Chapter 20

### PATIENT STORY

A 78-year-old, right-hand-dominant man was diagnosed with end-stage renal disease. It was deemed that he would require lifetime hemodialysis. Venous mapping with Duplex ultrasound was performed in both upper extremities to locate suitable veins for dialysis access. Left proximal radial artery to cephalic vein arteriovenous fistula was created. Patient had an uneventful postoperative course. He demonstrated an excellent thrill and bruit throughout the course of fistula. He had palpable radial and ulnar pulses. Approximately 8 weeks later, the fistula was used for hemodialysis. The patient started complaining of pain in all the digits of the left hand and noticeable discoloration of the left hand during dialysis. His symptoms resolved completely upon discontinuing dialysis.

### DIAGNOSIS AND TREATMENT COURSE

• Photoplethysmography of the left hand digits showed diminished waveforms in all fingers of the left hand. The waveforms improved upon compression of the fistula (Figures 20-1 and 20-2).

• Duplex ultrasound examination of the fistula showed reversal of flow in the radial artery (Figures 20-3,20-4, and 20-5).

• Diagnostic arteriogram of the left upper extremity was performed that showed normal arterial vasculature of left upper extremity. Selective catheterization of the ulnar artery showed antegrade flow in the ulnar artery, filling of the palmar arch, and retrograde flow in the radial artery (Figure 20-6).

• The patient was brought to the operating room and under local anesthetic, the distal radial artery was ligated. He had dialysis after the procedure and had no further symptoms of digit ischemia during dialysis.

###### FIGURE 20-1

Plethysmographic waveforms of left second and fifth digits with and without compression of arteriovenous fistula showing improvement in perfusion with compression of the fistula.

###### FIGURE 20-2

Plethysmographic waveforms of the right thumb with and without compression of the arteriovenous fistula showing improvement in perfusion with compression of the fistula.

###### FIGURE 20-3

Direction of blood flow across the anastomosis into the proximal and distal cephalic vein (blue arrows). Reversal of blood flow in the artery distal to the anastomosis is shown by the red arrow.

###### FIGURE 20-4

Arterial duplex ultrasound study showing the anastomosis (blue arrow).

###### FIGURE 20-5

Arterial duplex ultrasound study: antegrade flow in radial artery (red color). Retrograde flow in ulnar artery (blue color). The anastomosis is indicated by the blue arrow.

###### FIGURE 20-6

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

## Subscription Options

### AccessCardiology Full Site: One-Year Subscription

Connect to the full suite of AccessCardiology content and resources including textbooks such as Hurst's the Heart and Cardiology Clinical Questions, a unique library of multimedia, including heart imaging, an integrated drug database, and more.