title: Consider use of a collateral venous circuit before abandoning the arteriovenous fistula--the experience of a complex vascular access case.
abstract: We describe a 65-year-old woman with diabetes on hemodialysis maintenance, with a number of complications associated with high-flow arteriovenous fistula (AVF, anastomosis between brachial artery and medial vein of the forearm) requiring an extended diagnostic and individual approach. The patient was admitted to our hospital because of pain, edema of the limb, hand ischemia, and infection caused by steal syndrome. To reduce fistula flow, banding of the proximal cephalic vein was performed. Simultaneously because of necrosis, amputation of the fifth finger was necessary. Following this procedure, the cephalic vein on the arm thrombosed. The fistula was patent through the collateral circuit, which was diagnosed in detail during the late course. A long course of antibiotics and sessions in a hyperbaric chamber allowed limb rescue. Single-needle dialysis was carried out because of problems in finding an appropriate second place. After an episode of bleeding from the puncture site caused by ulceration, we were forced to search for an alternative needling point. On the basis of ultrasound scans, an anatomic schema of the blood circuit was created. The fistula demonstrated flow from the brachial artery resulting in retrograde flow in the section of the cephalic vein distal to the anastomosis in the upper forearm. This was then seen to drain in an antegrade direction via the median vein of the forearm after the 2 vessels connected in the mid forearm. Using the diagram, 2 alternative places for needling were found and it allowed the adequate hemodialysis to be continued. Complex and complicated cases associated with native AVF could be resolved using simple diagnostic tools to preserve the fistula use for hemodialysis. Both clinical examination and ultrasound scan with the Doppler option appear to be valuable methods for finding the optimal cannulation place.
authors: Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland. Electronic address: tgolebiowski@op.pl.
authors: Tomasz
authors: T
authors: Gołębiowski
authors: Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
authors: Mariusz
authors: M
authors: Kusztal
authors: Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
authors: Ewa
authors: E
authors: Wątorek
authors: Department of Radiology, Wroclaw Medical University, Wroclaw, Poland.
authors: Jerzy
authors: J
authors: Garcarek
authors: Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
authors: Krzysztof
authors: K
authors: Letachowicz
authors: Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
authors: Wacław
authors: W
authors: Weyde
authors: Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
authors: Marian
authors: M
authors: Klinger
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000379:methods*; D001916:Brachial Artery / Q000601:surgery*; D005260:Female; D006801:Humans; D012039:Regional Blood Flow; D006435:Renal Dialysis; D012086:Reoperation; D018608:Ultrasonography, Doppler; D014656:Vascular Surgical Procedures / Q000379:methods*; D014680:Veins / Q000601:surgery*