Dear Nephrolors':

We recently had a discussion as to what to do when a fistula develops with aberrant drainage down the arm instead of up.  I thought everyone might like to see how this can be used in revising the drainage in a fistula by interventional, non-surgical   techniques.

The patient presented with a painful shoulder.  He had a left upper arm fistula which was 6 months old.  On exam the fistula was patent from the elbow to the middle of the biceps.  Above that was a hard cord for about
4 to 6 cm. and then nothing. pic #1 and #2 demonstrate the drainage as I first found it on angiography.  The arrows demonstrate the direction of flow.  The flow went up the arm to the level of the biceps (#1) and then turned 180 degrees south towards the elbow.  In #2 you see (follow the arrows) how the drainage went down to below the antecubital fossa and then spread into multiple channels.  The fistula was very hyper-pulsatile clinically and I feared the whole access would clot if left alone.  I was able to get a wire around all of this and actually up to the central circulation and therefore I felt we could potentially create a useable channel. #3 illustrates an 8 mm balloon in the fistula over the wire.  This photo demonstrates how tight some of the strictures were (see the waists on the left half of the balloon).  These areas were present in pretty much the entire drainage. I am leaving out the majority of the technical details. If anyone is interested I will be happy to provide them.  The original channel was so small (tight) that the wire and balloons occluded it to the point that significant clot formed and flow stopped. #4 demonstrates the clot which shows up as filling defects within the dark areas of contrast.  I proceeded to occlude the channel with a balloon inflated deep in the outflow and laid 1.25 mg of tPA throughout the area of clot and manually "kneaded" the fistula.  I also heparinized the patient.  #5 demonstrates the final result.  Again the flow goes down to the right below the elbow and then in a big circle up the basilic system to the central circulation.  Please note that the collateral channels that were seen on #2 have disappeared.  This was  accomplished without ligating any vessels. Thus it demonstrates my contention that if one simply dilates and creates a main channel, the flow will go into it preferentially, making ligation often not necessary.

Let me know if you have questions.  As always comments are welcome.  I hope this was enjoyable and educational.

Don

Donald Schon, MD, FACP
LifeLine Vascular Lab
Phoenix, AZ