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15 Popliteal Entrapment Syndrome
alternative treatments for atypical claudication with chronic exertional compartment syndrome (CECS). Entrapment release was performed via either the medial or
posterior approach. Of the 51 patients evaluated for CECS, 18 were diagnosed with
CECS and underwent fasciectomy; the remaining 33 patients opted for conservative
management consisting of activity modication and physical therapy. Exercise with
an ankle-brachial index in the functional popliteal artery entrapment syndrome
(FPAES) cohort demonstrated a statistically signicant difference of −14mm Hg in
systolic blood pressure. Arterial Doppler ultrasound examination showed a trend
toward statistical signicance with plantarexion, but requires further study.
Magnetic resonance angiography with plantarexion was positive in 6 of 11 patients
with FPAES.Because different provocative maneuvers and testing modalities yield
widely different diagnostic yields for diagnosing FPAES, the authors recommended
using a combination of exercise ankle-brachial index, plantarexion Doppler ultrasound examination, venous ultrasound examination, and plantarexion magnetic
resonance angiography for the diagnosis of FPAES.
The importance of patient position when dening normal versus pathological
functionality in the diagnosis of PAES with duplex ultrasound was investigated by
Barrett etal. [11]. To reduce false positive rates (from asymptomatic compression)
and scanning time, the recommended ultrasound protocol assesses potential PAES
candidates only in the erect position (i.e., scanning supine may not be required),
paying particular attention to changes (diameter, peak systolic velocities (PSV),
waveform, and occlusions) on plantarexion (but still assesses dorsiexion), in the
distal below knee popliteal artery. There is no need to complete ankle brachial pressure index testing, but exercise is important.
15.3.3.3 Studies
Functional popliteal artery entrapment syndrome (FPAES) is an uncommon overuse
injury in young physically active adults manifest by neuromuscular symptoms (gastric/soleus cramping, plantar paresthesias). It is commonly confused with chronic
recurrent exertional compartment syndrome (CRECS). Turnipseed [12] evaluated
the diagnostic testing, mechanism of injury, and treatment differences between
FPAES and CRECS.Between 1987 and 2007, 854 patients (557 women, 297 men;
mean age, 28.5years) were surgically treated for the diagnosis of CRECS or FPAES,
or both. Compartment pressures were measured in all patients who had anterior
lateral or posterior supercial calf symptoms (normal pressure < 15 mm Hg).
Noninvasive stress positional plethysmography was routine. Stress positional magnetic resonance imaging (MRI) or angiography (MRA) was performed on patients
with positive plethysmography result and symptoms consistent with FPAES.Of the
854 patients, 757 (95%) had elevated compartment pressures (>25mm Hg), and
fasciectomy was performed for CRECS under local anesthesia (anterior lateral,
508; posterior supercial, 191; distal deep posterior, 101). MRA/MRI demonstrated
normal musculotendinous anatomy and lateral neurovascular compression with
plantar exion in 43 patients. All patients had normal compartment pressures. Under
general anesthesia, all had excision of the soleal band, with relief from symptoms.
15.3 Results
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In conclusion, FPAES and CRECS occur in the same population with similar symptoms but require different treatment.
Popliteal artery entrapment syndrome (PAES) is still underdiagnosed, yet it may
signicantly interfere with lifestyle, especially among young sportspeople, with
symptoms like intermittent claudication. In a population of 327 consecutive explored
symptomatic sportspersons, PAES was conrmed in 35 patients on 61 pathologic
limbs [13]. In this center, when sportspersons are referred for chronic leg pain during exercise, they systematically receive color duplex ultrasonography (CDUS)
with dynamic manoeuvres specic to the search for a PAES.When patients were
suspected of PAES after CDUS, the diagnosis was conrmed by computed tomography angiography (CTA) or magnetic resonance angiography (MRA), with the foot
in the neutral position and dynamic plantar exion of the ankle during resistive
exercises to demonstrate vascular (arterial compression, stenosis, occlusion or
aneurysm, deviated course) and extravascular (abnormal muscle position or muscular hypertrophy) abnormalities linked to this disease. The median time with the
symptoms before diagnosis was 34months (range, 3–180months). The mean age of
patients was 30.5years (range, 17–52years) with 83% of males. The proportion of
patients diagnosed with bilateral PAES was 74%. The main sports practiced were
running (15 patients, 43%), soccer (nine patients, 26%), rugby (two patients), and
athletics (two patients). Among 21 patients, intra-compartmental pressure measurements (ICP) found 18 (86%) to have an associated chronic exertional compartment
syndrome (CECS). Of the 35 patients with a conrmed PAES on 61 legs, 21 nally
underwent surgery on 37 legs: three patients were operated only for PAES (ve
legs), eight patients were operated for PAES and CECS (15 legs) and 10 persons
were treated only for CECS (17 legs). Among the patients followed up after PAES
surgery, 80% were able to resume sport at a level comparable to that before the
onset of pain. PAES could be sought earlier in young sportspeople who experience
unexplained leg pain during exercise to diagnose the disease and avoid complications in a timely manner. Compartmental pressures should systematically be measured in the search for an associated CECS.
Lavingia etal. [14] reported on the surgical management of functional popliteal
entrapment syndrome in 36 athletes (56 limbs). Of the patients, 27 (75%) had bilateral symptoms and evidence of entrapment; however, only 20 of the 36 (56%)
underwent bilateral surgical treatment for symptom resolution. The mean amount of
gastrocnemius muscle removed was 7.6cm3. Nine percent of limbs underwent a
bypass along with debulking owing to arterial occlusion at presentation.
Postoperatively, there were no nerve or vascular complications noted, although two
patients had wound/seroma complications (6%). At follow-up, more than threefourths of athletes limited by FPAES demonstrated full return to prior competitive
levels with fasciotomy and surgical debulking of the anterolateral quadrant of the
medial gastrocnemius muscle. Provocative CTA protocols can help to guide the
location of muscle debulking to alleviate the functional entrapment that occurs in
these athletes with exercise.
Deveze etal. [15] described a cohort of 38 patients who underwent surgery for
PAES.Among them, 36 (94.7%) were functional PAES.The mean age at the time
of surgery was 24.7± 9 years. Clinical presentation was bilateral in 30 patients
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(81.1%). The most frequent symptom was intermittent claudication with calf cramp
during exercise. Surgical procedures were performed through direct posterior popliteal approaches in ventral prone position. Surgery always consisted of a complete
popliteal artery examination after neurovascular bers of the popliteal region were
recognized and dissected free. In case of muscular or tendon abnormalities causing
compression of the popliteal vessel these were sectioned. All patients also had systematic gastrocnemius muscles fascia incisions, especially when no abnormality
was found. The mean time of follow-up was 2.3months +/− 1.2months. After surgery, D-scan showed no signs of remaining popliteal artery compression in 92.5%
of the cases. Twelve patients (33.3%) were able to resume sport, 18 (50%) partially,
and 6 (16.6%) did not resume sport yet.
15.3.3.4 Botulinum Toxin asaTreatment forFPAES
Botulinum toxin A (BoNT-A) has been proposed as an alternative approach to
reduce the volume and/or tonus of gastrocnemius muscles in patients with
FPAES.Isner-Horobeti [16] reported the case of a patient with bilateral FPAES who
was treated by intramuscular injection of BoNT-A in the gastrocnemius muscles
after unsuccessful surgical intervention. The disappearance of exercise-induced
pain and the improvement in physical performance were maintained in the short and
medium term. Neither adverse effects nor motor decit of the gastrocnemius muscles was reported.
Hislop etal. [17] reported a larger cohort of patients suffering from functional
PAES. Twenty-seven patients met diagnostic criteria conrming the presence of
functional PAES and agreed to go ahead with ultrasound-guided BTX-A injection
at the level of artery occlusion. Two occlusion sites per calf were consistently identied: the deep proximal medial gastrocnemius muscle belly in the intercondylar
fossa adjacent to the popliteal artery and the plantaris muscle belly immediately
overlying the popliteal artery at the level of the proximal tibial metaphysis. Each of
these sites was then targeted and injected under ultrasound guidance. No patients
reported being worse off after the intervention; 59% of patients were categorized as
having a good response (i.e., initial improvement that was maintained at 12months),
22% a mixed response (i.e., an initial improvement that subsequently reduced over
12months) and 19% a poor response (i.e., no difference) to treatment. The authors
concluded that ultrasound-guided BTX-A injection represents a viable alternative to
surgery in the treatment of functional PAES.
15 Popliteal Entrapment Syndrome
15.4 Conclusions forClinical Practice
1. Popliteal artery entrapment (PAES) is by far the most common entrapment and
is responsible for a signicant proportion of intermittent claudication (IC) in
young patients.
References
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2. Therapy has two approaches: Correction of the anomaly and repair of any dam-
age that has occurred to the artery. If the basic problem is one of an abnormal
course of the artery around the medial head of the gastrocnemius, this muscle
should be divided so as to restore the artery to its proper course. If the artery is
constricted by an aberrant origin of the gastrocnemius or the plantaris muscle,
this muscle should be divided to release the artery.
3. The anatomical variants that can lead to compression of the popliteal artery must
be distinguished from functional PAES (FPAES), where no abnormalities, no
anatomical trap are discovered and in which entrapment of the artery occurs as a
result of hypertrophy of the gastrocnemius muscle, especially in intensively
trained young athletes.
4. In FPAES, surgery always consists of a complete popliteal artery examination
after neurovascular bers of the popliteal region were recognized and dissected
free. Muscular or tendon abnormalities causing compression of the popliteal
vessel should be sectioned and gastrocnemius muscles fascia incisions should be
performed.
5. In case of suspicion of FPAES, compartmental pressures should systematically
be measured in the search for an associated chronic exertional compartment syndrome (CECS).
6. CECS and FPAES occur in the same population with similar symptoms but
require different treatment. Patients with CECS show elevated compartment
pressures (>25mm Hg), and fasciectomy is the treatment of choice.
References
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2. Rignault DP, Pailler JL, Lunel F.The "functional" popliteal entrapment syndrome. Int Angiol.
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3. Hameed M, Coupland A, Davies AH. Popliteal artery entrapment syndrome: an approach to
diagnosis and management. Br J Sports Med. 2018;52:1073–4.
4. Sinha S, Houghton J, Holt PJ, Thompson MM, Loftus IM, Hinchliffe RJ.Popliteal entrapment
syndrome. J Vasc Surg. 2012;55:252–62.
5. Fujimura N, Obara H, Takahashi A, Miyata H, Hosaka A, Obitsu Y, Zempo N, Miyata T, Azuma
N, Komori K, Japanese Society for Vascular Surgery Database Management Committee.
Surgical treatment for popliteal artery entrapment syndrome in Japan: a retrospective, multicentre study using a National Clinical Registry. Eur J Vasc Endovasc Surg. 2023;66:381–8.
6. Lejay A, Delay C, Georg Y, Gaertner S, Ohana M, Thaveau F, Lee JT, Geny B, Chakfe N.Five
year outcomes of surgical treatment for popliteal artery entrapment syndrome. Eur J Vasc
Endovasc Surg. 2016;51:557–64.
7. Settembre N, Bouziane Z, Bartoli MA, Nabokov V, Venermo M, Feugier P, Malikov S.Popliteal
artery entrapment syndrome in children: experience with four cases of acute ischaemia and
review of the literature. Eur J Vasc Endovasc Surg. 2017;53:576–82.
8. Shahi N, Arosemena M, Kwon J, Abai B, Salvatore D, DiMuzio P.Functional popliteal artery
entrapment syndrome: a review of diagnosis and management. Ann Vasc Surg. 2019;59:259–67.
9. Campano D, Robaina JA, Kusnezov N, Dunn JC, Waterman BR. Surgical Management for
Chronic Exertional Compartment Syndrome of the leg: a systematic review of the literature.
Arthroscopy. 2016;32:1478–86.
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10. Morgan C, Huang A, Turnipseed W.Optimizing the diagnostic approach of functional popliteal artery entrapment syndrome. J Vasc Surg. 2023;77:580–7.
11. Barrett DW, Carreira J, Bowling FL, Wolowczyk L, Rogers SK.The importance of patient position when dening Normal versus pathological functionality in the diagnosis of popliteal artery
entrapment syndrome with duplex ultrasound. Eur J Vasc Endovasc Surg. 2023;65:760–1.
12. Turnipseed WD.Functional popliteal artery entrapment syndrome: a poorly understood and
often missed diagnosis that is frequently mistreated. J Vasc Surg. 2009;49:1189–95.
13. Corneloup L, Labanère C, Chevalier L, Jaussaud J, Mignot A, Gencel L, Corneloup O, Midy
D. Presentation, diagnosis, and management of popliteal artery entrapment syndrome: 11
years of experience with 61 legs. Scand J Med Sci Sports. 2018;28:517–23.
14. Lavingia KS, Dua A, Rothenberg KA, Fredericson M, Lee JT.Surgical management of functional popliteal entrapment syndrome in athletes. J Vasc Surg. 2019;70:1555–62.
15. Deveze E, Bruneau A, Hersant J, Ammi M, Abraham P, Picquet J.Popliteal entrapment syndrome: diagnostic, surgical management, and short-term results of a ten-year experience. Ann
Vasc Surg. 2023;88:139–44.
16. Isner-Horobeti ME, Muff G, Masat J, Daussin JL, Dufour SP, Lecocq J. Botulinum toxin
as a treatment for functional popliteal artery entrapment syndrome. Med Sci Sports Exerc.
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17. Hislop M, Brideaux A, Dhupelia S.Functional popliteal artery entrapment syndrome: use
of ultrasound guided Botox injection as a non-surgical treatment option. Skelet Radiol.
2017;46:1241–8.
15 Popliteal Entrapment Syndrome
Chapter 16
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Vascular Access forHaemodialysis
16.1 Guidelines
16.1.1 Clinical Practice Guidelines oftheEuropean Society
forVascular Surgery (ESVS)
The ESVS recommends, among others [1]:
Clinical decision-making
• Recommendation 1: Referral of chronic kidney disease patients to the nephrolo-
gist and/or surgeon for preparing vascular access is recommended when they
reach stage 4 of chronic kidney disease (glomerular ltration rate < 30 ml/
min/1.73 m2), especially in cases of rapidly progressing nephropathy. Class I
recommendation; Level of evidence C
• Recommendation 2: A permanent vascular access should be created 3–6months
before the expected start of haemodialysis treatment. Class I recommendation;
Level of evidence B
• Recommendation 3: An autogenous arteriovenous (AV) stula is recommended
as the primary option for vascular access. Class I recommendation; Level of
evidence A
• Recommendation 4: The radiocephalic arteriovenous stula is recommended as
the preferred vascular access. Class I recommendation; Level of evidence B
• Recommendation 5: When vessel suitability is adequate, the non-dominant
extremity should be considered as the preferred location for vascular access.
Class IIa recommendation; Level of evidence C
• Recommendation 6: A lower extremity vascular access should be considered
only when upper extremity access is impossible. Class IIa recommendation;
Level of evidence C
Switzerland AG 2023
E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,
https://doi.org/10.1007/978-3-031-47397-5_16
337© The Author(s), under exclusive license to Springer Nature
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16 Vascular Access forHaemodialysis
• Recommendation 7: Tunnelled cuffed central venous catheters as a long- standing
haemodialysis modality should be considered when the creation of arteriovenous
stulas or grafts is impossible or in patients with limited life expectancy. Class
IIa recommendation; Level of evidence B
Pre-operative imaging
• Recommendation 8: Pre-operative ultrasonography of bilateral upper extremity
arteries and veins is recommended in all patients when planning the creation of
a vascular access. Class I recommendation; Level of evidence A
• Recommendation 9: Duplex ultrasound is recommended as the rst line imaging
modality in suspected vascular access dysfunction. Class I recommendation;
Level of evidence B
• Recommendation 10: Computed tomographic angiography may be considered in
patients with inconclusive ultrasonographic or angiographic results concerning
the degree of central venous stenosis. Class IIb recommendation; Level of
evidence C
• Recommendation 11: Contrast enhanced magnetic resonance angiography is not
recommended in patients with end stage renal disease, because of the potential
risk of gadolinium associated nephrogenic systemic brosis. Class III recommendation; Level of evidence C
• Recommendation 12: In vascular access dysfunction digital subtraction angiog-
raphy should be performed only when subsequent intervention is anticipated.
Class I recommendation; Level of evidence C
Technical aspects
• Recommendation 15: Broad spectrum antibiotics should be given prior to inser-
tion of an arteriovenous graft including prophylaxis for Staphylococcus aureus.
Class I recommendation; Level of evidence A
• Recommendation 17: Patients should be examined prior to surgery with a tour-
niquet in a warm room and the proposed site of an arteriovenous stula should
be marked pre-operatively. Class I recommendation; Level of evidence C
• Recommendation 18: Regional anaesthesia should be considered in preference
to local anaesthesia for vascular access surgery because of a possible improvement in access patency rate. Class IIa recommendation; Level of evidence B
• Recommendation 19: In adults when the inner radial arterial diameter is less than
2.0mm and/or the cephalic venous diameter is less than 2.0mm by ultrasound
measurement an alternative site for access should be considered. Class IIa recommendation; Level of evidence B
• Recommendation 20: If there is an indwelling central venous catheter or pace-
maker the vascular access should be created in the opposite arm because of the
risk of central venous stenosis and reduced access patency. Class I recommendation; Level of evidence C
• Recommendation 21: When the upper arm cephalic vein is unavailable, a basilic
vein transposition arteriovenous stula should be considered in preference to an
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arteriovenous graft because of its improved patency and the reduced risk of
infection. Class IIa recommendation; Level of evidence A
• Recommendation 22: When lower limb vascular access is necessary a femoral
vein transposition should be considered in preference to an arteriovenous graft.
Class IIa recommendation; Level of evidence B
• Recommendation 23: When an arteriovenous stula cannot be created, a biologi-
cal graft should be considered in preference to a synthetic graft in the presence
of infection. Class IIa recommendation; Level of evidence C
• Recommendation 24: The implantation of a self-sealing arteriovenous graft is
recommended for patients who have difcult central venous access and who
require early cannulation for haemodialysis. Class I recommendation; Level of
evidence C
• Recommendation 27: In patients with early peri-operative (<30days) autoge-
nous arteriovenous stula infection and absence of haemorrhage or pseudoaneurysm, appropriate antibiotic therapy is recommended. Class I recommendation;
Level of evidence C
• Recommendation 28: Early peri-operative (<30days) arteriovenous graft infec-
tion with systemic sepsis, purulent discharge, perigraft abscess or haemorrhage
should be treated by total graft removal. Class I recommendation; Level of
evidence C
• Recommendation 29: For early autogenous arteriovenous stula infection in the
presence of systemic signs, bleeding and involvement of the anastomosis, stula
ligation should be performed. Class I recommendation; Level of evidence C
• Recommendation 30: For early limb threatening vascular access induced isch-
aemia and for all cases of early ischaemic monomelic neuropathy in the absence
of steal, the access should be ligated urgently. Class I recommendation; Level of
evidence C
• Recommendation 31: For vascular access salvage after early thrombosis, throm-
bectomy and revision (if needed) should be performed as soon as possible. Class
I recommendation; Level of evidence C
• Recommendation 33: Establishing vascular access training programs is recom-
mended in order to supervise adequate numbers (>25) of autogenous stulas for
each trainee. Class I recommendation; Level of evidence C
Surveillance of vascular access
• Recommendation 34: Arteriovenous stulas should be considered for cannula-
tion 4–6weeks after creation, and standard arteriovenous grafts after 2–4weeks.
Class IIa recommendation; Level of evidence B
• Recommendation 38: Structured post-operative hand exercise training should be
considered, to increase arteriovenous stula maturation. Class IIa recommendation; Level of evidence B
• Recommendation 39: Long-term anti-thrombotic therapy should not be used to
prolong vascular access patency in haemodialysis patients. Class III recommendation; Level of evidence C
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16 Vascular Access forHaemodialysis
• Recommendation 45: It is recommended that vascular access surveillance is per-
formed by ow measurement of arteriovenous grafts monthly and arteriovenous
stulas every 3months. Class I recommendation; Level of evidence B
• Recommendation 46: When arteriovenous stula blood ow measurements dur-
ing dialysis indicate the presence of a vascular access stenosis based on an access
blood ow <500ml/min, angiographic assessment of the access should be considered. Class IIa recommendation; Level of evidence B
Late vascular access complications
• Recommendation 52: Surgical revision of vascular access aneurysms is recom-
mended if cannulation sites and access diameter can be preserved. Class I recommendation; Level of evidence C
• Recommendation 53: Surgical revision of pseudoaneurysms in arteriovenous
grafts is recommended when the aneurysm: limits the availability of cannulation
sites or is associated with pain, poor scar formation, spontaneous bleeding and
rapid expansion. Class I recommendation; Level of evidence C
• Recommendation 54: Stent graft exclusion of vascular access aneurysms may be
considered in selected patients. Class IIb recommendation; Level of evidence C
• Recommendation 60: Balloon angioplasty is recommended as primary treatment
for inow arterial stenosis of any type of vascular access. Class I recommendation; Level of evidence C
• Recommendation 61: Surgical proximal relocation of the vascular access anasto-
mosis should be considered in juxta-anastomotic stenosis in the forearm. Class
IIa recommendation; Level of evidence C
• Recommendation 62: Balloon angioplasty is recommended for the treatment of
venous outow stenosis. Class I recommendation; Level of evidence C
• Recommendation 63: Endovascular treatment with stent grafts should be consid-
ered for the treatment of cephalic arch stenosis. Class IIa recommendation; Level
of evidence B
• Recommendation 66: After creation of a vascular access, evaluation of persistent
arm oedema by stulography or computed tomographic angiography is recommended to evaluate ipsilateral central venous outow. Class I recommendation;
Level of evidence C
• Recommendation 67: Balloon angioplasty as primary treatment of symptomatic
central venous outow disease is recommended, with repeat interventions if
indicated. Class I recommendation; Level of evidence C
• Recommendation 68: The use of stent grafts may be considered for the treatment
of central vein stenosis. Class IIb recommendation; Level of evidence C
• Recommendation 69: Stenting or repeat balloon angioplasty should be consid-
ered if there is signicant elastic recoil of the central vein after balloon angioplasty or if the stenosis recurs within 3months. Class IIa recommendation; Level
of evidence C
• Recommendation 70: In patients with symptomatic vascular access induced
extremity ischaemia with arterial inow stenosis balloon angioplasty should be
considered. Class IIa recommendation; Level of evidence C
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16.2 Results
16.2.1 Meta-Analyses andSystematic Reviews
16.2.1.1 Medical Adjuvant Treatment toIncrease Patency
ofArteriovenous Fistulae
In a Cochrane Review, various medical therapies were compared to placebo to measure the effect on the patency of arteriovenous stula (AVF) and prosthetic arteriovenous graft (AVG) for haemodialysis [2]. Thirteen studies with 2080 participants
were included. Medical adjuvant treatments used in the included trials were aspirin,
ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, sh oil, clopidogrel,
sulphinpyrazone and glyceryl trinitrate (GTN) patch. The meta-analyses of three
studies for ticlopidine, which all used the same dose of treatment but with a short
follow-up of only 1month, suggest ticlopidine may have a benecial effect as an
adjuvant treatment to increase the patency of AVFs and AVGs in the short term.
There was insufcient evidence to determine if there was a difference in graft
patency between placebo and other treatments.
16.2.1.2 Percutaneous Endovascular Arteriovenous Fistula
The rst approved by the US Food and Drug Administration, percutaneous AVF
(pAVF) systems were introduced in 2018 and include the Ellipsys
(Medtronic,Minneapolis, MN) and EverlinQ devices (BD, Murray Hill, NJ). The 6F
EverlinQ has been replaced by the second generation, 4F WavelinQ (BD) in 2019,
making Ellipsys and WavelinQ the two devices currently commercially available.
Bontinis etal. [3] performed a systematic review, followed by both aggregated data
and individual participant data (IPD) meta-analyses, to assess the short-term and
midterm safety and effectiveness of pAVF creation. Eighteen studies with 1863
patients were included. The overall pAVF, primary patency, secondary patency,
functional cannulation and abandonment rates were 54.01%, 87.27%, 79.94%, and
15.58%, respectively. The overall pAVF, technical success, maturation, reinterven-
tion per person-years and mean time to maturation rates were 97.08%, 82.13%,
0.80, and 58days, respectively. Secondary patency and pAVF abandonment rates
where the only end points were WavelinQ and Ellipsys displayed statistically signicant differences of 81.36% versus 92.12% and 32.54% versus 11.13%. An IPD
meta- analysis of hazard ratios for primary and secondary patency between pAVF
and surgical AVF (sAVF) were 1.27 (95% CI, 0.61–2.67) and 1.25 (95% CI,
0.87–1.80), favoring sAVF. Statistically signicant difference between pAVF and
sAVF were solely depicted for steal syndrome relative risk of 5.91 (95% CI,
1.12–31.12) and wound infections relative risk of 4.19 (95% CI, 1.04–16.88).
Percutaneous AVFs could potentially provide a viable alternative for a medical condition where surgery has failed to produce consistent results. Although this review
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