Arterial angioplasty to treat hand ischemia in a radial-cephalic fistula

A chronic hemodialysis patient was referred to interventional nephrology for evaluation of left hand pain. The patient had been receiving hemodialysis through a left radial-cephalic arteriovenous fistula and reporting hand pain during dialysis. Physical examination demonstrated cold hand and reduced capillary refill compared with the right hand. Clinical features, differential diagnosis, and physical examination findings were consistent with the diagnosis of hand ischemia due to dialysis access. Arteriography revealed >80% stenosis of the distal ulnar artery. Percutaneous balloon angioplasty successfully dilated the lesion with resolution of symptoms. Although uncommon, patients with forearm fistula can also experience symptoms of hand ischemia. This case demonstrates that in addition to the history, clinical features, differential diagnosis, and physical examination, arteriography is a vital step in the management of patients presenting with signs and symptoms of hand ischemia. Further, employment of a basic procedure (percutaneous balloon angioplasty) can successfully resolve the condition and maintain the dialysis access.