Proximal Radial Artery Ligation after Distalization of a High flow Brachio-Cephalic Fistula. A Novel Approach to Inflow Reduction

Abstract

High flow fistulae present a common challenge to vascular access (VA) surgeons and many strategies have been described, each with their benefits and limitations. There are no NK-DOQI guidelines for the management of high flow fistulae or indeed the management of those refractory to more conventional approaches. We discuss a novel technique to inflow reduction in a previously distalized brachiocephalic fistula and recommend the technique of proximal radial artery ligation.

A scoping review on surgical reduction of high flow arteriovenous haemodialysis access

“…Sixty-six articles encompassing 940 patients fulfilled study criteria (mean age 56 years [3–90], male 62%). 5,6,13,18–81…”

“…6,25 Some authors ignored Qa thresholds and executed Qa reduction when cardiac complaints or HAIDI were present. 44,62,75 One author stated that 'surgery was performed for high flow' but provided neither symptoms nor predefined threshold values. 46 Echocardiography supporting a decision of Qa reduction was used in 24 articles describing 381 patients (41%).…”

Proximal Radial Artery Ligation (PRAL) for Reduction of Flow in Autogenous Radial Cephalic Accesses for Haemodialysis

“…As an illustration, Smith and Calder recently reported a clear improvement in the cardiac status of a 32-year-old patient after ligation of the proximal radial artery in a brachial cephalic fistula whose high flow was insufficiently reduced after distalisation of the anastomosis to the upper radial artery by interposition of a piece of graft (450 ml/min after vs. 3 l/min before PRAL). 25 Aneurysmal degeneration with or without chronic venous hypertension is an emerging new indication. The majority of RCFs develop aneurysmal degeneration with time for several reasons: hyper-flow is almost the rule when no stenosis develops, repeated cannulations weaken the vein wall and outflow stenoses develop at the elbow or upper arm level.…”

The prognostic role of finger pressures and access flows in hemodialysis patients

“…For 21,61 Some authors ignored Q a complaints or HAIDI were present. 40,59,73 One author stated that 'surgery was 42…”

“…The access is perfused via the ulnar artery and the 75 Theoretically, a PRUL (proximal ulnar artery ligation) may be used if the ulnar Three articles reported on PRAL (n=31 patients, 55% male, mean age 45 ; table 4). 73,75,74 Q a -drop was 1 L/min (1.8 to 0.8 L/min). Complications were absent.…”