Skin ulcer due to hemodialysis access-induced distal ischemia treated with arteriovenous fistula banding and endovascular therapy.

A 58-year-old woman with pallor on her left hand due to chronic hemodialysis presented with a recent intractable skin ulcer on her left 3rd finger; the skin perfusion pressure (SPP) was 19 mmHg. Preoperative angiography revealed an occluded proximal left radial artery, no communication between the ulnar and superficial palmar arteries, several collaterals from the left ulnar to the radial artery, and no visualization of the finger arteries. Successful endovascular therapy to the occluded radial artery increased flow to the arteriovenous fistula (AVF), but not to the fingertips. Slightly compressing the AVF augmented the flow and wound blush at the wound sites on the 3rd fingertip, leading to a diagnosis of hemodialysis access-induced distal ischemia (HAIDI). Surgical AVF banding with intra-operative SPP monitoring improved the SPP to 34 mmHg, leading to complete wound healing over 1 month with a preserved AVF. We performed a bilateral temporal artery biopsy and diagnosed giant cell arteritis. As the angiographic wound blush at wound sites is reportedly an important factor for wound healing, angiography with AVF manual compression is essential to diagnose HAIDI and evaluate the blood flow for wound healing. <Learning objective: Hemodialysis access-induced distal ischemia (HAIDI) is a potentially devastating complication of an arteriovenous fistula (AVF). As it is difficult to diagnose, it may necessitate major amputation. The angiographic wound blush is related to wound healing, making angiography an essential modality for evaluating blood flow in HAIDI, especially in case of an ischemic intractable ulcer. Angiography with AVF manual compression is not only essential to diagnose HAIDI, but also effective to evaluate the flow for wound healing.>.