title: The difficult hemodialysis access extremity: proximal radial arteriovenous fistulas and the role of angioscopy and valvulotomes.
abstract: BACKGROUND
  Native arteriovenous (AV) fistulas (NAVF) offer significantly lower risks than grafts or catheters. Individuals with a difficult access extremity (DAE) are often viewed as unsuitable for NAVFs. The proximal radial artery (PRA) NAVF offers a safe and reliable opportunity for a direct fistula in most patients, and we find it an important surgical option in the DAE.
  
  
  METHODS
  Consecutive vascular access operations were reviewed to find individuals with DAE. We defined the DAE patient group as those individuals where a wrist (Cimino) or upper arm brachiocephalic NAVF was not possible or was predicted to fail.
  
  
  RESULTS
  Preoperative physical and ultrasound examinations identified 58 individuals with DAE. Mean age was 56 years (range 11 to 87), 34 were female, 29 were diabetic, and 27 had previous access surgery. NAVFs were constructed in all patients. No grafts were utilized. Forty-six patients had a PRA NAVF constructed. NAVF patency was 91%. Twenty-three patients required retrograde angioscopy or passage of a valvulotome to gain forearm access. Twenty-one of these 23 individuals maintained an open NAVF segment in the forearm.
  
  
  CONCLUSIONS
  NAVFs were constructed in all patients. PRA NAVFs play an important role in extending hemodialysis by NAVF for this difficult patient group. Forearm access is often possible in these patients and may be successfully augmented by angioscopy or valvulotomes.
authors.affiliation: Department of Surgery, The University of Oklahoma College of Medicine, Tulsa, 4502 E. 41st St., Tulsa, OK 74135-2512, USA.
authors.forename: Justin K
authors.initials: JK
authors.lastname: Roberts
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Sideman
authors.forename: William C
authors.initials: WC
authors.lastname: Jennings
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017546:Angioscopy; D001166:Arteriovenous Shunt, Surgical / Q000379:methods*; D001916:Brachial Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D002404:Catheterization; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012189:Retrospective Studies; D014463:Ultrasonography