Late Basilic Vein Superficialization Combined with Revision Using Distal Inflow (RUDI) Operation to Treat a Symptomatic High Flow Fistula

Abstract

BackgroundVascular access (VA)-related high flows (HF) are common with brachial artery based fistulas. Flow-reduction procedures are indicated in symptomatic patients or asymptomatic ones with flows >2 L/min. However concomitant issues increase their complexity. We describe a case of a patient suffering congestive heart failure as a result of HF brachial-basilic fistula >3 L/min. A simultaneous late basilic vein transposition and revision using distal inflow (RUDI) was performed. MethodsA large diameter untransposed arterialized basilic vein was carefully and completely mobilized up to the proximal upper arm. After harvesting an autologous great saphenous vein (GSV) segment, a new inflow anastomosis was performed in the proximal ulnar artery. At the final stage, and after tunneling the mobilizing basilic vein in a subcutaneous semicircular configuration, an end-to-end anastomosis joining the two stumps (basilic vein outflow portion and GSV inflow arterial portion) was performed. A decision-making process in order to reach this complex option is discussed. Results Access flow and cardiac output were greatly attenuated following our approach. After a mean follow-up of 9 months no VA complications were observed, with flow still detected below 2 L/min. All cardiac symptoms and ultrasound investigations improved. ConclusionMultiple VA issues including HF pose a risk for abandonment and a challenge for the vascular surgeon. An effort toward increasing the “upper extremity life span” is advised.