Unusual Autologous Access Options

This chapter reviews the indications, techniques, and outcomes of unusual or uncommonly performed autologous hemodialysis accesses. Guidelines recommend the distal forearm ulnar artery-basilic vein AVF be in the algorithm for access construction after failure (or consideration of) distal forearm radiocephalic AVF. It is rarely constructed, because it is felt to be technically more difficult to perform than the radiocephalic AVF and thought incorrectly that second stage transposition is needed routinely. Loop forearm AVF is done when distal forearm arteries provide inadequate inflow. Loop upper arm AVF is used to prevent or correct steal syndrome. When the upper arm cephalic or basilic vein is unavailable, brachial vein AVF should be considered but requires two stages, and the technique is more demanding than the transposed brachiobasilic AVF. Outcomes are similar to those after graft placement, but this access carries less infection risk. Reverse and/or bidirectional flow can expand fistula options in some cases. In rare situations when central vein obstruction is uncorrectable, serious steal is unavoidable, or heart failure cannot tolerate any increase in cardiac output, superficialization of vessels for cannulation or an arterioarterial graft can be considered. Technical adjuncts including bifurcation advancement, translocation, use of saphenous vein, spiral and panel vein grafts, and fistula after failed graft are discussed.