The utility of fluoroscopic venography during arteriovenous access creation for hemodialysis: A case report.

Rationale: As the end-stage kidney disease (ESKD) population requiring vascular access for hemodialysis continues to grow, the Kidney Disease Outcomes Quality Initiative guidelines emphasize vessel preservation to ensure viability for future access. Preoperative ultrasound is commonly performed prior to arteriovenous (AV) access creation when available. However, its major limitation is the restricted imaging range, which impedes visualization of the complete vascular network. This study highlights the importance of reconsidering fluoroscopic venography as a complementary tool to ultrasound for improving AV access planning.

Patient Concerns: A man in his late forties and a septuagenarian woman with ESKD underwent AV access creation surgery for ongoing hemodialysis.

Diagnoses: The surgical plans could not be determined solely based on preoperative ultrasound findings. In Patient 1, AV access using an artificial graft with the brachial artery as the inflow and the brachial vein as the outflow in a forearm loop configuration was considered as the primary option. In Patient 2, the cephalic vein drainage was unclear with ultrasound due to the clavicle.

Interventions: The operation was performed with a transverse incision just below the elbow. Before the anastomosis, we conducted intraoperative fluoroscopic venography through the surgically exposed median cubital vein using a small amount of diluted contrast media to assess the overall venous drainage system in the upper arm.

Outcomes: The initial surgical plans based on ultrasound findings were modified through intraoperative fluoroscopic venography. In Patient 1, the distal anastomosis was redirected to the median cubital vein, thereby preserving the deep vein. In Patient 2, fluoroscopic venography enabled the successful creation of AV access using an autologous vein instead of a graft by directly visualizing the cephalic vein drainage. At early follow-up, both accesses achieved successful maturation; however, long-term outcomes could not be fully assessed, and no access-related complications were observed during the observation period.

Lessons: Intraoperative fluoroscopic venography allowed for more precise AV access planning by providing real-time visualization of venous anatomy. This approach can facilitate intraoperative decision-making and help expand access options for ESKD patients while preserving future options.