Treatment experience of a patient with critical upper limb ischemia undergoing program hemodialysis: case report

The number of patients with end-stage renal disease (ESRD) undergoing programmed hemodialysis remains high worldwide. Over time, the formation of an arteriovenous fistula increases the risks of access loss due to the progression of anastomosis stenosis, stenosis of the diversion vein, and pathology of the major arteries in the upper limb. These factors, individually or in in combination, can lead to adequate hemodialysis and fistula thrombosis.

We present a successful clinical case of treatment of a long-term hemodialysis patient with type 2 diabetes mellitus who developed vascular access pathology leading to critical ischemia of the right upper limb and progression of necrosis of the 3^rd, 4^th and 5^th fingers of the right hand. Given the extent of vascular involvement, the patient’s constitutional characteristics, and associated comorbidities, a minimally invasive intervention was deemed the appropriated course of action. The patient underwent balloon angioplasty with stenting of the diverting vein, as well as endovascular correction of both the subclavian artery and the arteriovenous fistula anastomosis. The patient was discharged on postoperative 4th day in satisfactory condition. A follow-up ultrasound confirmed the proper functioning of the reconstructed vascular segments and the arteriovenous fistula. The patient was referred again on the 47^th day of the postoperative period. On postoperative day 47, the patient was re-evaluated and reported no pain. A necrectomy of the distal phalanx of the 3^rd finger of the right hand was performed, while the 4^th and 5^th fingers showed no signs of trophic changes. Program hemodialysis was successfully continued through the fistula, with no pathology detected in the access zone. The case highlights the safety and efficacy of minimally invasive interventions in managing patients with concurrent major arterial disease and dialysis access complications. However, further studies and clinical observations are needed to establish a standardized treatment algorithm and facilitate its widespread implementation in clinical practice.

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