In this article, we present a patient who developed hand ischemia following the creation of a left brachiobasilic AVF and subsequently underwent a RUDI procedure, resulting in significant improvement of the ischemic symptoms.

Figure 1. Widespread ulceration and coldness, particularly on the dorsal surfaces of the second and third fingertips.

Manual compression of the AVF improved capillary refill, raised hand temperature, and relieved pain. After evaluation, the patient was diagnosed with VA-related ischemia. Under ultrasound guidance, the BB AVF, as well as the brachial, radial, and ulnar arteries, were evaluated. Given the patient’s clinical condition, a RUDI procedure was planned.

On the day of surgery, preoperative vascular mapping of the upper and lower extremity vessels was performed under sterile operating room conditions. Under local anesthesia, a left antecubital incision was made to identify the radial artery and BB AVF, which was isolated using a vessel loop. Simultaneously, an autologous graft measuring approximately 4 to 5 cm in length and 5 mm in diameter was harvested from the left saphenous vein. The segment of the basilic vein near the anastomosis of the existing BB AVF was ligated. The harvested saphenous vein graft was interposed between the proximal radial artery and the basilic vein using end-to-side anastomoses (Figure 2). Functionality of the newly created fistula was confirmed by a positive thrill test. Following hemostasis, anatomical closure of the layers was performed. Two hours postoperatively, the patient was evaluated in the cardiovascular surgery ward and reported improvement in fingertip pain. Her general condition and vital signs remained stable, and the patient was discharged the same day. At the two-week postoperative follow-up in the cardiovascular surgery outpatient clinic, hand warming was noted, and ischemic symptoms, particularly the ulcers, resolved. In the early postoperative period, at one-month follow-up, the graft was evaluated by our team using Doppler ultrasound and was found to be patent (Figure 3). The patient was subsequently followed by our team for approximately six months after the procedure. During this follow-up period, the ischemic symptoms had completely resolved (Figure 4). Written informed consent was obtained from the patient.

Figure 2. Perioperative image. The saphenous vein graft was interposed between the proximal radial artery and the basilic vein using end-to-side anastomoses.

Figure 3. The patient on postoperative Day 10. Significant improvement in ischemic findings was observed, including resolution of ulcer tension.

Figure 4. Postoperative ultrasonographic evaluation confirmed maintained patency of the saphenous vein.

Ischemia related to AVF formation is a significant complication which can lead to limb loss, if not promptly managed. Various surgical strategies have been developed to address this issue, including AVF ligation, banding, DRIL, PAI, and RUDI.[3] While banding and ligation are effective in relieving symptoms, their primary limitation lies in the sacrifice of VA. Some authors propose that multiple moderate stenoses created by sequential banding may be preferable to a single tight band; however, this still remains controversial.[3]

The DRIL procedure, involving ligation of the artery distal to the AVF anastomosis and creation of a bypass from a more proximal arterial source, preserves access while restoring distal perfusion. Despite a reported secondary patency rate of up to 80%, DRIL is technically complex, typically requires general anesthesia, and carries a 10 to 20% risk of incision-related complications.[4] Additionally, limb perfusion becomes entirely dependent on bypass graft patency, potentially compromising limb viability.

The PAI involves redirecting arterial inflow to the AVF from the axillary artery, which offers higher flow and pressure. This technique reduces the steal phenomenon and preserves distal perfusion through collateral branches. However, its reliance on prosthetic grafts increases infection risk and lowers long-term patency rates.[5]

The RUDI, a relatively novel technique, involves relocating the AVF inflow to a more distal artery, most often the proximal radial artery, using an interposed graft. This approach is particularly suited for high-flow, proximally located AVFs. Autologous vein grafts (e.g., saphenous, cephalic, or basilic) are preferred over prosthetic materials due to superior patency, reduced infection risk, and cost-effectiveness.

In the present case, considering the patient’s advanced age and proximal AVF anatomy, the RUDI procedure was selected. In this patient, the AVF flow rate was high (1600 mL/min), and, therefore, the banding technique was deemed inappropriate. In patients with high-flow AVFs, the degree of stenosis created by ligature during the banding procedure may be difficult to titrate accurately. In some cases, the AVF may become non-functional, while in others, insufficient tightening of the ligature may fail to resolve the ischemic symptoms. Therefore, the RUDI procedure was considered a more suitable option for this patient. Compared to DRIL, RUDI offers several advantages, including higher AVF flow rates and lower risk of postoperative bleeding, while maintaining similar patency and symptom resolution outcomes. A recent review reported that RUDI resulted in ischemic symptom resolution in approximately 82% of cases, with AVF function preserved for a median of one year.

In conclusion, upper extremity ischemia is a rare but clinically significant complication following the creation of an arteriovenous fistula (AVF) in hemodialysis patients. Early diagnosis and timely intervention are crucial for optimal outcomes. In clinical practice, several surgical techniques are available to manage AVF-related hand ischemia, including RUDI, PAI, DRIL, and banding. Each of these methods has its own advantages and limitations. Therefore, the choice of surgical approach should be individualized based on the patient's overall condition, the anatomical characteristics of the fistula (as assessed by ultrasonography), and the severity of ischemia.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: All authors contributed equally to this article.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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2) Henriksson AE, Bergqvist D. Steal syndrome after brachiocephalic fistula for vascular access: Correction with a new simple surgical technique. J Vasc Access 2004;5:13-5. doi: 10.1177/112972980400500103.

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