Prompt Identification and Intervention for Ischemic Monomelic Neuropathy in Preventing Major Patient Disability.

Abstract

Ischemic monomelic neuropathy (IMN) is a rare complication of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs). Diagnosis of the condition is often delayed, with debilitating outcomes for patients. We present two cases of IMN in which prompt identification and intervention prevented major disability. The first case involved an 84-year-old female who underwent a left upper extremity brachioaxillary AVG. The procedure was performed under local anesthesia and a 4 - 7 mm tapered PTFE Propaten graft was used. At the conclusion of the case, a palpable radial artery pulse was noted. In the post-anesthesia care unit (PACU), the patient had ipsilateral increasing arm and hand pain. On exam, the patient had a cool left hand with a 2+ radial pulse. The patient was taken back to the operating room and the AVG was ligated with repair of the brachial artery. The second case involved a 64-year-old male who underwent a single-staged right brachiobasilic AVF with transposition. Surgery was performed with local and regional block. At case completion, the patient was noted to have a palpable radial pulse. In the PACU, patient had increased pain and paralysis to the right hand. Patient's right hand had complete paralysis of the fingers and reported severe forearm pain. Within 10 min of fistula ligation under local anesthesia, his symptoms resolved. We present two cases involving different arteriovenous access conduits. The time from procedure completion to reported onset of symptoms was approximately 260 min, and time from symptoms onset to surgical incision was 70 min. Early recognition, diagnosis, and management of IMN in these cases protected patients from major long-term morbidity. Owing to this pathology, post-op observation protocols and even re-admission protocols should be set after hemodialysis access creation in order to avoid delays in diagnosis and patient disability.