Technical note: An alternative method for AV access superficialization

Introduction: An arteriovenous fistulae for dialysis access is only functional if superficial enough for reliable cannulation. We describe a previously unreported technique to superficialize arteriovenous fistulae too deep for reliable cannulation. Method: The path of the fistula is marked using ultrasound, and three to four transverse incisions are made along this path. The subcutaneous tissue is separated from the dermis over this entire area. The fistula is then accessed through transverse incisions and by dividing the overlying adipose tissue. The mobilized vein is then “trapped” directly under the dermis by closing the superficial fascia and adipose tissue beneath it and using this tissue to elevate the fistula. No anastomotic revisions are necessary, and moderate straightening can be performed. Results: We have performed this procedure on 20 patients with 100% technical success. One fistula had thrombosis within 8–10 weeks of the superficialization procedure and one patient refused access due to pain, but all other fistulas were successfully cannulated. Two patients were lost to follow-up, and one patient developed skin breakdown in the area of the flap which delayed cannulation. Our 3-month patency was 94.4% with a functional patency, defined as a clinically patent fistula successfully being used for hemodialysis, of 87.5%. Conclusion: The technique described allows elevation of the vein to the level of the dermis without division and re-anastomosis or re-tunneling, through several small incisions maintaining virgin skin and normal contour for easier cannulation.