The fistula elevation procedure: a valuable technique for maximizing arteriovenous fistula utilization.

Many patients are not considered candidates for radiocephalic fistula (RCF) or brachiocephalic fistula (BCF) creation or have fistulas that do not mature because the cephalic vein is too deep or tortuous to be accessed. Other patients have not been candidates for the basilic vein transposition (BVT) because limited length of adequate caliber vein precludes subcutaneous tunneling of the vein. In an effort to maximize arteriovenous fistula (AVF) utilization, we developed an adjunctive procedure designed to make the deep or tortuous fistula accessible to needle cannulation. The fistula elevation procedure (FEP) involves mobilization of the fistula, approximation of the subcutaneous tissue beneath the fistula, and subcuticular skin closure over the fistula. The procedure enhances the accessibility of the fistula by placing it in a more superficial position. The overlying cicatrix also acts as a guide for dialysis needle insertion. Between June 1998 and January 2001, 45 patients underwent a natural AVF that could not be accessed secondary to venous depth, tortuosity, or length. In each case, a FEP was performed to salvage the fistula. The FEP was performed as an adjunct to a BCF in 20 patients, a RCF in 7 patients, and a BVT in 8 patients. The FEP is a simple procedure that enhances AVF utilization by making the fistula more accessible to dialysis needle cannulation. The procedure is particularly helpful in obese patients who would not traditionally be considered candidates for natural AVF creation.