The fistula elevation procedure: a valuable technique for maximizing arteriovenous fistula utilization

Area of Science:

• Vascular Surgery
• Nephrology
• Dialysis Access

Background:

• Many patients are unsuitable for radiocephalic fistula (RCF) or brachiocephalic fistula (BCF) creation due to deep or tortuous cephalic veins.
• Limited vein length can preclude basilic vein transposition (BVT) for subcutaneous tunneling.
• Arteriovenous fistula (AVF) maturation and accessibility remain significant challenges in hemodialysis access.

Purpose of the Study:

• To introduce and evaluate the fistula elevation procedure (FEP) as an adjunctive technique to enhance AVF accessibility.
• To improve the utilization of AVFs that are otherwise difficult to cannulate for dialysis.
• To determine the efficacy of FEP in salvaging fistulas not amenable to standard cannulation.

Main Methods:

• The fistula elevation procedure (FEP) involves fistula mobilization, subcutaneous tissue approximation, and subcuticular skin closure.
• FEP aims to create a more superficial fistula position for easier needle access.
• The procedure was performed adjunctively in 45 patients with challenging AVFs (BCF, RCF, BVT) between June 1998 and January 2001.

Main Results:

• FEP successfully salvaged 45 natural AVFs that were previously inaccessible due to depth, tortuosity, or length.
• The procedure facilitated needle cannulation by creating a superficial fistula and a guiding cicatrix.
• FEP was applied to brachiocephalic fistulas (20), radiocephalic fistulas (7), and basilic vein transpositions (8).

Conclusions:

• The fistula elevation procedure (FEP) is a simple and effective method to enhance AVF accessibility for dialysis needle cannulation.
• FEP significantly increases AVF utilization, particularly in challenging cases such as obese patients.
• This adjunctive technique offers a valuable solution for improving hemodialysis access in a broader patient population.