Radial Artery Harvest: A Potential Cause of ArteriovenousAccess-Associated Hand Ischemia

Arif Asif,* Gary Siskin,* Vishesh Kumar,* Syed S Haqqie,* Roy O Mathew,* ShouwenWang,‡ Ali Nayer,† Donna Merrill,* and Loay Salman†*Albany Medical College and Veterans Affairs Medical Center, Albany, NY, †University of Miami MillerSchool of Medical, Miami, FL, and ‡Arizona Kidney Disease and Hypertension Center, Phoenix, AZ

ABSTRACT

Hand ischemia has multiple causes. In this article, wereport an additional factor that can induce hand ischemiain hemodialysis patients. A 64-year-old white man withcoronary artery disease underwent a coronary arterybypass graft procedure using the left radial artery as thebypass graft. Several months later, a left extremity Graczfistula was created for arteriovenous access. Ever sincedialysis was performed via the fistula the patient has expe-rienced a cold hand and pain during dialysis that wassomewhat relieved by wearing a woolen glove while ondialysis. Absence of the radial artery in the context of anipsilateral arteriovenous access was highlighted as a possi-

ble etiology. A complete arteriography to determine thepresence of stenoses, distal arteriopathy, and true stealwas recommended, but the patient refused to undergo anyinvestigation or procedure and instead decided to con-tinue wearing the glove during the treatment. A plan forclose follow-up and possible interventions in the event ofworsening pain/ulceration was agreed upon. Radial arteryharvest can result in hand ischemia if an ipsilateralarteriovenous access is created. We suggest that thecontralateral extremity should be considered if anarteriovenous access is required to minimize this risk ofthis phenomenon.

Distal hypoperfusion ischemic syndrome (DHIS)is an important complication in patients receivinglong-term hemodialysis using an arteriovenousaccess (1). DHIS typically manifests as hand pain(on and off dialysis) and less frequently as loss ofdistal function and tissue death. The pathophysio-logic mechanisms governing DHIS are complexand poorly understood. Whereas shunting of bloodto a low-resistance area (arteriovenous access)resulting in hypoperfusion distal to the anastomosishas been suggested to be the cause, increased resis-tance to blood flow offered by the presence ofarterial stenosis as well as distal arteriopathy(vascular calcification) observed in end-stage renaldisease patients can also play critical roles in thepathogenesis of DHIS (1–6). In this report, wepresent a case wherein harvesting of a radial arteryfor coronary artery bypass grafting might haveplaced the patient at increased risk for developingDHIS.

Case Report

A 64-year-old white man was seen during dialysisrounds for a painful, cold hand while on dialysis.The symptoms occurred only during hemodialysis.He had been wearing a glove on the hand, whichhelped with reducing his symptoms. The patientwas diagnosed with end-stage renal disease due tohypertension and diabetes and had been receivingchronic hemodialysis therapy for the past 9 months.Two years before presentation, he was diagnosedwith coronary artery disease and had undergone acoronary artery bypass grafting procedure. At thattime, the left radial artery was harvested and usedas a conduit for the bypass procedure. As soon asthe patient was started on hemodialysis with atunneled dialysis catheter, he was referred for arte-riovenous fistula creation. A left upper extremityGracz fistula was created (Fig. 1 A). After2 months, dialysis was performed with the fistula.Since that time, however, the patient reported acold hand and pain during dialysis therapy thatwas somewhat relieved by wearing a woolen glovewhile on dialysis (Fig. 1 B).On average blood flow rates during this patient’s

dialysis sessions have been in the range of 450 cc/min. The arterial pressure has been between 150and 190 mmHg and venous pressure has ranged

Address correspondence to: Arif Asif, MD, FASN, FNKF.,Professor and Chief: Division of Nephrology and Hyperten-sion, Albany Medical College, 25 Hacket Blvd, Albany, NY12208, Tel.: +518-262-0769, or e-mail: AsifA@mail.amc.edu.

Seminars in Dialysis—Vol 26, No 3 (May–June) 2013 pp.E17–E19DOI: 10.1111/sdi.12084© 2013 Wiley Periodicals, Inc.

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Case Report

from 160 to 180 mmHg. Examination of the armrevealed a left upper extremity Gracz fistula. A lon-gitudinal scar was noted on the volar aspect of theforearm where the radial artery was harvested(Fig. 1 A, B). Careful inspection of the hand andfingers did not reveal any ulcers or skin break.There was no atrophy of the thenar or hypothenareminence (compared to the contralateral side). Pal-pation revealed a colder hand compared with thecontralateral side. Radial and ulnar arterial pulsa-tion was absent on the affected extremity. Occlusionof the fistula did not result in ulnar pulsation. Thecapillary refill was 2–3 seconds in the fingers. Sen-sory motor functions of the hand were intact andthere was no deformity or evidence of joint diseaseor carpal tunnel syndrome. There was no evidenceof mega (serpentine) fistula. The diameter of thefistula was noted to be approximately 1 cm (mea-sured from the skin with a ruler). On palpation andauscultation the venous outflow from the fistula wasthrough the basilic vein in the upper arm. Here,there was a soft pulse that was associated with acontinuous thrill. The access augmented well onaugmentation and demonstrated near-total collapsewith arm elevation. The cephalic vein in the upperarm ended in a stump with no discernible pulse,thrill, or bruit indicating no flow through thecephalic system.

A detailed discussion regarding possible evalua-tion and intervention was held with the patient.However, he did not want to undergo any investiga-tion or procedure at that point in time and pre-ferred to continue wearing the glove duringhemodialysis treatment. Options and description ofdiagnostic possibilities and their impact on the handwere discussed and documented. Ultimately, a plan

for close follow-up was agreed upon and possibleintervention would be considered if the pain wors-ened or if ulceration of the fingers occurred. It wasalso highlighted that evaluation would be conductedif the patient gave permission to do so at any time.Patient was advised not to use the left hand fingersfor blood sugar assessment.

Discussion

Existing data have emphasized the role of arterialsteal, arterial stenoses, and distal arteriopathy in thepathogenesis of DHIS (1–7). However, the indexcase presented in this report demonstrates an addi-tional factor that is capable of increasing the risk ofhand ischemia. Radial artery harvesting is under-taken in patients where this artery is used as a graftin the event that coronary artery bypass is required.In such a situation, the blood supply to the hand isusually maintained by the ulnar artery. In mostcases this situation does not result in symptoms.The evidence for this notion comes from the well-established observation that a great majority ofpatients with radial-cephalic (forearm) fistulae donot develop hand ischemia despite the fact that inmost of these patients, flow is diverted toward thelow-resistance fistula and not the hand itself (8,9).In other words, the antegrade flow in the radialartery does not contribute immensely to flowtoward the hand (8,9). In addition, a great majorityof radial-cephalic fistulae demonstrate retrogradeflow in the radial artery distal to the anastomosis(8). In such patients hand ischemia would onlydevelop if the existing ulnar artery suffered fromstenosis or vascular calcification. It is worth men-tioning that both the conditions have been reportedto exist in the dialysis population and can ultimatelycause hand ischemia (7,10).The current case is important from the standpoint

that it demonstrates an additional contrivance(radial artery harvesting) that can increase the riskof hand ischemia. The creation of brachial-arterybased arteriovenous access in such patients has thepotential to divert flow to the fistula and limit flowdistal to the anastomosis. Because there is only oneartery mainly responsible for hand supply in thesepatients, ischemia could potentially ensue even with-out the presence of a mega fistula stealing excessiveflow from the brachial artery (7). Nevertheless, oneshould ask how this might be different in the pres-ence of both ulnar and radial arteries. Would flownot be limited distal to the anastomosis if two fore-arm arteries were present? Because of the lack ofstudies determining distal flow in patients with twoversus one forearm artery it is hard to comment onthis point. However, it is conceivable that removinga major collateral route of flow to the hand (i.e.,the radial artery) would roughly double the periph-eral resistance and facilitate flow into the low-resistance arteriovenous fistula. The presence ofstenosis and/or vascular calcification in the ulnar

Fig. 1. (A) Patient receiving dialysis through a Gracz fistula.

The basilic outflow was patent while the cephalic outflow did not

have any flow. A long scar on the anterior surface of radial

artery harvest was seen (arrows). (B) Patient is wearing woolen

glove to combat cold hand.

E18 Asif et al.

artery would further compromise flow to the hand.It is important to emphasize that vascular calcifica-tion in end-stage renal disease is not an uncommonscenario (7).

What should be the management strategy forthis situation? Although uncommon the conditionrequires a plan to avoid devastating consequencesof hand ischemia such as loss of fingers, tissuenecrosis, or loss of hand function. In the presenceof upper arm arteriovenous access and handischemia we still would first recommend a goodphysical examination with careful attention to thepresence of capillary refill, pulse and the presenceof any ischemic ulcers as the first step in theevaluation of these symptoms. A complete arterio-gram should be undertaken from the aortic archto the Palmar arch to discern the presence of ste-nosis or distal arteriopathy (vascular calcification).Angiography must also focus on the presence ofsteal into the fistula. Determination of the size ofthe anastomosis (mega anastomosis) and flowquantitation in the fistula should also be a part ofthis examination. An arteriogram with and withoutocclusion of the arteriovenous access should beperformed as well to assess the anatomy of flowto the forearm.

Once the arteriogram has been completed, angio-plasty should be considered in the presence of arte-rial stenosis or stenoses amenable to a percutaneousintervention. In the presence of mineral metabolismdysregulation (vascular calcification) and diabetesan optimal control of calcium, phosphate, and glu-cose are desirable with the understanding that suchabnormalities might not be entirely reversible. Insituations where stenosis is not amenable or unre-sponsive to angioplasty, progression of symptomsto ulceration and tissue necrosis should prompt seri-ous consideration of surgery (including access liga-tion) to avoid ongoing ischemia and its devastatingconsequences. In the presence of true steal, a proce-dure that limits the flow into the fistula should beconsidered. A scenario that is particular to a Graczfistula is worth considering here. In such fistulaeboth upper arm basilic and cephalic vein can serveas outflow tracks. In this context, true steal fromthe artery is likely. However, this was not the situa-tion in this case as outflow was through the basilicvein. Nevertheless, flow-limiting procedures couldinclude surgical interventions or a minimally inva-sive limited ligation endoluminal-assisted revisionprocedure to combat a true arterial steal (11). It isprudent to have a strategy where flow determinationis performed while the limitation of flow is intensi-fied to avoid access thrombosis. In this context, wesuggest that a simple ultrasound be used while abanding procedure is performed to obtain optimalresults. Finally, proximalization of the arterialinflow can also be used as a strategy to amelioratehand ischemia.

Because the radial artery is not an uncommonartery to be harvested for coronary bypass grafting,it is important to contemplate the development ofDHIS subsequent to the creation of an arteriove-nous access in the same extremity. We believe thatan extremity where the radial artery has alreadybeen harvested should be approached very carefullyfor arteriovenous access creation. In this scenariowe suggest access creation contralateral to theextremity that is devoid of the radial artery. Vascu-lar calcification as well as arterial stenoses areprevalent in this population and a single artery(ulnar) may jeopardize blood flow to the hand. Itwould therefore be prudent to use the contralateralside for access creation. We also suggest that vascu-lar mapping, particularly arterial evaluation usingduplex ultrasound, should be strongly consideredbefore creation of AV access; this should include anassessment of vascular calcification, diameter,stenoses, flow, pulse wave analysis, and reactivehyperemia. A complete discussion with the patient,surgeons, nephrologists, and interventionalists mightbe needed to optimally address access creation insuch patients.

Acknowledgments

This project is not supported by any grants or fundingagencies.

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