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 64-year-old male patient had been treated by HD in the last 5 years via right brachiocephalic fistula (BCF). He presented with gradually increasing painful swelling of the right upper limb, a sign of VH. He was evaluated with CT angiography and documented to have right internal jugular vein (IJV) stenosis with extensive collaterals in upper limb [].\nUnder all aseptic precautions, right IJV access was secured with 7 Fr sheaths. 5 Fr KMP catheter was used to negotiate across the IJV stenosis over a guide wire. A 10 mm × 40 mm balloon dilator was deployed across the stenosis and dilatation done. 14 mm × 40 mm self-expandable stent was passed across the stenosis. Poststent check angiogram revealed few collaterals still persisting around the stenotic site []. The AVF was cannulated via radial artery and fistulogram done revealing multiple stenosis along the whole length of the cephalic vein which were dilated sequentially from central to the peripheral. The venogram revealed persistent stenosis in IJV proximal to the level of the stent already in situ. Another 14 mm × 40 mm self-expandable stent was deployed proximal to the first one and final check angiogram revealed good direct flow in central vein []. AE of the peripheral collaterals near the anastomotic site was also done to give a further advantage.