A modified approach of proximalization of arterial inflow technique for hand ischemia in patients with matured basilic and cephalic veins.

OBJECTIVE: Proximalization of arteriovenous inflow (PAI) is an established technique for treating patients with access-induced hand ischemia. However, a prosthetic graft, used as arterial inflow, could minimize the benefits of a purely native fistula. In this study, a new PAI technique is reported, which avoids the use of prosthetic grafts in patients with matured basilic and cephalic veins.

PATIENTS AND METHODS: Eight patients (seven men, one woman; mean age 62 (45-82) years old) with grade III/IV critical dialysis access-related ischemia (DARI) and with a pre-existing Gracz fistula underwent an operation using modified PAI. The basilic and cephalic veins were preoperatively matured. During the operation, the former arteriovenous anastomosis was closed and the basilic vein was used as arterial inflow.

RESULTS: All procedures were technically successful. All patients but one could be discharged with a warm, neurologically improved extremity with a significant reduction in pain. After a mean follow-up of 43.5 (0-52) months, there were no recurrent steal symptoms and all necrotic hand lesions healed. Two patients died during the follow-up, but with well-functioning fistulae. One fistula failed during follow-up and one further fistula was ligated because of chronic neurological damage, which was not improved after the PAI procedure. Four AVFs are still available for hemodialysis.

CONCLUSIONS: The modification of the PAI technique with a basilic vein as presented here showed similar results to the original PAI procedure. This new procedure does not require prosthetic grafts as in the original PAI technique or a central venous catheter and leads to the enlargement of the puncture site as a result of the superficialization of the basilic vein. Therefore, it is believed that this new technique could be a good option for those patients with matured cephalic and basilic veins who suffer from severe access-related ischemia.