ASDIN Clinical Case Focus Timing of Secondary Arteriovenous Fistula Creation Avoids Tunneled Catheter Placement Tushar J. Vachharajani,*† Naveen K. Atray,† Sarjit Gill,‡ Gazi Zibari,‡ and Kenneth D. Abreo† *Dialysis Access Group of Wake Forest University, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, Departments of †Nephrology and ‡Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana ABSTRACT The concept of secondary arteriovenous fistula, though not novel, is seldom practiced for lack of initiative or hesitancy in deciding the appropriate timing to abandon the existing access. We report a case illustrating the benefits of implementing the strategy in an elderly diabetic dialysis patient, successfully avoiding a tunneled cuffed catheter placement. Case Mr. D is a 62-year-old gentleman who has end-stage renal failure secondary to long-standing diabetes mel- litus and hypertension. His other comorbidities include chronic obstructive lung disease, coronary artery disease with congestive heart failure, and peripheral vascular disease. He was initiated on hemodialysis via a left fore- arm looped transposed cephalic vein arteriovenous fis- tula (AVF) (forearm cephalic vein to brachial artery) as shown in Fig. 1. The patient required angioplasty for his juxta-anastomotic stenosis 4 months after initiating dial- ysis as shown in Fig. 2. He presented with a thrombosed fistula 2 months after his first intervention with recur- rence of the lesion. During the thrombectomy procedure the draining cephalic and basilic veins in the upper arm were found to be well developed and without any pathol- ogy as shown in Fig. 3. As the juxta-anastomotic stenosis had recurred in a relatively short interval, the long-term survival of this AVF was deemed to be poor. A proactive decision to create a secondary AVF was made by the vascular access team. As shown in Fig. 4, a new fistula was created with a side to side anastomosis between the brachial artery and the cephalic vein in the upper arm leaving the existing forearm loop fistula intact. The new brachio-cephalic AVF was ready for use Brachial artery Juxta-anastamotic Stenosis Fig. 2. Recurrent juxta-anastomotic stenosis. Address correspondence to: Tushar J. Vachharajani, MD, FASN, FACP, Section of Nephrology, Dialysis Access Group of Wake Forest University, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, or e-mail: tvachhar@wfubmc.edu. Seminars in Dialysis—Vol 21, No 4 (July–August) 2008 pp. 364–366 DOI: 10.1111/j.1525-139X.2008.00448.x ª 2008 Copyright the Authors. Journal compilation ª 2008 Wiley Periodicals, Inc. Fig. 1. Transposed forearm cephalic loop arteriovenous fistula (dotted line) with arterialized upper arm cephalic vein (solid line). 364