The thrombosed brachial-cephalic fistula used for renal dialysis--a cautionary note

Arteriovenous fistulae (AVF) are commonly required for dialysis prior to renal transplantation, and are subsequently left insitu, even if thrombosed. The authors present one of two patients in whom progressive digital ischaemia occurred, and was initially overlooked, many years following formation of an AVF. The patient was surgically explored and clot protruding from the thrombosed vein into the brachial artery was noted. The arterial defect was closed with a vein patch and histological examination of the fistula confirmed clot. The patient recovered satisfactorily and remained well 6 months postoperatively. The authors would suggest that embolisation from a thrombosed AVF does occur, has a significant morbidity and can lead to digital loss. Furthermore, transplant patients are usually long suffering and will often put up with what they describe as 'aches and pains' as part of their illness. The authors suggest those patients suffering with evidence of ischaemia warrant excision of the fistula.