The transposed forearm loop arteriovenous fistula: A valuable option for primary hemodialysis access in diabetic patients

The distal forearm is the site of first choice for creation of an arteriovenous fistula for hemodialysis. The archetypal procedure, the primary radial-cephalic fistula as described by Brescia, yields excellent functional patency for many patients. Results are much less favorable in patients with diabetes mellitus, for whom non-maturation rates as high as 70% have been reported. This is likely due to inadequate inflow caused by atherosclerotic disease of the forearm arteries in diabetics. Secondary autologous access procedures often involve upper arm configurations such as transposed brachial-basilic fistulas. The present study focuses on a valuable alternative for hemodialysis access in diabetic patients, the transposed forearm loop arteriovenous fistula. Over a 2-year period, 16 forearm loop fistulas were created in 16 diabetic patients who either had a failed radial-cephalic fistula or had arterial anatomy deemed inadequate for wrist fistula formation. In each case, the forearm segment of the basilic or cephalic vein was transposed to form a U-shaped loop and anastomosed to the brachial, proximal radial, or proximal ulnar artery distal to the antecubitai fossa. Functional patency was defined as usability for dialysis. Patency rates were calculated by Kaplan-Meier survival analysis. From our results we determined that the forearm loop fistula is an excellent but underutilized technique that exploits the forearm veins while circumventing the distal arterial supply, thus preserving the upper arm vasculature for future use.