The master publishing plan has been to compose complete and comprehensive discussions of a given topic with illustrations, almost like a chapter in a book, and then publish them to the blog – but guess what? It all takes time, in such short supply. So, while I am working on the blog chapters, I want to share some interesting cases more informally.
This patient had a fistula performed by another surgeon, and came to me with a bad case of digital ischemia, which can be caused by proximal arterial lesions (not enough blood coming down the arm), small vessel disease in the forearm limiting circulation to the fingers, an overly large anastomosis and fistula siphoning too much blood away from the forearm and hand, and some other more obscure etiologies. Normally we document digital ischemia in the non-invasive lab, and then do a fistulogram with flow measurements and a retrograde arterial study to determine the cause. Sometimes an immediate percutaneous intervention can solve the problem, but most often an open operation will need to be scheduled for inflow reduction, banding, branch ligation, or revision of inflow with distalization or proximalization.
In this unusual case, a “tarantula” fistula with multiple early diverting branches sucked nearly all the blood out of the artery at the anastomosis, leaving very little for the hand. LIGATING THE FISTULA ALONE WILL BE INEFFECTUAL unless you dissect all the way down to the arterial anastomosis to exclude the early diverting branches. On fistulogram, the flow was modest, and there were no inflow stenoses from the subclavian artery to the anastomosis. Correction of the problem required laborious dissection of the fistula to the anastomosis, doubly ligating and dividing each diverting branch until one sole fistula outflow remained.