Can a brachiocephalic arteriovenous fistula be created in a patient with a blocked radial artery from a previous fistula attempt but a patent ulnar artery?

Yes, a brachiocephalic AVF can be created in this patient with a blocked radial artery and patent ulnar artery.

A brachiocephalic fistula is an appropriate and reliable next option after failed distal attempts, and the blocked radial artery does not preclude its creation since the brachial artery (which is proximal to both radial and ulnar arteries) remains the inflow source.

Anatomic Rationale

The key anatomic principle here is that a brachiocephalic AVF uses the brachial artery at the antecubital fossa level as its arterial inflow source, not the radial or ulnar arteries 1. The brachial artery bifurcates into the radial and ulnar arteries distally, so:

• The blocked radial artery is distal to the planned anastomosis site and therefore does not affect the technical feasibility of creating a brachiocephalic fistula
• The patent ulnar artery actually provides an advantage by maintaining hand perfusion and reducing steal syndrome risk
• The brachial artery itself should be evaluated for adequacy (typically >3mm diameter)

Clinical Evidence Supporting This Approach

Multiple studies demonstrate brachiocephalic AVF as the standard next option after forearm fistula failure:

• Brachiocephalic fistulas through the median cubital vein have shown excellent outcomes with primary patency of 96% and secondary patency of 92% in patients who failed forearm attempts 2, 3
• One case series specifically reported successful brachiocephalic fistula creation after failed forearm attempts due to small radial arteries, with mean flow rates of 1415 ml/min 3

Important Caveats and Assessment Requirements

Before proceeding, ensure:

1. Adequate brachial artery diameter (≥3mm) and flow on duplex ultrasound
2. Patent cephalic vein in the upper arm (≥4mm diameter preferred)
3. Adequate hand perfusion - the patent ulnar artery should provide sufficient collateral flow. Perform a Doppler-augmented Allen's test to confirm adequate palmar arch perfusion 4, 5
4. Central venous patency - rule out central stenosis from previous catheter use

Alternative Consideration: Proximal Ulnar Artery AVF

If the brachiocephalic option is not feasible (inadequate cephalic vein or brachial artery), a proximal ulnar artery AVF represents another viable option before resorting to grafts 4, 5. Studies show:

• Primary patency of 80% at 12 months and cumulative patency of 94% 5
• Very low steal syndrome rates (0-2%) when using proximal ulnar artery 4, 5
• Particularly useful when radial artery is occluded or inadequate 5

Recommended Approach Algorithm

1. First choice: Brachiocephalic AVF via median cubital or cephalic vein - this is the standard progression per KDOQI guidelines after forearm fistula failure 1
2. Second choice: Proximal ulnar artery to cephalic vein if brachial artery inadequate but ulnar artery robust (>2.5mm)
3. Third choice: Brachiobasilic transposition if superficial veins inadequate
4. Last resort: Prosthetic graft if all autogenous options exhausted

The blocked radial artery should not deter you from proceeding with a brachiocephalic fistula, which remains the preferred autogenous access option in this clinical scenario 2, 3.