Arteriovenous fistula in functional motor disability

  1. Shakti Swarup Sarangi ,
  2. Vikram Singh ,
  3. Deepak Prakash Bhirud and
  4. Arjun Singh Sandhu
  1. Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
  1. Correspondence to Dr Deepak Prakash Bhirud; deepakprakashbhirud05@gmail.com

Publication history

Accepted:01 Feb 2023
First published:07 Feb 2023
Online issue publication:07 Feb 2023

Case reports

Case reports are not necessarily evidence-based in the same way that the other content on BMJ Best Practice is. They should not be relied on to guide clinical practice. Please check the date of publication.

Abstract

Arteriovenous fistula (AVF) is the preferred route for vascular access in patients with chronic kidney disease on maintenance haemodialysis. Many studies have demonstrated the positive effects of perioperative hand exercise on fistula maturation. Here, we present our experience of radio cephalic AVF creation in patients with neuromuscular disorders who had difficulty performing isometric hand exercises. We created AVF in three patients with neurological disorders. First patient had essential tremor, which created difficulty during hand exercises and surgery while the other two patients had right hemiparesis. Perioperative isometric exercises have been shown to help in maturation of AVF. Due to neurological involvement, our patients had difficulty performing hand exercises. All had successful AVF despite taking longer than usual time to mature. Creation of AVF in neuromuscular diseases is feasible. A preoperative Doppler ultrasound to assess the vessels might help in making an informed decision. This might spare such patients the only functional arm.

Background

Arteriovenous fistula (AVF) is the preferred route for vascular access in patients with chronic kidney disease (CKD) on maintenance haemodialysis (HD). AVF is far superior than vascular catheter-based access in terms of infection rate and period of usage. For many patients living with CKD who are waiting for transplant or in whom transplant is not an option, AVF becomes the lifeline to survive. The radio cephalic-AVF (RC-AVF) has very high failure rate as noted by one meta-analysis.1 Several studies have shown the positive effects of perioperative hand exercise on fistula maturation rate.2 3 Here, we present our experience of three cases of RC-AVF creation in patients with functional motor disability.

Case presentation

Case 1: A male patient in his 40s was diagnosed to have CKD and was initiated on maintenance HD 3 months ago. He was referred to us for the creation of RC-AVF. The patient had hypertension and essential tremors. The tremor was intermittent and mild, but it interfered with isometric hand exercises. The patient also had a history of infection from neckline insertion.

Case 2: Male patient in his 50s was diagnosed with CKD 2 years ago. He initially had hypertension and later right hemiparesis following a stroke 2 years ago. At that time, he was diagnosed to have CKD stage 3 during evaluation. His renal function deteriorated gradually over the next 2 years and was started on HD. He was referred for AVF creation. At the time of the presentation, the patient was doing his daily routine with the help of left hand as his dominant (right) hand was rendered weak following the stroke. His right upper limb had motor function of 3/5 power with partial flexion deformity. The patient was unable to perform isometric exercises with the right hand.

Case 3: Female patient in her late 60s was diagnosed with CKD 8 months ago. She had history of stroke and right sided hemiparesis 6 months ago. She was a right dominant person and like the previous case she was doing her daily routine with left arm with minimal motor function remaining on the right side (3/5).

Investigations

Case 1: The patient was evaluated with Doppler ultrasound and found to have radial artery diameter of 2.3 mm on the non-dominant (left) side and cephalic vein diameter of 2.2 mm.

Case 2: Colour Doppler study of right arm showed radial artery diameter of 2 mm and cephalic vein diameter of size 1.8 mm.

Case 3: Doppler of her radial artery and cephalic vein showed diameters of 2 mm each.

Differential diagnosis

No relevant differential diagnosis with respect to these cases.

Treatment

Case 1: He was planned for left RC-AVF and intraoperatively there were tremors which created nuisance during the surgery, especially made the suturing difficult. It was managed by one assistant manually restraining the left forearm for the period of surgery.

Case 2: He was explained the chances of failure in the right arm and the possibility of creating the AVF in his only working left arm. The patient chose right forearm for AVF creation. He was operated on the right side and RC-AVF was created. Intraoperatively both the vessels were normal in wall thickness although being on the lower end of diameter spectrum, as the minimum diameter of cephalic vein we considered for RC -AVF creation is 1.5 mm.

Case 3: The patient underwent right AV fistula creation and she had an uneventful recovery. Intraoperatively, narrow calibre vein and artery were present.

Outcome and follow-up

Case 1: Postsurgery, the patient had a working fistula in left hand and HD was started after 6 weeks of surgery.

Case 2: The patient had an uneventful recovery. His fistula slowly matured and was ready for dialysis after 8 weeks of creation with a flow rate of >250 mL/min.

Case 3: Patient’s AV fistula matured slowly and dialysis was started after 8 weeks.

Discussion

Feldman et al demonstrated that cerebrovascular accidents are poor prognostic indicators for AVF maturation.4 Perioperative isometric exercises have been shown to help in maturation of AVF.2 3 Due to neurological involvement, our cases had difficulty in doing hand exercises. The second and third cases were met with difficult circumstance as disuse atrophy following neurological disorders not only affects the muscles, but also the vessels of the affected limb. A study on effect of paralysis on blood vessels observed that following flaccid paralysis, intimal hyperplasia of arterial wall leads to decrease in blood flow in the affected limb.5 Two of our patients had spastic hemiparesis. In our cases, we did not encounter any intimal hyperplasia, although the vessels being of smaller size. This can be attributed to some residual power left in the affected limb. Considering all these information, the chances of a successful AVF creation seemed low. However, considering the patients had only single functional upper limb, decision was made to create AVF on the affected limb after discussing the risks and benefits with the patients. There have also not been many cases of AVF creation in neuromuscular disorders. We could only find one more case report of a similar case.6 The authors had created a successful AVF in a patient with hemiplegia and deformed upper limb similar to our cases.

Learning points

  • Creation of arteriovenous fistula (AVF) is feasible in limbs involved by neuromuscular diseases, although the chances of success might decrease as the patient cannot perform isometric hand exercises.

  • The AVF may take longer than usual to mature in patients of functional motor disability.

  • A preoperative Doppler ultrasound to assess the vessel diameter, vessel wall thickness and blood flow might help in making an informed decision.

  • Creation of AVF in hemiplegic/hemiparetic limb will spare the only functional limb.

Ethics statements

Patient consent for publication

Footnotes

  • Contributors VS: planning, conduct, reporting, conception and design, acquisition of data or analysis and interpretation of data. SSS: planning, conduct, reporting, conception and design, and interpretation of data. DPB: planning, conduct, reporting, conception and design. ASS: planning, conduct, reporting, conception and design.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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