Proximal Radial Artery Arteriovenous Fistulae

An arteriovenous fistula (AVF) is the preferred method for providing hemodialysis vascular access. A radiocephalic (RC) AVF remains the first choice when adequate vessels are available. The authors’ next option and most common AVF is a proximal radial artery (PRA) based fistula. A PRA-AVF offers many of the important benefits of a RC-AVF including moderate access flow with dramatically lower risks of hand ischemia or arm edema, fewer access aneurysms, lower risk of access associated cardiac issues, and likely lower incidence of cephalic arch stenosis when compared to brachial artery based AVFs. The anterior position and mobility of the PRA are important technical factors and superficial venous structures in the cubital fossa generally include multiple AVF outflow opportunities. The deep communicating vein (DCV) is often a convenient bridge from the PRA to the targeted superficial venous system. Importantly, the DCV, if not used for PRA-AVF construction, must be ligated to avoid AVF flow into the deep venous system. Establishing bidirectional flow with a reverse venous outflow forearm segment is often possible. The surgeon’s duplex ultrasound (DUS) examination is a key element for identifying these opportunities. Follow-up includes physical and DUS examinations until reliable cannulation is established. Initial cannulation is generally expected 4–6 weeks post-operatively. If the PRA-AVF is not mature or nearing maturation in that time period, a fistulagram is obtained with intervention as indicated. In a study of 1396 consecutive new patients, the authors reported primary and cumulative functional patency rates of 60% and 93% at 12 months and 47% and 91% at 24 months, respectively, with few complications.