A 78-year-old, right-hand-dominant man was diagnosed with end-stage renal disease. It was deemed that he would require lifetime hemodialysis. Venous mapping with Duplex ultrasound was performed in both upper extremities to locate suitable veins for dialysis access. Left proximal radial artery to cephalic vein arteriovenous fistula was created. Patient had an uneventful postoperative course. He demonstrated an excellent thrill and bruit throughout the course of fistula. He had palpable radial and ulnar pulses. Approximately 8 weeks later, the fistula was used for hemodialysis. The patient started complaining of pain in all the digits of the left hand and noticeable discoloration of the left hand during dialysis. His symptoms resolved completely upon discontinuing dialysis.

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  Photoplethysmography of the left hand digits showed diminished waveforms in all fingers of the left hand. The waveforms improved upon compression of the fistula (Figures 20-1 and 20-2).

  
  
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  Duplex ultrasound examination of the fistula showed reversal of flow in the radial artery (Figures 20-3,20-4, and 20-5).

  
  
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  Diagnostic arteriogram of the left upper extremity was performed that showed normal arterial vasculature of left upper extremity. Selective catheterization of the ulnar artery showed antegrade flow in the ulnar artery, filling of the palmar arch, and retrograde flow in the radial artery (Figure 20-6).

  
  
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  The patient was brought to the operating room and under local anesthetic, the distal radial artery was ligated. He had dialysis after the procedure and had no further symptoms of digit ischemia during dialysis.