Tag Archives: dialysis access

Print Release, Vascular Surgery

PUBLISHED: Snuffbox Radiocephalic Arteriovenous Fistula Creation for End-Stage Kidney Disease

Snuffbox Radiocephalic Arteriovenous Fistula Creation for End-Stage Kidney Disease
Brett J. Salomon, MD1; Christopher Holden-Wingate2,3; Mohamad A. Hussain, MD, PhD1,2; C. Keith Ozaki, MD1
1Mass General Brigham
2Harvard Medical School
3University of Illinois College of Medicine

The snuffbox arteriovenous fistula (SBAVF) is a distal-first dialysis access strategy connecting the posterior branch of the radial artery and cephalic vein within the anatomical snuffbox to preserve proximal vascular sites for patients requiring long-term hemodialysis (HD). This low-flow forearm fistula, which represents only 4% of forearm access creations in a contemporary large registry, provides significant clinical advantages over high-flow alternatives. These benefits include a significantly lower risk of high-output heart failure (HOHF) and negligible rates of access-related hand ischemia (ARHI). Contemporary literature confirms that SBAVF offers primary and secondary patency rates comparable to wrist AVFs at 18 months, supporting a “snuffbox first” approach for eligible candidates.

This case details successful SBAVF creation in a 38-year-old male with end-stage kidney disease (ESKD), which was selected to maximize vessel preservation given his prolonged expected duration of HD. Postoperatively, the patient was discharged without complication and subsequently cleared to trial HD after successful maturation. Although it is common for SBAVFs to require adjunctive procedures and more time to achieve maturation, long-term durability (5–9 years) remains outstanding, reinforcing the value of this technically precise procedure as a safe and durable primary access option.

Print Release, Vascular Surgery

PUBLISHED: Fistulogram for a Cephalic Arch Aneurysm

Fistulogram for a Cephalic Arch Aneurysm
Tiffany R. Bellomo, MD1,2; Brett J. Salomon, MD1,2; Jonah Thomas, MD2; Anahita Dua, MD, MS, MBA, FACS1
1Massachusetts General Hospital
2Mass General Brigham

More than 100,000 arteriovenous fistulas (AVFs) are created annually in the United States, but are frequently complicated by venous outflow stenosis, aneurysm formation, and aneurysms that often require angiographic evaluation and intervention. Cephalic arch stenosis is a particularly common cause of dysfunction in brachiocephalic fistulas due to high flow. This is typically managed with fistulogram-guided angioplasty, although repeated interventions are associated with restenosis and access-related complications.

This article present the case of a 63-year-old, right-hand dominant male with end-stage renal disease secondary to glomerulonephritis on dialysis through a left upper extremity brachiocephalic AVF that was complicated by recurrent cephalic arch stenosis requiring multiple angioplasties, which ultimately resulted in the development of a cephalic arch aneurysm. Subsequent fistulograms demonstrated a high-grade stenosis that could not be traversed despite multiple attempts.

Comprehensive preoperative evaluation included focused history, physical examination, duplex ultrasound, and computed tomography venography. The fistulogram described in this article demonstrated a patent, high-flow AVF with a saccular aneurysm of the proximal cephalic vein measuring up to 28 mm without thrombus and no hemodynamically significant flow-limiting stenosis. Given the absence of flow limitation and the risk of compromising future access, stent placement was deferred.

This case highlights the importance of individualized decision-making in the management of complex AVF complications. Fistulograms serve as a critical diagnostic and therapeutic tool, allowing real-time assessment of anatomy and flow to guide intervention. In select patients, conservative endovascular management with surveillance may preserve access durability and delay the need for more invasive procedures.