A 45-year-old male patient, formerly hypertensive, who had been involved in an automobile accident 17 years previously, was diagnosed with hemothorax and underwent thoracotomy and tracheostomy. He remained in the intensive care unit for 105 days, during which period he was given nephrotoxic antibiotics, and developed chronic renal failure. He had a brachiocephalic AVF in the left arm, which developed increased flow after 10 years, with ulcers on the fourth and fifth fingers and dorsum of the left hand (\n), causing pain that limited manual activities.\nVascular Doppler ultrasonography of the AVF showed a patent anastomosis. Arterial flow was normal from the brachial artery to the radial and ulnar arteries () and flow direction, systolic and diastolic velocity, resistance indices and other echographic features were all incompatible with venous access steal syndrome.\nThe diagnosis made according to clinical signs and supplementary echographic details was therefore venous hypertension due to occlusion of the vein in the arm providing return (the cephalic) and overdevelopment of the descending collateral (). The AVF flow diverted through the collateral branch was 446 mL/min, reaching 2,763 mL/min at the level of the wrist ().\nHaving detected the complication in course, the patient underwent an examination with mapping to detect the best site to construct a new AVF, which was a superficialized right brachiobasilic fistula. The patient continued receiving dialysis via the AVF in the left upper limb until the new AVF had matured, and it was not necessary to insert a catheter.\nAfter maturation of the AVF, the tributary in the left limb was ligated and sectioned at the most proximal point possible (in the elbow). Edema had improved and the finger ulcers started to heal within 1 week of the operation. The patient returned to the clinic in the second week, with the ulcers already healed. At follow-up, 2 months after discharge, function in the left hand had already been recovered (). The right brachiobasilic fistula had good thrill and flow during hemodialysis, and only a darker coloration of the right limb remained.
A 49-year-old man underwent catheter ablation for drug-refractory atrial fibrillation using right femoral access. A 3-French sheath was placed in the right CFA, and an 8-French sheath was placed in the right FV during the catheterization. After the procedure, he developed swelling around the puncture site, and a bruit was audible in the right groin on auscultation. An AVF was detected by color Doppler ultrasound (Figure ). Ultrasound-guided compression was attempted but was unsuccessful. Enhanced computed tomography (CT) showed an MCFA originating from the CFA that crossed anterior to the FV and an arteriovenous communication (Figure ).\nExpecting spontaneous resolution, the patient was initially treated conservatively. After six months of follow-up, the AVF did not disappear on ultrasonography, and he suffered recurrence of atrial fibrillation. Considering the risk of future cardiac complications due to sustained volume overload, surgical intervention was performed. Surgical exploration revealed a dilated MCFA that crossed anterior to the FV (Figure ).\nThe MCFA was attached to the FV, and thrill was present. Ligation of the AVF was performed. A completion angiogram demonstrated successful closure of the AVF (Figure ).\nThe postoperative course was uneventful, and the patient was discharged on postoperative day 4.