Proximalization of arteriovenous inflow as native loop utilizing the upper arm basilic and forearm cephalic veins for the treatment of hemodialysis access induced hand ischemia

BACKGROUND: Up to 10% of hemodialysis patients with an arteriovenous fistula (AVF) suffer hemodialysis access induced distal ischemia (HAIDI). We report a treatment option of HAIDI by proximalization of arterial inflow (PAI) to the axillary artery as native upper arm loop and salvaging the matured forearm cephalic vein after previous creation of a radio-cephalic AVF (RCAVF). METHODS: A 79-years-old multimorbid male patient with end-stage kidney disease presented with an elsewhere placed left-sided RCAVF. With the start of cannulations, the patient suffered severe HAIDI. Due to the low/normal AVF-flow of 550 ml/min, a PAI procedure using the matured forearm cephalic and upper arm basilic veins in a form of native upper arm loop was performed. RESULTS: Patient's symptoms resolved postoperatively with successful cannulations and tunneled dialysis catheter removal after 5 weeks. During a follow-up period of 64 months, several interventions were performed to maintain the patency, yet the AVF remained patent for >5 years. CONCLUSIONS: This modified PAI technique using native vessels in form of upper arm loop graft is a feasible and durable option to maintain long-term cumulative patency and should be considered as a valid native treatment option for HAIDI.