Brachio-Cubital Fasciotomy for Resistant Stenosis of Arterio-Venous Fistula

Abstract

Purpose: Radio-cephalic arterio-venous fistula can become dysfunctional due to venous outflow stenosis along its course. When the median cubital and the upper arm cephalic vein are small or obliterated, all the forearm cephalic vein blood flow can go through the perforating deep median vein into the brachial vena comitans. These deeply located veins, when dilated, become compressed by the overlying antecubital fascia and bicipital aponeurosis. These ensuing stenoses are usually resistant to endovascular balloon dilatation angioplasty or recur rapidly afterwards. Brachio-cubital fasciotomy was utilized to help relieve the compression and salvage the access. Methods:For the confirmed resistant stenoses of the AVF, open fasciotomy was performed along the medial aspect of the antecubital fossa. Endovascular angioplasty of the stenotic lesions was accomplished in conjunction with vascular skeletonization while the balloon was inflated inside the AVF. Results:Nineteen patients recognized to have resistant stenoses of their AVF underwent brachio-cubital fasciotomy. Through the fasciotomy, stenoses were resolved and intra-access pressure reduced to satisfactory levels in all patients. Three patients required resection of the constricted segment and reanastomosis of the mobilized fistula in addition to the fasciotomy. At the follow-up observation of minimum 9 months, all but one of the rescued stenotic lesions stayed patent and required no further intervention. Conclusions:Radio-cephalic arterio-venous fistula can become dysfunctional due to the development of outflow stenosis from compression by overlying fascia and this stenosis is usually resistant to the dilatation angioplasty. Brachio-cubital fasciotomy resolves these stenoses successfully and allows complete angioplasty with vascular skeletonization and open revision if required.