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| CASE REPORT |
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| Year : 2021 | Volume
: 8
| Issue : 6 | Page : 178-180 |
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Novel use of forearm perforator in vascular access
T Krishna Prasad, Nayan J Timbadiya
Department of Urology, NU Hospitals, Bengaluru, Karnataka, India
| Date of Submission | 11-May-2021 |
| Date of Decision | 02-Aug-2021 |
| Date of Acceptance | 10-Aug-2021 |
| Date of Web Publication | 20-Jan-2022 |
Correspondence Address:
T Krishna Prasad
Department of Urology, NU Hospitals, Bengaluru, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijves.ijves_49_21
A 65-year-old male was initiated on hemodialysis through a radio-cephalic arteriovenous fistula. He required a proximal brachiocephalic fistula due to a failing radiocephalic fistula. Both fistulae could be functionalized simultaneously due to a forearm cephalic perforator vein. The radiocephalic fistula was subsequently ligated, allowing the patient to use the mature brachiocephalic fistula instead of a bridging temporary/tunneled catheter.
Keywords: Arteriovenous fistula, forearm, perforating vein
How to cite this article:
Prasad T K, Timbadiya NJ. Novel use of forearm perforator in vascular access. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:178-80 |
| Introduction | |  |
The use of perforator veins in vascular access if practiced is poorly documented. We report the use of a cephalic vein perforator in an existing radiocephalic fistula to provide adequate outflow while a simultaneous brachiocephalic fistula was created in the same limb.
| Case Report | | |
A 65-year-old male diagnosed to have chronic kidney disease (CKD) Stage III was referred for the creation of an arteriovenous fistula (AVF) impending initiation of hemodialysis.
He underwent clinical and ultrasound vein mapping evaluation of both his upper limbs. Having discussed the options of a brachio-basilic AVF (BB-AVF) on the left versus a right radiocephalic AVF (RC-AVF); the patient preferred the RC-AVF.
His ultrasound Doppler at 5 weeks' postoperative revealed cephalic vein diameters were 3.2–4.5 mm and the flows in the brachial artery (BA) was 553 ml/min. There was a stenotic lesion 75 mm from the anastomotic site measuring 15 mm × 1.9 mm. Eight weeks from the creation of the RC-AVF, he underwent an ultrasound-guided fistuloplasty. The stenotic lesion was dilated with an 18 mm × 4 mm balloon. The stenotic area postdilatation measured 2.7 mm, the BA flow had increased to 740 ml/min; however, the vein diameter continued to be in the range of 3.4–4.0 mm.
Dialysis was initiated though the fistula 12 weeks after creation when his clinical condition mandated the need for renal replacement therapy. Twenty weeks after creation of the RC-AVF, he was advised a review by the dialysis unit in view of significantly elevated dynamic venous pressures (in excess of 300 mmHg). A clinical examination revealed re-stenosis, an ultrasound confirmed the same findings. He underwent a second successful fistuloplasty of the lesion. 32 and 60 weeks after the creation of the RC-AVF, he was reviewed again for similar issues; was offered and accepted two further sessions of fistuloplasty.
At this point, the patient voiced a concern about repeated interventions and wished for a more durable access. He opted for the creation of another fistula proximally.
He was offered the option of the left BB-AVF, however preferred the fistula in the same limb wanting to preserve the functional use of his left upper limb and also wished to avoid a temporary/tunneled catheter. The option of a proximal mid-forearm RC-AVF was not favorable, as the stenotic segment was in the mid-forearm and would leave a very short cephalic vein in the forearm for cannulation. Particularly considering the longer length needed to reach the deeper radial artery in the forearm and excluding the juxta-anastomotic segment which would not be usable for needling in the normal course. In addition, such a short upper forearm segment when needled could lead to extravasation if the patient flexed his forearm during hemodialysis. Finally a brachiocephalic AVF (BC-AVF) of the same limb would not have been a an immediate option as the vein diameters were still inadequate and would need to some time to attain maturity and would need a bridging dialysis catheter, which the patient had refused.
A repeat ultrasound vein mapping of the right forearm, revealed that the cephalic vein of the forearm had both a deep communicating perforator to the radial vein just below the cubital fossa and also continued as the cephalic of the arm [Figure 1]. Taking advantage of this normal perforator, it was decided to create a proximal BC-AVF after disconnecting the cephalic cranial to the perforator [Figure 2]. He underwent the creation of the BC-AVF; on the table, the cephalic vein cranial to the perforator was clamped temporarily to ascertain that the RC-AVF would continue to have adequate flows once the cranial outflow was disconnected. The BA continued to have flows >500 ml/min after clamping; hence, the cephalic vein cranial to the perforator was divided to create the BC-AVF. Meanwhile, he continued to dialyze with the RC-AVF. Three weeks after surgery, an ultrasound revealed the cephalic vein diameter was >6 mm from the lower to upper arm [Figure 3]. The BA flow was 1900 ml/min. The BC-AVF was cannulated 21 days after it was created, and the RC-AVF was ligated 68 weeks after creation. | Figure 1: The cephalic of the forearm, with the cannulation areas and the site of the perforator vein (marked as-deep) and continuation of the vein into the arm. The dotted line marks the planned route of the divided cephalic to create the brachiocephalic fistula with the brachial artery (marked as - brachial artery)
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 | Figure 2: The cranial extension of the cephalic vein divided and anastomosed with the brachial artery to create the proximal brachiocephalic arterio-venous fistula
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 | Figure 3: At 3 weeks; simultaneously functioning radiocephalic arterio-venous fistula and the matured brachiocephalic arterio-venous fistula ready for early cannulation, with an adequate length of straight dilated vein
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The patient continued to use the BC-AVF, 60 weeks after, it was created with no intervention, flow, or pressure issues. The patient has not used a catheter for dialysis; which is currently 130 weeks from dialysis initiation till he moved to a different dialysis unit.
| Discussion | | |
Vascular access without the use of a catheter is the “gold standard” for any patient with CKD. For those patients who have been fortunate to get an AVF created before the initiation of hemodialysis; the challenge lies in avoiding catheters between the loss of one AVF to the creation and maturation of the next. With the reported primary patency of AVF in Indian literature being reported at 53%[1] in 2 years, there no doubt will be a period that patients with end-stage renal disease (ESRD) will be using bridging catheters between fistulae.
The way to avoid this is to monitor the current fistula and to create the next before the first one fails. The timing of this is obviously crucial to providing a catheter-free experience to the ESRD patient. However, it may also mean balancing the need for additional procedures (e.g., fistuloplasty) to keep the current fistula in a usable state versus early initiation of dialysis before the commonly accepted 4 weeks' period after fistula creation.
The venous drainage of the forearm skin and subcutaneous tissue occurs through the superficial and deep systems, with communicating perforators, the radial forearm-free flap uses this drainage pattern extensively and remains the workhorse of various reconstructive surgeries in plastic surgery.[2],[3],[4],[5] However, the role of the perforators in vascular access which is the most common vascular procedure in the forearm of an ESRD patient finds only a passing mention.[6]
Ten Berge et al.[6] mapped the location of the perforators in the cephalic, ulnar, and basilic veins and reported that the cephalic vein had 1.04–0.9 (mean) perforators to the radial venae comitans and interossea, respectively. They found that at least 1.3 (0–2; range) perforators had a diameter of >1.3 mm. They also, however, noted that the cephalic vein had fewer perforators when compared to the basilic vein. These veins obviously dilate in the case of a preexisting fistula allowing for simultaneous outflow into the cranial superficial system and the deep venous system.
This physiological process had caused dilatation of the perforators in our patient. This twin outflow was used to the advantage of the patient, in that it allowed for simultaneous fiatuale to be created with each having their own outflows.
The meticulous use of the ultrasound in mapping the anatomy of the fistula and understanding the outflow patterns allowed for a catheter-free experience for this patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Sahasrabudhe P, Dighe T, Panse N, Deshpande S, Jadhav A, Londhe S. Prospective long-term study of patency and outcomes of 505 arteriovenous fistulas in patients with chronic renal failure: Authors experience and review of literature. Indian J Plast Surg 2014;47:362-9.  [ PUBMED] [Full text] |
| 2. | Nakajima H, Imanishi N, Aiso S, Fujino T. Venous drainage of the radial forearm and anterior tibial reverse flow flaps: Anatomical and radiographic perfusion studies. Br J Plast Surg 1997;50:389-401. |
| 3. | Vathulya M, Ansari MS. An important superficial vein of the radial aspect of the forearm: An anatomical study. Indian J Plast Surg 2018;51:231-4. [Full text] |
| 4. | Golash A, Bera S, Bhaviya BS, Kanoi AV, Pai AA, Golash A. Clinical utility of the communicating vein in free radial artery forearm flaps: Best of both worlds. J Plast Reconstr Aesthet Surg 2019;72:1219-43. |
| 5. | Bai S, Xu ZF, Duan WY, Liu FY, Huang DH, Sun CF. Single superficial versus dual systems venous anastomoses in radial forearm free flap: A meta-analysis. PLoS One 2015;10:e0134805. |
| 6. | Ten Berge MG, Yo TI, Kerver A, de Smet AA, Kleinrensink GJ. Perforating veins: An anatomical approach to arteriovenous fistula performance in the forearm. Eur J Vasc Endovasc Surg 2011;42:103-6. |
[Figure 1], [Figure 2], [Figure 3]
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