertension, ischaemic heart disease, smoking, cerebrovascular disease and renal failureBelow knee PTFE bypass with both interposition vein cuff and adjuvant AVF (31) vs. below knee PTFE bypass and vein cuff alone (28)Patients requiring peripheral bypass with
        • critical limb ischaemia
        • with no suitable vein
        • -
          Non critical ischaemia
        • -
          bypass to non-crural artery
      • outcomes: primary and secondary outcomes were extracted.
      The risk of bias in each individual study was assessed using the Downs and Black quality assessment tool for both randomised and non randomised studies.
      • Downs S.
      • Black N.
      The feasibility of creating a checklist for the assessment of the methodological quality of both of the randomised and non-randomised studies of health care interventions.

      Data management

      Results were stratified according to the mode of intervention being compared. Review Manager Version 5.3.5
      was used for statistical analysis. Pooled risk ratios (RR) were calculated using the random effects model of DerSimonian and Laird.
      • DerSimonian R.
      • Laird N.M.
      Evaluating the effect of coaching on sat scores – a meta-analysis.
      Statistical heterogeneity between published works was assessed using Cochran's Q statistic. A p value < .05 was considered to be statistically significant. Bias evaluation was performed in conjunction with previously published guidance.
      • Sterne J.A.C.
      • Egger M.
      • Moher D.
      Addressing reporting biases.
      Following pooled data analysis, subgroup analyses were carried out including analysis of randomised studies, outcomes of synthetic graft in conjunction with AVF alone, and outcomes of vein graft in conjunction with AVF alone.

      Results

      Study selection (Fig. 1)

      The initial search yielded 1,069 initial abstracts with 18 full text articles reviewed for potential inclusion. After eligibility assessment nine studies were identified for qualitative analysis. At this point, nine papers were excluded from the analysis
      • Ascer E.
      • Gennaro M.
      • Pollina R.M.
      • Ivanov M.
      • Yorkovich W.R.
      • Ivanov M.
      • et al.
      Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency.
      • Laurila K.
      • Aho P.S.
      • Albäck A.
      • Teittinen K.
      • Kantonen I.
      • Lepäntalo M.
      The impact of adjuvant AV-fistula on cuffed femorocrural PTFE bypass grafting: flow and pressure response.
      • Neufang A.
      • Espinola-Klein C.
      • Dorweiler B.
      • Pitton M.
      • Savvidis S.
      • Schmiedt W.
      • et al.
      Questionable value of adjuvant arteriovenous fistula in pedal bypass at high risk for early failure.
      • Ascher E.
      • Scheinman M.
      • Mazzariol F.
      • Kallakuri S.
      • Hingorani A.
      Comparison between supra- and infrainguinal inflow sites for infrapopliteal PTFE bypasses with complementary arteriovenous fistula and vein interposition.
      • Hingorani A.P.
      • Ascher E.
      • Marks N.A.
      • Schutzer R.W.
      • Mutyala M.
      • Nahata S.
      • et al.
      A 10-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses.
      • Jakobsen H.L.
      • Baekgaard N.
      • Christoffersen J.K.
      Below-knee popliteal and distal bypass with PTFE and vein cuff.
      • D'Andrea V.
      • Lepäntalo M.
      • Kantonen I.
      • Biancari F.
      • Di Matteo F.M.
      • Bartolucci R.
      • et al.
      Adjuvant arteriovenous fistula in infrapopliteal bypasses.
      • Parsons R.E.
      • Suggs W.D.
      • Veith F.J.
      • Sanchez L.A.
      • Lyon R.T.
      • Marin M.L.
      • et al.
      Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: a better option than amputation in patients without autologous vein.
      • Doerrler J.
      • Mix C.
      • Maurer P.C.
      • Pickl U.
      • Holzman T.
      Extended femoro-distal bypasses for limb salvage: are they worthwhile?.
      as eight were non-comparative
      • Ascer E.
      • Gennaro M.
      • Pollina R.M.
      • Ivanov M.
      • Yorkovich W.R.
      • Ivanov M.
      • et al.
      Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency.
      • Laurila K.
      • Aho P.S.
      • Albäck A.
      • Teittinen K.
      • Kantonen I.
      • Lepäntalo M.
      The impact of adjuvant AV-fistula on cuffed femorocrural PTFE bypass grafting: flow and pressure response.
      • Neufang A.
      • Espinola-Klein C.
      • Dorweiler B.
      • Pitton M.
      • Savvidis S.
      • Schmiedt W.
      • et al.
      Questionable value of adjuvant arteriovenous fistula in pedal bypass at high risk for early failure.
      • Ascher E.
      • Scheinman M.
      • Mazzariol F.
      • Kallakuri S.
      • Hingorani A.
      Comparison between supra- and infrainguinal inflow sites for infrapopliteal PTFE bypasses with complementary arteriovenous fistula and vein interposition.
      • Hingorani A.P.
      • Ascher E.
      • Marks N.A.
      • Schutzer R.W.
      • Mutyala M.
      • Nahata S.
      • et al.
      A 10-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses.
      • Jakobsen H.L.
      • Baekgaard N.
      • Christoffersen J.K.
      Below-knee popliteal and distal bypass with PTFE and vein cuff.
      • Parsons R.E.
      • Suggs W.D.
      • Veith F.J.
      • Sanchez L.A.
      • Lyon R.T.
      • Marin M.L.
      • et al.
      Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: a better option than amputation in patients without autologous vein.
      • Doerrler J.
      • Mix C.
      • Maurer P.C.
      • Pickl U.
      • Holzman T.
      Extended femoro-distal bypasses for limb salvage: are they worthwhile?.
      • Dardik H.
      Update on the role of the distal arteriovenous fistula as an adjunct for improving graft patency and limb salvage rates after crural revascularization.
      and one was a review article.
      • D'Andrea V.
      • Lepäntalo M.
      • Kantonen I.
      • Biancari F.
      • Di Matteo F.M.
      • Bartolucci R.
      • et al.
      Adjuvant arteriovenous fistula in infrapopliteal bypasses.
      Included studies consisted of two randomised controlled trials
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      and seven retrospective cohort studies.
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      • Dardik H.
      • Sussman B.
      • Ibrahim I.M.
      • Kahn M.
      • Svoboda J.J.
      • Mendes D.
      • et al.
      Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.

      Study characteristics

      The characteristics, inclusion criteria and outcomes of each study are summarised in Table 1. All studies compared the merits of adjunctive AVF with peripheral arterial bypass to a control peripheral bypass group. Two studies
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      provided no data for meta-analysis; however, their outcome and quality assessment are reported.

      Description of included studies

      Seven studies
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      • Dardik H.
      • Sussman B.
      • Ibrahim I.M.
      • Kahn M.
      • Svoboda J.J.
      • Mendes D.
      • et al.
      Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      compared the use of AVF in conjunction with synthetic peripheral bypass with a control synthetic bypass group. These studies included two randomised and five retrospective cohort studies
      One cohort study by Laurila et al.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      assessed the merits of adjuvant AVF with peripheral vein bypass.
      Harris et al.
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      retrospectively compared synthetic bypass with adjuvant AVF with autologous bypass alone.

      Participants

      In total, 966 peripheral arterial bypasses were assessed. All included patients had objective evidence of severe limb ischaemia. Only Harris et al.
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      included patients with debilitating claudication for bypass, with all other patients included having critical limb ischaemia. Patient baseline demographics, inclusion, and exclusion criteria are reported in Table 1.

      Risk of bias

      Individual risk of bias for each study is summarised in Table 2 using the Downs and Black quality assessment tool.
      • Downs S.
      • Black N.
      The feasibility of creating a checklist for the assessment of the methodological quality of both of the randomised and non-randomised studies of health care interventions.
      Table 2Downs and Black methodological assessment of included studies.
      QuestionDardik
      • Dardik H.
      • Sussman B.
      • Ibrahim I.M.
      • Kahn M.
      • Svoboda J.J.
      • Mendes D.
      • et al.
      Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
      Harris
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      Jacobs
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      Kreienberg
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      Scheltinga
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      Ducasse
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      Laurila
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      Hamsho
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      Laurila
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      Hypothesis/objective clear?YesYesYesYesYesYesYesYesYes
      Main outcomes clearly described in introduction or methods?YesYesYesYesYesYesYesYesYes
      Are patients' characteristics clearly described?NoYesYesYesYesYesYesYesYes
      Are interventions clearly described?YesYesYesYesYesYesYesYesYes
      Are confounders equally distributed?NoYesNoYesNoYesYesNoYes
      Are the main findings clearly described?YesYesYesYesYesYesYesYesYes
      Are estimates or variability provided?NoNoNoYesYesYesYesNoNo
      Are important adverse events reported?YesYesYesYesYesNoYesYesYes
      Are the characteristics of those lost to follow up described?YesNoYesNoNoNoYesNoYes
      Are specific p value reported?YesYesYesYesYesYesNoYesYes
      Were potentially eligible subjects representative of the population?YesYesYesYesYesYesYesYesYes
      Were participating subjects representative of the populationYesYesYesYesYesYesYesYesYes
      Were staff, places and facilities representative of the treatment most patients receive?YesYesYesYesYesYesYesYesYes
      Was an attempt made to blind subjects to the intervention they received?NoNoNoNoNoNoNoNoNo
      Was an attempt made to blind main outcome assessors?NoNoNoNoNoNoNoNoNo
      If any results reflect data dredging, is this clear?NoYesYesYesYesYesYesYesYes
      Do analyses adjust for length of follow up differences?YesYesYesYesYesYesYesYesYes
      Were appropriate statistical analyses used?YesYesYesYesYesYesYesYesYes
      Was compliance with the intervention reliable?YesYesYesYesYesYesYesYesYes
      Were the main outcome measures valid and reliable?YesYesYesYesYesYesYesYesYes
      Were study groups recruited from the same population?YesYesYesYesYesYesYesYesYes
      Were subjects recruited over similar time periods?NoNoNoNoNoNoYesYesYes
      Were study subjects randomised to intervention groups?NoNoNoNoNoNoNoYesYes
      Was treatment assignment concealed?NoNoNoNoNoNoNoNoNo
      Was there adequate adjustment for confounders in the analysis?NoNoNoNoNoNoNoNoNo
      Were losses of patients to follow-up taken into account?YesUn-determinedYesNoUn-determinedNoYesYesYes
      Was an appropriate sample size calculation carried out?NoNoNoNoNoNoNoNoNo
      Number of “Yes” results161718181717201921
      The evidence assessing the merits of adjunctive AVF was generally weakened by small, retrospective studies with heterogeneous cohorts. Individual Downs and Black scores are included in Table 2 with a median score of 18 calculated across all nine studies.

      Effects of interventions

      Primary patency

      In total, seven included studies
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      examined the effect of an adjuvant AVF on the primary patency of a peripheral bypass graft at 12 months. Four studies
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      including 408 bypass procedures included data suitable for meta-analysis. In the intervention group 84 of 203 bypasses remained patent at 12 months, with 69 of 205 remaining patent in the control (pooled RR = 1.25, 95% CI 0.73–2.16) (Fig. 2). Further subgroup analysis revealed no significant difference in primary patency rates when RCTs were separately analysed
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      (primary patency of 29/79 intervention group vs. 26/69 control at 12 months) (RR = 0.98, 95% CI 0.64–1.48) or studies assessing synthetic grafts were compared
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      (primary patency of 54/126 intervention vs. 36/128 control) (pooled RR = 1.43, 95% CI 0.67–3.06).
      Figure thumbnail gr2
      Figure 2Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for primary graft patency of all studies. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
      Similarly, Laurila et al.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      identified no improvement in primary graft patency when an AVF was used in conjunction with a vein graft (RR = 0.91, 95% CI 0.62–1.33).
      Scheltinga et al.
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      and Ducasse et al.
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      reported no significant difference in primary patency between groups at 12 months, with Harris et al.
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      reporting a 2-year primary patency rate of 61% for prosthetic grafts with adjuvant AVF and vein cuff, 25% for grafts with AVF alone and 64% for vein grafts.

      Secondary patency

      All studies examined the role of AVF with regard to secondary patency. Seven studies provided data for meta-analysis.
      • Dardik H.
      • Sussman B.
      • Ibrahim I.M.
      • Kahn M.
      • Svoboda J.J.
      • Mendes D.
      • et al.
      Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      A total of 842 procedures were included in this group. At 12 months 152 of 397 in the intervention group versus 164/445 in the control group maintained secondary patency (pooled RR = 1.16, 95% CI 0.82–1.66) (Fig. 3).
      Figure thumbnail gr3
      Figure 3Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for secondary graft patency of all studies included. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
      Subgroup analysis again revealed no significant difference between groups when RCTs alone
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      (RR = 0.97, 95% CI 0.66–1.44), studies comparing synthetic grafts [14,16,17,19,20] (pooled RR = 1.45, 95% CI 0.86–2.46), or those contrasting vein grafts
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      were analysed (RR = 0.95, 95% CI 0.69–1.31).

      Limb salvage

      All studies assessed the effect of adjuvant AVF on limb salvage at 12 months, with six
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      studies including 732 procedures providing data suitable for meta-analysis. At 1 year 158 of 336 in the AVF group and 173 of 396 in the non-AVF group had retained their limbs post bypass (pooled RR = 1.13, 95% CI 0.80–1.60) (Fig. 4).
      Figure thumbnail gr4
      Figure 4Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for limb salvage rates of all studies included. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
      Subgroup analysis revealed no significant difference between the intervention and control group for RCTs
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      (RR = 0.90, 95% CI 0.59–1.38), synthetic
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      (pooled RR = 1.40, 95% CI 0.74–2.64), or vein grafts
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      (RR = 0.88, 95% CI 0.56–1.41) with regard to limb salvage.

      Reintervention rates

      Seven studies report reintervention rates following bypass surgery, with five
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      included for meta-analysis. In total, 434 bypasses were included with 37 of 217 in the AVF group requiring reintervention after bypass compared with 51 of 217 in the non-AVF group (pooled RR = 0.74, 95% CI 0.51–1.06).
      Significantly more reinterventions were seen in the control group when the pooled synthetic graft data
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      were examined (pooled RR = 0.55, 95% CI 0.30–0.98) (Fig. 5).
      Figure thumbnail gr5
      Figure 5Forest plots show results of meta-analysis of peripheral arterial bypass with adjuvant arteriovenous fistula compared with bypass alone for re-intervention of studies assessing synthetic grafts. The solid squares represent the relative risk, the horizontal lines represent the 95% confidence intervals (CIs), and the diamond represent the pooled relative risk.
      Further sub-group analysis revealed no significant difference in reintervention rates between included groups in both the RCT
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      (RR = 0.78, 95% CI 0.24,2.61) and vein graft groups
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      (RR = 0.88, 95% CI 0.56, 1.41).

      Operative morbidity and mortality

      Three studies including 320 procedures reported on operative complications. In the AVF group 43 of 156 had a reported complication versus 57 of 164 in the non-AVF cohort. These were primarily cardiorespiratory and wound complications. Of note, a total of nine graft infections were reported, with three observed in the AVF group and six in the control group. Meta-analysis of three studies
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      confirmed no significant difference in operative complications between groups (pooled RR = 0.81, 95% CI 0.51–1.30) while meta-analysis of five further studies
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      revealed no significant difference in 30-day mortality (pooled RR = 0.84, 95% CI 0.19–3.75).

      Risk of bias across studies

      Bias was investigated using further sensitivity analyses of larger studies (>100 participants), studies excluding the incorporation of veins cuffs, and studies examining the relationship of cuffed grafts with or without AVF and AVF alone. Of note, only limb salvage in grafts associated with distal vein cuff displayed a statistically significant improvement in outcome (RR = 0.49, 95% CI 0.32–0.77).

      Discussion

      This review has shown that although the use of adjuvant AVF in peripheral arterial bypass is not associated with additional morbidity (with no impact on operative complications or 30-day mortality), it did not offer superior patency of the grafts at 12 months, increased rates of limb salvage, or reduced reintervention rates. However, those undergoing synthetic grafting with AVF experienced a lower reintervention rate than those with synthetic graft alone, suggesting that AVF may have a role to play in reducing graft occlusion in synthetic grafts only. Of note, included data were subject to a significant risk of bias (Table 2).

      Quality of the evidence

      This review comprised nine studies, including two RCTs and seven cohort studies. Each article reported on a minimum of two study outcomes, with four reporting on all six. However, variable methodological quality was identified with a median Downs and Black score of 18. Although both RCTs were deemed to be at a moderate risk of bias, the included cohort studies reported outcomes of small, retrospective studies with heterogeneous cohorts, with six studies deemed to be at a relatively high risk of bias (Table 2).

      Significance of results to practice

      Patency rates in femoral below-knee bypass remain relatively poor, particularly in patients with no available autologous venous conduit.
      • Veterans Administration Cooperative Study Group 141
      Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibial-peroneal revascularization.
      Importantly, venous conduits to the distal arterial segment offer up to four times greater patency than that of synthetic grafts.
      • Veith F.J.
      • Gupta S.K.
      • Ascer E.
      • White-Flores S.
      • Samson R.H.
      • Scher L.A.
      • et al.
      Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.
      However, aggressive policies toward both limb salvage and coronary revascularization may increasingly necessitate the use of synthetic bypass materials as autogenous vein availability wanes.
      Because of this challenge a number of adjuncts to distal synthetic bypass have been assessed. Vein cuffs have previously been subject to review with Khalil et al.
      • Khalil A.A.
      • Boyd A.
      • Griffiths G.
      Interposition vein cuff for infragenicular prosthetic bypass graft.
      reporting some weak evidence to support their use. This small benefit was also identified by Twine et al.,
      • Twine C.P.
      • Williams I.M.
      • Fligelstone L.J.
      Systematic review and meta-analysis of vein cuffs for below-knee synthetic bypass.
      who noted marginally improved patency and limb salvage at 2 years for femoral below-knee popliteal cuffed bypass with no benefit seen distally. This has also been suggested by the results of this analysis examining the relationship of cuffed grafts with or without AVF and AVF alone.
      This review has not indicated that an AVF has any impact on the patency or limb salvage rates associated with either synthetic or vein grafts. However, the intervention was not associated with any increase in operative complications or mortality, although it is associated with longer operating times.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      Thus, at the very least it offers a similar complication rate to standard bypass procedures and may be associated with a modest reduction in reintervention rates when a synthetic graft is used.
      Comparisons beyond 12 months (12–36 months) have been carried out by many of the included studies with the majority
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      • Dardik H.
      • Sussman B.
      • Ibrahim I.M.
      • Kahn M.
      • Svoboda J.J.
      • Mendes D.
      • et al.
      Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
      • Harris P.L.
      • Bakran A.
      • Enabi L.
      • Nott D.M.
      ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
      • Kreienberg P.B.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Paty P.S.
      • Lloyd W.E.
      • Shah D.M.
      Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
      • Laurila K.
      • Luther M.
      • Roth W.D.
      • Vilkko P.
      • Kantonen I.
      • Teittinen K.
      • et al.
      Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
      • Hamsho A.
      • Nott D.
      • Harris P.L.
      Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      reporting no significant difference between groups at their endpoint. Only Dardik et al.
      • Dardik H.
      • Sussman B.
      • Ibrahim I.M.
      • Kahn M.
      • Svoboda J.J.
      • Mendes D.
      • et al.
      Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
      and Jacobs et al.
      • Jacobs M.J.
      • Reul G.J.
      • Gregoric I.D.
      • Ubbink D.T.
      • Tordoir J.H.
      • Kitslaar P.J.
      • et al.
      Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
      at 24 and 12 months respectively reported AVF to have any superiority over bypass alone, with one further study
      • Laurila K.
      • Lepäntalo M.
      • Teittinen K.
      • Kantonen I.
      • Forssell C.
      • Vilkko P.
      • et al.
      ScanPAC Study Group
      Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
      reporting an episode of venous hypertension related to AVF as a longer term complication. Most recently, Dardik et al.
      • Dardik H.
      Update on the role of the distal arteriovenous fistula as an adjunct for improving graft patency and limb salvage rates after crural revascularization.
      published series data comparing the use of AVF as an adjunct to bypass over three decades. Interestingly, primary and secondary patency rates as well as limb salvage progressively improved over the study period. These outcomes would suggest that the continued refinement of this operative technique and improved patient selection might result in a continued evolution in outcomes. However, until these endpoints are consistently identified by randomised data this technique is likely to remain an underused adjunct to peripheral bypass.

      Study strengths and limitations

      This review is subject to a number of limitations. Many of the included studies were deemed to be at significant risk of bias. The majority were retrospectively performed cohort studies involving small numbers of patients. In fact, the expected superiority of venous conduits for bypass was not identified on subgroup analysis, suggesting that numbers in this particular analysis were too small to identify a meaningful outcome. In addition, studies were generally old with no recent comparative studies, suggesting that adjunctive AVF is not a widely used technique in modern bypass surgery. The randomised studies included assessed relatively small numbers of procedures with no power calculations. Although study groups in the RCT were well matched, a number of the cohort studies reported on heterogeneous sets of patients. In addition, while each study compared the use of an adjunctive fistula with a suitable control, there was some variation in the exact operative technique employed in each individual study with further sensitivity analysis suggesting that cuffed grafts may have resulted in a degree of data contamination. Finally, raw data from two studies
      • Scheltinga M.R.
      • Poeze M.
      • de Haan M.W.
      • Tordoir J.H.
      • Kitslaar P.J.
      Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
      • Ducasse E.
      • Chevalier J.
      • Chevier E.
      • Forzy G.
      • Speziale F.
      • Sbarigia E.
      • et al.
      Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
      could not be attained and were not included for meta-analysis.
      The comprehensive protocol-derived methodology is the primary strength of this review. All data-based studies assessing AVF have been systematically identified by two independent reviewers, assessed for bias, and included for systematic review. To date, this is the most complete assessment of adjunctive AVF to peripheral arterial bypass.

      Conclusions

      Peripheral arterial bypass remains the gold standard of care in patients with severe lower limb arterial disease with long-segment vessel occlusion. However, graft patency and limb salvage continue to challenge surgeons, particularly in bypasses to the distal arterial segment. To date, the literature assessing the use of adjunctive AVF is subjected to bias, weakened by small, retrospective studies with heterogeneous cohorts (Table 2). Data from this analysis suggest that while the use of an AVF is associated with a similar complication rate to standard bypass, there is little evidence to support its use to improve either graft patency or limb salvage rates.

      Conflict of Interest

      None.

      Funding

      None.

      References

        • Criqui M.H.
        • Franek A.
        • Barrett-Connor E.
        • Klauber M.R.
        • Gabriel S.
        • Goodman D.
        The prevalence of peripheral arterial disease in a defined population.
        Circulation. 1985; 71: 510-515
        • Schroll M.
        • Munck O.
        Estimation of peripheral arteriosclerotic disease by ankle blood pressure measurements in a population study of 60-year-old men and women.
        J Chron Dis. 1981; 34: 261-269
        • Selvin E.
        • Erlinger T.P.
        Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000.
        Circulation. 2004 Aug 10; 110: 738-743
        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).
        Eur J Vasc Endovasc Surg. 2007; 33: S1-S75
        • Veterans Administration Cooperative Study Group 141
        Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibial-peroneal revascularization.
        Arch Surg. 1988; 123: 434-438
        • SCAMICOS
        PTFE bypass to below-knee arteries: distal vein collar or not? A prospective randomised multicentre study.
        Eur J Vasc Endovasc Surg. 2010; 39: 747-754
        • Veith F.J.
        • Gupta S.K.
        • Ascer E.
        • White-Flores S.
        • Samson R.H.
        • Scher L.A.
        • et al.
        Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.
        J Vasc Surg. 1986; 3: 104-114
        • Bergan J.J.
        • Veith F.J.
        • Bernhard V.M.
        • Yao J.S.
        • Flinn W.R.
        • Gupta S.K.
        • et al.
        Randomization of autogenous vein and polytetrafluorethylene grafts in femoral-distal reconstruction.
        Surgery. 1982; 92: 921-930
        • Sauvage L.R.
        • Walker M.W.
        • Berger K.
        • Robel S.B.
        • Lischko M.M.
        • Yates S.G.
        • et al.
        Current arterial prostheses. Experimental evaluation by implantation in the carotid and circumflex coronary artery of the dog.
        Arch Surg. 1979; 114: 687-691
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • for the PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • Scheltinga M.R.
        • Poeze M.
        • de Haan M.W.
        • Tordoir J.H.
        • Kitslaar P.J.
        Prosthetic femorocrural bypass surgery and adjuvant arteriovenous fistulae.
        Ann Vasc Surg. 2003; 17: 203-209
        • Ducasse E.
        • Chevalier J.
        • Chevier E.
        • Forzy G.
        • Speziale F.
        • Sbarigia E.
        • et al.
        Patency and limb salvage after distal prosthetic bypass associated with vein cuff and arteriovenous fistula.
        Eur J Vasc Endovasc Surg. 2004; 27: 417-422
        • Downs S.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality of both of the randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
        • Dardik H.
        • Sussman B.
        • Ibrahim I.M.
        • Kahn M.
        • Svoboda J.J.
        • Mendes D.
        • et al.
        Distal arteriovenous fistula as an adjunct to maintaining arterial and graft patency for limb salvage.
        Surgery. 1983; 94: 478-486
        • Harris P.L.
        • Bakran A.
        • Enabi L.
        • Nott D.M.
        ePTFE grafts for femoro-crural bypass—improved results with combined adjuvant venous cuff and arteriovenous fistula?.
        Eur J Vasc Surg. 1993; 7: 528-533
        • Jacobs M.J.
        • Reul G.J.
        • Gregoric I.D.
        • Ubbink D.T.
        • Tordoir J.H.
        • Kitslaar P.J.
        • et al.
        Creation of a distal arteriovenous fistula improves microcirculatory hemodynamics of prosthetic graft bypass in secondary limb salvage procedures.
        J Vasc Surg. 1993; 18: 1-8
        • Kreienberg P.B.
        • Darling 3rd, R.C.
        • Chang B.B.
        • Paty P.S.
        • Lloyd W.E.
        • Shah D.M.
        Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
        J Vasc Surg. 2000; 31: 696-701
        • Laurila K.
        • Luther M.
        • Roth W.D.
        • Vilkko P.
        • Kantonen I.
        • Teittinen K.
        • et al.
        Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.
        J Vasc Surg. 2006; 44: 985-991
        • Hamsho A.
        • Nott D.
        • Harris P.L.
        Prospective randomised trial of distal arteriovenous fistula as an adjunct to femoro-infrapopliteal PTFE bypass.
        Eur J Vasc Endovasc Surg. 1999; 17: 197-201
        • Laurila K.
        • Lepäntalo M.
        • Teittinen K.
        • Kantonen I.
        • Forssell C.
        • Vilkko P.
        • et al.
        • ScanPAC Study Group
        Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia? A prospective randomised multicentre trial.
        Eur J Vasc Endovasc Surg. 2004; 27: 180-185
      1. Review Manager (RevMan) [Computer program]. Version 5.3. The Nordic Cochrane Centre, Copenhagen2014
        • DerSimonian R.
        • Laird N.M.
        Evaluating the effect of coaching on sat scores – a meta-analysis.
        Harv Educ Rev. 1983; 53: 1-15
        • Sterne J.A.C.
        • Egger M.
        • Moher D.
        Addressing reporting biases.
        in: Higgins J.P.T. Green S. Cochrane handbook for systematic reviews of interventions, Version 5.1.0. Wiley, Chichester2011
        • Ascer E.
        • Gennaro M.
        • Pollina R.M.
        • Ivanov M.
        • Yorkovich W.R.
        • Ivanov M.
        • et al.
        Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency.
        J Vasc Surg. 1996; 24: 134-143
        • Laurila K.
        • Aho P.S.
        • Albäck A.
        • Teittinen K.
        • Kantonen I.
        • Lepäntalo M.
        The impact of adjuvant AV-fistula on cuffed femorocrural PTFE bypass grafting: flow and pressure response.
        Eur J Vasc Endovasc Surg. 2005; 29: 425-428
        • Neufang A.
        • Espinola-Klein C.
        • Dorweiler B.
        • Pitton M.
        • Savvidis S.
        • Schmiedt W.
        • et al.
        Questionable value of adjuvant arteriovenous fistula in pedal bypass at high risk for early failure.
        Ann Vasc Surg. 2008; 22: 379-387
        • Ascher E.
        • Scheinman M.
        • Mazzariol F.
        • Kallakuri S.
        • Hingorani A.
        Comparison between supra- and infrainguinal inflow sites for infrapopliteal PTFE bypasses with complementary arteriovenous fistula and vein interposition.
        Eur J Vasc Endovasc Surg. 2000; 19: 138-142
        • Hingorani A.P.
        • Ascher E.
        • Marks N.A.
        • Schutzer R.W.
        • Mutyala M.
        • Nahata S.
        • et al.
        A 10-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses.
        Vasc Endovasc Surg. 2005; 39: 401-409
        • Jakobsen H.L.
        • Baekgaard N.
        • Christoffersen J.K.
        Below-knee popliteal and distal bypass with PTFE and vein cuff.
        Eur J Vasc Endovasc Surg. 1998; 15: 327-330
        • D'Andrea V.
        • Lepäntalo M.
        • Kantonen I.
        • Biancari F.
        • Di Matteo F.M.
        • Bartolucci R.
        • et al.
        Adjuvant arteriovenous fistula in infrapopliteal bypasses.
        G Chir. 1998; 19: 117-119
        • Parsons R.E.
        • Suggs W.D.
        • Veith F.J.
        • Sanchez L.A.
        • Lyon R.T.
        • Marin M.L.
        • et al.
        Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: a better option than amputation in patients without autologous vein.
        J Vasc Surg. 1996; 23: 347-354
        • Doerrler J.
        • Mix C.
        • Maurer P.C.
        • Pickl U.
        • Holzman T.
        Extended femoro-distal bypasses for limb salvage: are they worthwhile?.
        Int Angiol. 1986; 5: 131-135
        • Dardik H.
        Update on the role of the distal arteriovenous fistula as an adjunct for improving graft patency and limb salvage rates after crural revascularization.
        Ann Vasc Surg. 2015; 29: 1022-1028
        • Khalil A.A.
        • Boyd A.
        • Griffiths G.
        Interposition vein cuff for infragenicular prosthetic bypass graft.
        Cochrane Database Syst Rev. 2012; (12;9:CD007921)
        • Twine C.P.
        • Williams I.M.
        • Fligelstone L.J.
        Systematic review and meta-analysis of vein cuffs for below-knee synthetic bypass.
        Br J Surg. 2012; 99: 1195-1202

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