Preoperative ultrasound for runoff-venous decompression of peripheral nerves for arteriovenous access-related pain in the upper limb

Abstract

Hemodialysis patients frequently develop upper limb pain, especially following ipsilateral arteriovenous access (AVA). Various etiologies of AVA-related pain include needle ABSTRACT Introduction: Arteriovenous access (AVA)-related pain treated successfully with runoff-venous decompression of the causative nerve, following ultrasound (US)-assisted preoperative evaluation, has never been reported. Case presentation: A 57-year-old man suffering from constant exhausting pains along the outflow cephalic vein of the radiocephalic arteriovenous fistula at the wrist and the antecubital fossa, was treated surgically after the diagnosis of AVA-related pain derived from cephalic vein compression on two peripheral cutaneous nerves, the superficial radial nerve (SRN) and the lateral antebrachial cutaneous nerve (LACN). Technique: The SRN and LACN, which ran along and/or provided sensory innervation to the painful regions in the upper limb, were traced using ultrasonography in the short axis and proved to be compressed by and in contact with veins where the pain existed, at the wrist and the antecubital fossa. Once diagnostic US-guided blocks of both were performed and pain disappeared, they were identified as the causative nerves. The cephalic venous decompression surgeries that separated and transposed the veins away from the SRN and the LACN were performed sequentially under pneumatic tourniquet inflation to improve nerve visualization. Results: The pains disappeared after the operations. An adequate length of the runoff cephalic vein was maintained for needle cannulations during hemodialysis. Conclusions: Outflow venous compression to the peripheral nerves may be a cause of AVA-related pain. USguided assessments of the nerves may improve the safety and efficiency of venous decompression surgeries to treat AVA-related pains.

Surgical intervention for upper extremity nerve compression related to arteriovenous hemodialysis accesses

“…The phenomenon of arteriovenous hemodialysis access–related nerve compression has been scarcely reported from the literature. 16 –25 Most patients had elbow and upper arm autogenous AVFs with sensory deficits in the territory of the median nerve. The outcome of surgical nerve release was generally good with relief of symptoms and maintenance of the vascular access (Table 3).…”

Cutaneous nerve-conscious surgical repair of vascular access-related aneurysm assisted by anatomical ultrasonography in hemodialysis patients

“…The evolution of nerve scanning techniques also influenced the use of US-guided selective peripheral nerve block as anesthesia for VA surgery. 4,5 We demonstrated that, depending on the site of the aneurysm, the target cutaneous nerve trunk could be identified by preoperative US examination. The US identification of the peripheral nerves, for which an understanding of their topographical anatomy is prerequisite, could contribute to nerve-sparing surgery as a complementary procedure.…”

“…1,9,11 Medical devices such as pneumatic tourniquet could help increase the visibility of the cutaneous nerve in bloodless operative fields, in addition to loupe magnification. 4,11 The clinical significance of preventing cutaneous nerve injury is to avoid postoperative neuropathies, including sensory deficits and potential neuropathic pain caused by neuroma formation at an injured nerve. In our study, four patients had severed single or multiple cutaneous nerve branches and complained of postoperative hypoesthesia depending on the number and site of the impaired nerve branch.…”

“…To avoid such lesions, nerve ultrasonography (US), which is necessary for US-guided regional anesthesia consisting of peripheral nerve block for executing VA surgery, was employed to assess the cutaneous nerve paths during preoperative evaluation performed in our hospital. 4,5 Thus, this study mainly aimed to retrospectively assess the cutaneous nerve-preserving repair of VA-related aneurysms assisted by preoperative US visualization of the cutaneous nerves adjacent to the aneurysm to avoid intraoperative nerve injury. This study also sought to discuss the clinical utility, feasibility, and pitfalls of this procedure for the prevention of surgery-induced neuropathy.…”

“…1,3 Furthermore, while dissecting the outflow cutaneous veins, we can encounter the following nerves: (1) the SRN, which passes alongside the cephalic vein (CeV) in the wrist; (2) the lateral antebrachial cutaneous nerve (LACN), which lies parallel to the CeV at the antecubital fossa; and (3) the medial antebrachial cutaneous nerve (MACN), which runs beside the basilic vein (BaV) in the distal upper arm. 1–5 However, there are very few reports of sensory cutaneous nerve lesions associated with VA surgery. Cutaneous nerve injury is probably underreported because it causes only mild neurological deficits and does not affect daily life.…”