The intraoperative intravascular lithotripsy to recruit a calcified radial artery for creating a distal radio-cephalic fistula

Abstract

Guidelines for vascular access recommend that the distal autogenous arteriovenous fistula (AVF) should be the first choice-access procedure for patients starting dialysis. Arteriosclerosis of radial artery may cause early failure, as well as failure of maturation of distal arteriovenous fistulas. To increase the incidence of distal AVFs, our team, specialized in vascular access surgery from 2004 onwards, has introduced Intraoperative Transluminal Angioplasty (ITA) under ultrasound (UG) or fluoroscopic guidance, to recruit inadequate arterials for creating distal fistulas. Intravascular lithotripsy (IL) is a novel approach to treat luminal and medial calcifications in patients with peripheral arterial disease and coronary disease. We believe that intraoperative IL may be an opportunity to recruit calcified radial arteries for creating distal radio-cephalic fistulas. Purpose of this study is to describe the intraoperative IL technical applied in our clinical experience. A 37-year-old diabetic patient with distal radio-cephalic fistula was recruited for the first IL experience. One year ago, a wrist radio-cephalic fistula was created in the right upper limb, with intraoperative UG radial artery angioplasty for extensive calcifications. The fistula was functioning but showed a delay in maturation. An angioplasty was unsuccessfully attempted to facilitate the maturation. Subsequently, a surgical revision of the fistula was performed, creating a new anastomosis immediately upstream of the previous one by performing an intraoperative IL UG of the radial artery. The fistula was immediately well functioning, and was cannulated with two needles after 1 month. It is currently being used with intradialytic adequate blood flow. The positive outcome of the case described in this paper, even if only anecdotal, could act as a trigger for further experiences with IL.