Successful arteriovenous fistula creation in a chronic kidney disease G5 patient with bilateral ulnar artery absence: A case report.

Hemodialysis access induced distal ischemia (HAIDI) represents a serious complication following arteriovenous fistula (AVF) creation, with increased risk in elderly patients with arterial abnormalities. Bilateral congenital absence of ulnar arteries is an exceptionally rare anatomical variant with optimal AVF creation strategies remain undefined due to the theoretical high risk of HAIDI. We report a female patient in her 80s with chronic kidney disease G5. She had bilateral congenital absence of ulnar arteries and required vascular access creation. Preoperative assessment revealed radial artery dominance with negative modified Allen tests bilaterally. Standard ultrasound evaluation was inconclusive for distal arterial anatomy, necessitating angiographic evaluation. Angiography revealed bilateral absence of the ulnar arteries and demonstrated the presence of radial arteries and the ulnar trunks continuing into the common interosseous arteries, which were suitable for surgical access. Based on the need to preserve radial circulation and create the most distal feasible access, we performed anastomosis between the ulnar trunk and antecubital perforating vein using 7-0 polypropylene sutures. The patient successfully initiated hemodialysis 7 months postoperatively with optimal AVF maturation, with no clinical signs of HAIDI during 12 months of follow-up from the initiation of dialysis. When standard preoperative assessments are inconclusive, angiography provides crucial anatomical detail enabling safer vascular access planning in patients with rare anatomical variants.