A Rare Complication of Arteriovenous Fistula – Access-related Hand Ischemia – Surgical Repair Done by Modification in Revision using Distal Inflow Technique

Background and Objective: Access Related Hand Ischemia (ARHI) is a rare but significant complication of arteriovenous (AV) fistulas used for hemodialysis. Various surgical techniques, including DRIL (Distal Revascularization with Interval Ligation), RUDI (Revision Using Distal Inflow), and PAI (Proximalisation of Arterial Inflow), exist to manage this condition. This case report describes a modification of the RUDI(Revision Using Distal Inflow) procedure, where a distal branch of the cephalic vein in the arm is used as a conduit, instead of a reversed saphenous vein graft. Methods: A patient presenting with ischemic symptoms secondary to a brachial artery-based AV fistula underwent a modified RUDI procedure. The technique involved using the distal branch of the cephalic vein as a conduit anastomosed to the radial artery to reduce access flow and restore distal hand perfusion. Postoperative assessment included arterial Doppler studies and clinical examination. Results: Postoperative Doppler on day 1 showed normalized flow in distal radial and ulnar arteries with a reduced fistula flow rate of 700 ml/min. Ischemic symptoms significantly improved immediately after surgery. The patient was discharged on day 4 and hemodialysis through the same AV fistula was resumed from day 15. Follow-up at two weeks revealed a decrease in aneurysmal dilatation of the forearm cephalic vein. Conclusion: The modified RUDI procedure effectively reduces high flow in AV fistulas and resolves ischemic complications in ARHI. This surgical approach, using a branch of the cephalic vein in arm, instead of using a reversed saphenous vein graft, provides symptomatic relief and preserves fistula functionality, representing a viable treatment option for ARHI. This approach can be considered in cases where traditional methods are inadequate or contraindicated.