Lipectomy is a safe, effective, and durable approach to make deep arterialized forearm veins accessible for routine cannulation for hemodialysis in obese patients. It might even be hypothesized that incident obese dialysis patients will eventually have the highest proportion of radial-cephalic fistulas because they often have distal veins that have been preserved by their fat from previous attempts at cannulation for blood sampling or infusion.

Objective: The aim of this study was to report our midterm results of percutaneous arteriovenous fistula (pAVF) creation using the Ellipsys (Avenu Medical, San Juan Capistrano, Calif) device and to present technical recommendations and our algorithm of pAVF maintenance.Methods: A single-center comprehensive database of all consecutive predialysis and end-stage renal disease patients who had a pAVF creation with the Ellipsys device was reviewed retrospectively. Study end points included technical success, maturation, functional patency, and required interventions.Results: Between May 2017 and July 2019, there were 234 patients (mean age, 64 years; 148 male [63%]) who had a pAVF created. Technical success was achieved in 232 individuals (99%), and average duration of the procedure was 15 minutes (7-35 minutes). Average follow-up was 252 days (range, 83-696 days). The 1-year primary, primary assisted, and secondary patency rates were 54%, 85%, and 96%, respectively. Average pAVF flow was 923 mL/min (range, 425-1440 mL/min). There were no significant adverse events related to the procedure. Only three patients (1%) required a later conversion of the pAVF anastomosis to a surgical fistula. Twenty-four (10%) patients required superficialization of deep outflow veins because of difficult cannulation. Average maturation time was 4 weeks (range, 1-12 weeks). Fourteen patients (6%) had early (<2 weeks after creation) cannulation of the pAVF. Conclusions:The Ellipsys pAVF device allows the rapid and safe creation of a reliable autogenous access. Rates of technical success, patency, and maturation were excellent. For patients unsuited for a distal radiocephalic arteriovenous fistula, it should be considered the next preferred access option.

Femoral vein transposition in the lower limb is a valuable alternative to arteriovenous grafts in terms of infection and long-term patency. Secondary venous percutaneous angioplasties may be necessary. High flow rates are frequently observed and patient selection is essential to avoid ischemic complications.

PRAL is a simple, safe, and effective technique for reduction of flow in RCFs.

When a distal access fails to mature because of forearm artery lesions, PTA should be done and will salvage the fistula without risk of distal ischemia and cardiac failure. Efficacy of PTA clearly influences surgical strategy and is a major argument in favor of attempting to create distal accesses in patients with mild distal artery lesions. Even in cases of failure, such as early occlusion of the fistula, this technique does not jeopardize further proximal access creation. Forearm access creation should be avoided only in cases of extremely severe distal artery lesions.