Damar Cer Derg 2013;22(2)
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he autogenous arteriovenous fistula (AVF) at the wrist is considered as the best choice of vascular access (VA) in hemodialysis (HD)
pa-tients due to its low complication and high patency rates.1Comorbid
diseases affecting the vascular system such as diabetes mellitus and hyper-tension are frequently seen in elderly, which may reduce the success of cre-ation and maintenance of AVF. In end stage renal disease patients, VA becomes useless after a successful renal transplantation (RT). Following RT, there is no consensus about the fate of the AVF. Although the AVF may close spontaneously, the dilemma is whether to preserve the vascular access in case of restarting HD or perform a surgical closure concerning the
pos-sible complications.2In this case report, we present a young patient whose
radial AVF fistula was repaired due to low ulnar arterial flow at the upper extremity selected for HD access. We believe that, in such young patients, dual arterial blood flow to the extremity should be maintained if possible.
CASE REPORT
A 28-year-old patient had been operated for left radiocephalic side to side AVF formation three years before RT. Six months after RT, she was
admit-Repair of Radial Artery with Autogenous Cephalic
Vein Graft Interposition After Closure of
Arteriovenous Fistula in a Young
Renal Transplantation Patient: Case Report
AABBSS TTRRAACCTT Au to ge no us ar te ri o ve no us fis tu la at the wrist is con si de red as the best cho i ce of vascu lar ac cess in he mo di aly sis pa ti ents. In this ca se re port, we pre sent a yo ung re nal trans plant pa ti -ent who un der w-ent au to lo go us fis tu la ve in in ter po si ti on and clo su re of ar te ri o ve no us fis tu la to pro vi de con ti nu ity of the ra di al ar tery.
KKeeyy WWoorrddss:: Re nal di aly sis; ar te ri o ve no us fis tu la; kid ney trans plan ta ti on Ö
ÖZZEETT He mo di ya liz has ta la rın da el bi le ğin de açı lan oto log ar te ri yo ve nöz fis tül, vas kü ler eri şim için en iyi se çe nek ola rak dü şü nül mek te dir. Bu va ka su nu mun da, ra di yal ar te rin de vam lı lı ğı sağ la mak için oto log fis tül ven in ter po zis yo nu ya pı lan ve ar te ri ve nöz fis tü lü ka pa tı lan genç re nal trans plant -lı has ta tak dim edil miş tir.
AAnnaahh ttaarr KKee llii mmee lleerr:: Böb rek di ya li zi; ar te ri yo ve nöz fis tül; böb rek trans plan tas yo nu DDaammaarr CCeerr DDeerrgg 22001133;;2222((22))::225522--33
Arda ÖZYÜKSEL,a
Sinan Sabit KOCABEYOĞLU,b
Erdem ÇETİN,c Ertekin Utku ÜNALb
aClinic of Cardiovascular Surgery,
Medipol University Hospital, İstanbul
bClinic of Cardiovascular Surgery,
Türkiye Yüksek İhtisas Training and Research Hospital,
Ankara
cClinic of Cardiovascular Surgery,
Diyarbakır Memorial Hospital, Diyarbakır
Ge liş Ta ri hi/Re ce i ved: 31.12.2012 Ka bul Ta ri hi/Ac cep ted: 17.03.2013 Ya zış ma Ad re si/Cor res pon den ce: Sinan Sabit KOCABEYOĞLU Türkiye Yüksek İhtisas Training and Research Hospital,
Clinic of Cardiovascular Surgery, Ankara,
TÜRKİYE/TURKEY s4126k@yahoo.com.tr
doi: 10.9739/uvcd.2012-33404 Cop yright © 2013 by
Ulusal Vasküler Cerrahi Derneği
Damar Cer Derg 2013;22(2) 253 REPAIR OF RADIAL ARTERY WITH AUTOGENOUS CEPHALIC VEIN GRAFT INTERPOSITION... Arda ÖZYÜKSEL et al.
ted to our cli nic with swel ling and cya no sis of the left hand. The AVF had not be en used af ter RT. The re was pal pab le thrill and ane urysm for ma ti on at the si te of anas to mo sis. Left ul nar ar tery was we akly pal pab le, but ra di al ar tery dis tal to the AVF was not. The pa ti ent was comp la i ning abo ut isc he mic pa in at mo de ra te ef fort with that hand. Pre o pe ra ti ve Dopp -ler ul tra so nog raphy re ve a led ste no tic dis tal ra di al ar tery and bip ha sic low ul nar ar te ri al flow. The ane -urysm was 20x25 mm in di a me ter. The pa ti ent was ope ra ted un der lo cal anest he si a, the ane urysm was re sec ted and the AVF was clo sed. Ra di al ar tery segment in cor po ra ted in the anas to mo sis zo ne was ste -no tic wit ho ut dis tal run off. A ste -no tic seg ment of 3 cm si ze was re sec ted and back flow at the wrist le -vel was de tec ted. Cep ha lic ve in seg ment that was pre vi o usly used in AVF for ma ti on was in ter po sed bet we en the pro xi mal and dis tal ra di al ar tery (Fi gu -re 1). Dis tal ra di al ar tery was pal pab le af ter the anas-to mo sis was comp le ted. Pos anas-to pe ra ti ve co ur se was une vent ful. Dis tal ra di al ar tery was pal pab le one month af ter the ope ra ti on at fol low up.
DIS CUS SI ON
In this ca se of AVF clo su re af ter RT, ste no tic ra di -al ar tery seg ment which was in cor po ra ted in the anas to mo sis was re sec ted and ar te ri al con ti nu ity was pro vi ded with au to lo go us fis tu la ve in in ter po -si ti on. Du al ar te ri al blo od supply to the hand was ma in ta i ned in this yo ung pa ti ent.
Car di ac fa i lu re, high flow at the AVF, vas cu lar ac cess comp li ca ti ons and est he tic con cerns can be con si de red as the ma jor in di ca ti ons for AVF clo su re af ter RT with a well func ti o ning kid ney.2La te occur ren ce of ane urysms pro xi mal to ra di al ar tery ye -ars af ter clo su re of AVF has al so be en des cri bed.3In our pa ti ent, the ra di o cep ha lic si de to si de AVF led to swel ling and cya no sis of the dis tal ex tre mity. The pa-ti ent was al so comp la i ning abo ut isc he mic pa in at
mo de ra te ef fort with that hand, which was re la ted to in suf fi ci ent ul nar and col la te ral ar te ri al blo od flow to hand. Our pa ti ent had a his tory of su per fi ci al throm boph le bi tis of the lo wer ex tre mity, and sin ce the ope ra ti on was per for med un der lo cal anest he si -a, au to lo go us sap he no us ve in graft in ter po si ti on was im pos sib le. The re fo re we used the ar te ri a li zed seg-ment of the outf low ve in of AVF. The di sad van ta ge of this tech ni qu e co uld be the di a me ter mis match bet we en the cep ha lic ve in and ra di al ar tery, but we did not ca me ac ross a ma jor prob lem du ring the op-e ra ti on. Thop-e anop-e urysm for ma ti on did not al top-er thop-e ana to mi cal co ur se of ner ves sig ni fi cantly in the op-e ra ti vop-e fi op-eld. Any nop-e u ro lo gi cal prob lop-em was not op- en-co un te red in the pos to pe ra ti ve en-co ur se.
Alt ho ugh pri mary clo su re of the AVF and li g-a ti on of the pro xi mg-al g-and dis tg-al ends of the g-ar tery is a pos sib le cho i ce, we pre fer red pro vi ding the du al ar te ri al con ti nu ity of the hand, which is im por -tant es pe ci ally in yo ung pa ti ents with isc he mic signs and symptoms. Ca re ful cli ni cal eva lu a ti on of the pa ti ents may help to se lect pa ti ents for sur gi cal clo su re of AVF af ter RT.
C
Coonnfflliicctt ooff IInntteerreesstt
Authors declared no conflict of interest or financial sup-port.
FI GU RE 1: Ane urysm for ma ti on (black ar row) and dis tal ra di al ar tery seg ment (whi te ar row) is se en on the left si de. Cep ha lic ve in was in ter po sed bet we en the pro xi mal and dis tal ends of the ra di al ar tery (right si de).
1. Bres ci a MJ, Ci mi no JE, Ap pel K, Hur wich BJ. Chro nic ha e mo di aly sis using ve ni punc -tu re and a sur gi cally cre a ted ar te ri o ve no us fis tu la. N Engl J Med 1966;275(20):1089-92.
2. Man ca O, Pi sa no GL, Car ta P, Man ca EM, Pi red da GB, Pi li G, et al. The ma na ge ment of he mo di aly sis ar te ri o ve no us fis tu las in well func-ti o ning re nal trans plan ted pa func-ti ents: many do ubts, few cer ta in ti es. J Vasc Ac cess 2005;6(4):182-6.
3. Ba si le C, An to nel li M, Li but ti P, Te u to ni co A, Ca suc ci F, Lo mon te C. Is the re a link bet we en the la te oc cur ren ce of a brac hi al ar tery ane -urysm and the li ga ti on of an ar te ri o ve no us fis tu la? Se min Di al 2011;24(3):341-2.
