LAUSR

An endovascular approach to arteriovenous fistula (AVF) creation has increasingly gained acceptance over the last years as an alternative to the conventional surgical method. There are currently two technologies available for this purpose, the Ellipsys Vascular Access System (Avenu Medical, San Juan Capistrano, Calif) and the Wavelinq endoAVF System (BD Medical, Franklin Lakes, NJ). Based on our previous experience in percutaneous venous arterialization procedures using “off-the-shelf” conventional devices in patients with no-option critical limb ischaemia, we decided to perform a percutaneous AVF for hemodialysis in the upper limb of an 82-year-old patient with endstage renal failure who refused open surgical procedures. Preoperative ultrasound examination confirmed an adequate configuration of the perforator vein overlaying the brachial artery. Under local anesthesia, ultrasound-guided access in the basilic vein and radial artery was achieved and a 4F sheath (Cook Medical, Bloomington, Ind) was inserted in both access. Two 5-mm Gooseneck-Snare (eV3 Covidien/Medtronic,Minneapolis,Minn)wereadvanced through the sheaths, up to the level of the antecubital fossa. Once the two elements were aligned, a fluoroscopic view that overlapped both snares fully open was obtained. A 21G needle was advanced percutaneously (under fluoroscopy), toward and through the snare loops. A 0.014-inch guidewire (Terumo, Ann Arbor, Mich) was then inserted through the needle. The arterial snare was withdrawn maintaining the guidewire entrapped inside so that the wire could be externalized through the radial access. The venous snare was also closed and retrieved. Over this through-and-through crossover wire, a 3.5 40mm balloon catheter (Armada; Abbott, Chicago, Ill) was progressed and angioplasty of the AV anastomosis was performed (A and B). To confirm adequate venous runoff of the AVF, 2 mL of contrast medium was injected from the arterial sheath. No leakage was observed at the level of the anastomosis and an excellent drainage of the AVF through both the cephalic and basilic veins was verified (C/Cover). The fistula was first used 4 weeks after its creation with access flow at the brachial artery of 645 mL/min and no further interventions have been required to date. The patient consented to publish this case report and the accompanying images. A Supplementary Video is available showing the complete maneuver.