Saved by the collaterals

Lee et al1Lee K.S. Choong A.M.T.L. Ng J.J. A systematic review of brachial artery ligation as a safe and feasible option in the management arteriovenous dialysis access infection.J Vasc Surg. 2021; 74: 327-333Google Scholar have provided summary published reports regarding emergency setting an infected upper arm origin hemodialysis access. The data indicate that without repair is well tolerated when performed distal or antecubital area. This observation prompts us to consider marvelous adaptability circulation response disease, injury, surgical intervention. Reduced perfusion part by whatever cause alters pressure gradients induces vasodilation resistance beds, eliciting increased flow through alternative pathways with subsequent flow-mediated relaxation eventual expansile remodeling. role pre-existing collateral arteries their responses physiological stimuli has long been recognized ischemia due decreased arterial cause.2Strandness D.E. Collateral Circulation Clinical Surgery. W.B. Saunders, Philadelphia1969Google presence absence major determinant impact acute vs chronic occlusion. It known different beds capacities for development based on embryology mature anatomy particular vascular bed, malleability tree reduced age, other factors. Models intended clarify physiology fistulas better understand access-related steal syndrome emphasized critical played collaterals. models predict high likelihood symptomatic fistula inadequate collateralization. most commonly used treatment revascularization interval (DRIL) procedure combines more bypass. Interestingly, modeling shown improvement DRIL derived from little additional artery.3Gradman W.S. Pozrikidis C. Analysis options mitigating access–related ischemic phenomena.Ann 2004; 18: 59-65Google Scholar, 4Varble N. Day S. Phillips D. Mix Schwarz K. Illig K.A. al.In vitro hemodynamic model study hemodynamics native procedure.J 2014; 59: 1410-1417Google 5Zanow J. Krueger U. Reddemann P. Scholz H. Experimental procedures treat ischemia.J 2008; 48: 1559-1565Google Naturally, component essentially construction large into forearm. So, patients who had functioning artery-based enough serious infection requiring urgent removal not developed almost certainly well-developed collaterals sufficient support if acutely ligated. key here knowledge collateralization does arise primarily deep proximal but rather arcades formed superior inferior ulnar recurrent radial mid arm. Thus, this setting, may be. reminds expert armed development, resultant anatomy, adaptive capabilities arteries, disease intervention ability safely confidently address clinical situations potentially save both life limb. opinions views expressed commentary are those authors do necessarily reflect recommendations Journal Vascular Surgery Society