Impaired maturation of arteriovenous fistula for haemodialysis due to forearm artery stenosis: percutaneous endovascular treatment.

INTRODUCTION: Distal autogenous arteriovenous fistula (dAVF), considered the "gold standard" vascular access for haemodialysis, suffers from a high rate of impaired maturation. One of the usual causes is low-flow associated forearm arterial stenosis. In such cases, endovascular treatment by percutaneous transluminal angioplasty represents a helpful option to enable maturation of the vascular access.Currently, there are few reports concerning the treatment of this complication. Therefore, we describe our single-centre experience based on a retrospective review of prospectively collected data. PATIENTS AND METHODS: We treated 18 consecutive patients from July 2007 to January 2014 (16 radio-cephalic, 2 ulno-basilic distal AVF). A low flow due to forearm artery stenosis was diagnosed by duplex examination, as routinely performed one month after dAVF creation. An anterograde trans-brachial access was used for a 4-mm high-pressure angioplasty of the stenosed artery. RESULTS: All interventions resulted in patent fistulas. Isolated percutaneous transluminal angioplasty (PTA) was required without need of stent placement. Mean blood flow increased from 304 mL/min, preoperatively, to 671 mL/min (p<0.01), as checked one week after the procedure. One-year primary and secondary patency were 84% ±7.3% and 92% ± 9.2%, respectively. Under no circumstances did access-induced distal ischemia occurred during follow-up. CONCLUSIONS: Endovascular approach is a helpful and minimally invasive procedure for treatment of delayed maturation of dAVF related to forearm artery stenosis.

Preoperative duplex examination in patients with dialysis access-related hand ischemia: indication for distal radial artery ligation.

PURPOSE: To demonstrate that treatment with distal radial artery ligation (DRAL), based on preoperative evaluation with duplex ultrasound, is effective for correction of hand ischemia related to distal radiocephalic arteriovenous fistula (AVF). METHODS: Two patients with symptoms of hemodialysis access-induced distal ischemia (HAIDI) related to radiocephalic AVF at wrist (necrotic lesion of fingers, pain at rest and loss of sensory function) were studied with preoperative duplex examination. Color Doppler ultrasound (CDU) showed low-normal flux (700 and 500 mL/min respectively), retrograde flow in the DRA and increased digital perfusion after manual occlusion of DRA. They were both treated by ligation of the DRA. RESULTS: Both patients had immediate improvement of ischemic symptoms. Reversed DRA flow disappeared and peripheral flow ameliorated. Postoperative AVF flow was 500 and 350 mL/min, stable at 16 and 8 months of follow-up, respectively. CONCLUSIONS: Preoperative CDU examination, simulating reversed DRA flow interruption, seems to be an effective tool to predict the success of DRAL procedure.