Postepy Hig Med Dosw. (online), 2011; 65: 654-657
Case Report
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A rare variant route of the ulnar artery does not contraindicate the creation of a fistula in the wrist of a diabetic patient with end-stage renal disease
Rzadka odmiana przebiegu tętnicy łokciowej nie jest przeciwwskazaniem do wytworzenia przetoki w okolicy nadgarstka u pacjenta ze schyłkową niewydolnością nerek w przebiegu cukrzycy
Mirosław Banasik1  ABDEF, Katarzyna Madziarska1  ABDE, Wacław Weyde1  ABDEFG, Mariusz Kusztal1  BDEF, Tomasz Gołębiowski1  BDF, Sławomir Zmonarski1  BDF, Magdalena Krajewska1  ABD, Dariusz Janczak2  ABD, Marian Klinger1  ADEFG
1Department of Nephrology and Transplantation Medicine
2Department of Vascular, General and Transplantation Surgery, Wroclaw Medical University, Wroclaw, Poland
Corresponding author
Mirosław Banasik MD PhD, Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, ul. Borowska 213, 50-556 Wrocław; e-mail: m.banasik@interia.pl

Authors' Contribution:
A - Study Design, B - Data Collection, C - Statistical Analysis, D - Data Interpretation, E - Manuscript Preparation, F - Literature Search, G - Funds Collection

Received:  2011.08.04
Accepted:  2011.09.23
Published:  2011.10.10

Streszczenie
Powierzchowny wariant przebiegu tętnicy łokciowej jest rzadką odmianą układu tętniczego w oko­licy nadgarstka. Przebieg tętnic w tej okolicy jest niezmiernie ważny dla pacjentów ze schyłko­wą niewydolnością nerek z powodu konieczności wytworzenia przetoki tętniczo-żylnej do celów hemodializy. Uważa się, iż dostęp naczyniowy jest zbyt często wytwarzany z użyciem cewni­ków i protez naczyniowych dlatego każda możliwość wytworzenia dostępu z własnych naczyń powinna zostać wykorzystana. U naszego pacjenta rzadką odmianę przebiegu tętnicy łokciowej zaobserwowano w okolicy nadgarstka. Zamiast głębokiego przebiegu między mięśniami, tętnica nie tylko przebiegała powierzchownie, ale również nietypowo - początkowo bocznie, a następnie przyśrodkowo. Taki wariant przebiegu tętnicy łokciowej może wzbudzić obawę niedokrwienia ręki w następstwie wytworzenia przetoki tętniczo-żylnej do hemodializ. Obawa może się wią­zać z zaopatrzeniem w krew łuku dłoniowego utworzonego przez tętnicę promieniową oraz łok­ciową. Obawa lekarzy może w konsekwencji doprowadzić do odstąpienia od próby wytworzenia przetoki tętniczo-żylnej w okolicy nadgarstka. Autorzy udowadniają, iż przedstawiony wariant przebiegu tętnicy łokciowej nie jest przeciwwskazaniem do wytworzenia przetoki w okolicy nad­garstka z użyciem tętnicy promieniowej i nie ma powodu do obaw o niedokrwienie ręki.
Słowa kluczowe: hemodializa • dostęp naczyniowy • tętnica łokciowa


Summary
A superficial variant route of the ulnar artery is a rare variation of the arterial system of the wrist. The route of the arteries in that region is extremely important for patients with end-stage renal disease due to the necessity to create an arteriovenous fistula for hemodialysis. It is thought that the vascular access is too often achieved by catheters or vascular prostheses because of that each possibility to create a fistula in the wrist region should be utilized. In our patient a rare variant route of the ulnar artery was observed in the wrist region. Instead of a deep route between the muscles the artery did not only run superficially, but, also untypically, first laterally and then me­dially. A variation of the ulnar artery's route may evoke a fear of hand ischemia after creation arteriovenous fistula for hemodialysis. The fear may be connected with blood supply throw the palmar arch which is created by radial and ulnar artery. This fear of the doctor may result in avo­iding the attempt to create an arteriovenous fistula on the wrist. The authors demonstrate that the variant route of the ulnar artery is not a contraindication to the creation of a fistula on the wrist using the radial artery because of a fear of hand ischemia.
Key words: hemodialysis • vascular access • ulnar artery




Background
A superficial course of ulnar artery on the forearm is a rare variation, with an incidence of 0.7-7% [4,5,12]. This re­gion is extremely important in patients with end-stage re­nal disease because of the necessity of arteriovenous fistu­la creation for hemodialysis. The classical Cimino-Bresci fistula is without doubt the best vascular access in chroni­cally hemodialysed patients [6,9,14]. Analyses show that vascular access is too often achieved by means of catheters or vascular prostheses. A variation of the ulnar artery's ro­ute may evoke a fear of hand ischemia after creation arte­riovenous fistula for hemodialysis. This unfounded fear of the doctor may result in avoiding the attempt to create an arteriovenous fistula on the wrist. The fear may be connec­ted with blood supply throw the palmar arch which is cre­ated by radial and ulnar artery. After classic arteriovenous fistula creation end-to-end or rarer end-to-back hand ische­mia may be observed but even in a described case standard Allen test is adequate to check the blood supply. A super­ficial ulnar artery may be also mistaken for veins and can show the way to intra-arterial injection of drugs [3,7]. A superficial artery is in addition more vulnerable to trauma.
Variations in the arterial system of the upper limb are well documented [1,3,8,10,13]. Our own experience allowed us to determine that variation of the radial artery does not re­strict the successful creation of an arteriovenous fistula for hemodialysis [16]. The importance of vascular abnorma­lities in patients with autosomal dominant polycystic kid­ney disease who require the creation of an arteriovenous fistula was noted earlier by our group [15].
In this paper we present that this variant route of the ulnar ar­tery should not be a contraindication to the creation of a fistula on the wrist of a diabetic patient with end-stage renal disease.
Case presentation
A 63-year-old man was admitted to the hospital because of end­-stage renal disease. The patient had suffered from diabetes for 28 years and was being treated for hypertension. Deterioration of renal function had been detected 5 years before.
It was decided that hemodialysis would be the appropriate method of renal replacement therapy for this patient and vascular access creation was planned. During examination before fistula creation it was shown that no vein on the ri­ght forearm was available. On the left hand the veins were appropriately filled with blood, but the route of the ulnar artery was altered (Fig. 1, 2). Pulse was present in both the ulnar and radial arteries. Standard Allen test was performed to avoid hand ischemia after arteriovenous fistula creation.
Figure 1. The superficial variant route of the ulnar artery (arrow)

Figure 2. Atypical route of the ulnar artery

Survey x-ray of both upper limbs allowed viewing both arteries because of the presence of calcium salt deposits (Fig. 3). A rare variant route of the ulnar artery was obse­rved in the wrist region. Instead of a deep route between the muscles, the artery lay superficially. In the distal wrist segment the artery did not only run superficially, but, also untypically, first laterally and then medially. Despite these changes, the surgical procedure was performed in the ty­pical place with the creation of a fistula on the wrist using the radial artery and cephalic vein. The patient did not present symptoms of hand ischemia. During the follow-up plethysmography (PVR and PG module) of hands and fin­gers was performed before and after arterio-venous fistula creation to monitor hand's blood supply.
Figure 3. Superficial ulnar artery with diabetic angiopathy changes (arrow)

Discussion
The presented variant route of the ulnar artery involved a patient requiring hemodialysis. Today we know that an arteriovenous fistula on the wrist provides the best vascu­lar access for hemodialysis [6,9]. Anomalies of the arte­rial system of the upper extremity are well described, but such reports concerning patients with end-stage renal di­sease are rare [6,15] and we found no report involving the ulnar artery in the wrist region. It is extremely important for patients with end-stage renal disease who require vascu­lar access for renal replacement therapy, i.e. hemodialysis.
An additional difficulty in fistula creation is the intrava­scular presence of atherosclerosis with calcium deposits. Despite the changes, a flow of 750 ml/min in the fistula during hemodialysis session was achieved and we did not observe symptoms of hand ischemia.
The typical course of the ulnar artery begins distally to the bend of the elbow. It is the superior of the two termi­nal branches of the brachial artery. Proximally, the arte­ry lies deep to the antebrachial flexor muscles and distally above the flexor retinaculum. Then the ulnar artery forms the superficial palmar arch.
The superficial portion of ulnar artery is usually described as being near the cubital fossa in the proximal segment. Our patient had the superficial portion in the distal third of fore­arm. In the distal half of the forearm the ulnar artery normal­ly lies between the tendon of the flexor carpi ulnaris and the flexor digitorum superficialis. The described superficial route of the ulnar artery in the distal third of the forearm had a la­teral course (Fig. 3). Despite the variant route of the artery, an arteriovenous fistula was created without hand ischemia. Our own experiences demonstrate that even a rare variant route should not be a reason to abandon creation a Cimino-Bresci fistula on the wrist. Standard Allen test is adequate for blood supply checking before fistula creation.
It should also be emphasized that a superficial position of the ulnar artery may be mistaken for veins. Such a wrong interpretation can show the way to intra-arterial injection. A superficial artery is also more vulnerable to trauma. Knowledge of not only a potentially superficial ulnar, but also radial artery is very important not only for nephrolo­gists, but also for all physicians, surgeons, and nurses [2].
Conclusion
An arteriovenous fistula is extremely important for pa­tients with end-stage renal diseases. Each opportunity for its creation should be utilized. Even a different route of the artery is not an obstacle to attempting the creation of an arteriovenous fistula on the wrist before creating a fistula in the cubital fossa or catheterizing. We believe that a va­riant route of the ulnar artery is not a contraindication to the creation of a fistula on the wrist using the radial artery.
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The authors have no potential conflicts of interest to declare.