Fistulization of brachial artery transposition to a deep vein: Overcoming return vein failure in a severely access-challenged hemodialysis patient

Introduction: Brachial artery transposition (BAT) is a valuable tertiary vascular access (VA) option for hemodialysis (HD) patients at high risk of prosthetic graft/catheter infection. The primary limitation of BAT, however, is its dependence on a superficial vein for blood return, which frequently fails due to repeated cannulation. Case presentation: A 74-year-old female HD patient with a history of recurrent AVG infections presented with severe difficulty continuing dialysis due to the occlusion and thrombosis of her BAT’s return vein. Conventional VA options, including a new AVG or a cuffed catheter, were deemed high-risk due to her history of infection, and basilic vein transposition (BVT) was excluded due to the small caliber of the basilic vein. Technique: To salvage the patient’s native access, we performed a novel surgical procedure: the fistulization of the BAT to the adjacent deep brachial vein via an end-to-side anastomosis. This successfully converted the single-site arterial access into a functional brachio-brachial arteriovenous fistula (AVF). Post-conversion, the access was utilized for two-site cannulation entirely within the BAT segment (arterial withdrawal and venous return), effectively establishing an arterial-arterial cannulation approach. Results: The postoperative course was uneventful. The access was cannulated 1 day after surgery, demonstrating an access flow volume of 650 mL/min at 7-day follow-up. Venous pressure was stably maintained, confirming effective flow and minimal recirculation. The patient successfully maintained HD with adequate efficiency using the novel access for 2 years until her death, with no VA-related complications. Conclusion: Fistulization of the BAT to the deep vein successfully salvaged HD access in a severely challenged patient by overcoming return vein failure. This technique overturns the convention that the venous return needle must be placed in a vein, offering a valuable, autogenous option for specific patients with exhausted VA reserves and a high risk of graft infection.