I do fewer wrist fistulas because the arteries are smaller, the veins more likely to have been damaged by venipuncture and IVs, and the failure rates are higher. There is no reason to do a "pro forma" wrist fistula in dubious circumstances just to check an algorithmic box, and especially when the patient already has a catheter ticking or needs imminent dialysis, but there are some advantages to a more distal fistula, including a longer cannulation zone.

Sometimes this happens naturally - as in cases where the cephalic vein does not connect with the basilic system via the median ante/cubital bridge (maybe 10% of patients), but frequently the upper arm cephalic vein diminishes in size, flow and apparent usefulness with diversion of flow at the antecubital fossa (into the deep system via the perforating branches, and the basilic system via the median cubital - "MAC"), then via the first lateral branch above the antecubital fossa, where it drains to the veins of the profunda brachii. Above the first third of the arm it is also frequently deep.

To make the upper arm cephalic vein extension of a forearm fistula more usable, I frequently do an "antecubital disconnection" via a small incision just media to the cephalic, and over the first part of the median antecubital. After test clamping the MAC to make sure the fistula maintains its thrill, the MAC is doubly ligated and divided to expose the deep branch, which is then also skeletonized, doubly ligated and divided, making the cephalic the main outflow conduit and completing the disconnection. I generally skeletonize the cephalic thoroughly, as there may be several smaller deep branches in the area. This maneuver can be completed the same time at the wrist fistula, adding 20-30 minutes to the case.

A more ambitious modification is superficialization of the cephalic vein in the upper arm, not generally done at the same time as the wrist fistula, but always including the antecubital disconnection. If a robust median antecubital is left in place to drain the forearm to the low resistance basilic, the traumatized higher resistance cephalic vein may sclerose down and fail to develop, leaving you with nothing for your pains and promises. 

On 5/24 - The ASDIN International Outreach and Development Committee sponsored the first ASDIN Global Case Presentations.  The archived recording of the event may be viewed here - https://vimeo.com/830296261/434b996fea

We want to foster ongoing dialogue, so feel free to make comments below.

Cases and Presenters:

Another Percutaneous Cuffed Cather Not Working
presented by Steven May, MD, Tamworth, New South Wales, Australia

PD Catheter Complications after Percutaneous Placement
presented by Mark London, MD, Dialysis Access Institute, Orangeburg, South Carolina, USA

Panelists: Ted Saad, MD and Stephen Ash, MD

Moderators: Amy Dwyer, MD and Anil K. Agarwal, MD, 
Chairs, ASDIN International Outreach and Development Committee