Dissection in a Superficialized Brachial Artery for Hemodialysis Access: A Case Report

Dissection in a Superficialized Brachial Artery for Hemodialysis Access: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Dissection in a Superficialized Brachial Artery for Hemodialysis Access: A Case Report Kosuke Yuyama, Shota Nakada, Kazuho Oe, Kyohei Misawa, Junya Nishihata, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9200914/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Superficialization of the brachial artery is an alternative vascular access strategy for selected hemodialysis patients for whom conventional access options are limited. Dissection of a superficialized brachial artery (SBA) used for dialysis access has rarely been described, and its management is not well established. Case presentation: A 76-year-old man with end-stage kidney disease due to diabetic nephropathy underwent right brachial artery superficialization and maintenance hemodialysis via the superficialized artery. During routine cannulation, bedside duplex ultrasonography incidentally suggested a localized arterial dissection, despite the absence of local symptoms. Contrast-enhanced computed tomography revealed a focal dilatation of the SBA with an intraluminal thrombus. Hemodialysis was temporarily performed using a right internal jugular venous catheter to avoid cannulation of the suspected lesion. Duplex ultrasound showed preserved distal perfusion, and a flap-like structure with a mural thrombus and caliber irregularity near the antecubital fossa; the presumed entry site was approximately 2 cm proximal to the antecubital fossa. After confirming the feasibility of proximal cannulation under ultrasound guidance, the catheter was removed, and hemodialysis was continued using an adjusted puncture site approach. Conclusions This case suggests that bedside duplex ultrasound can be used in the early detection of arterial wall pathology in SBA access; and in selected patients with preserved distal perfusion and non-flow-limiting localized lesions, an ultrasound-guided conservative approach with repeat ultrasound assessment during hospitalization may allow the safe continuation of hemodialysis. superficialization of the brachial artery brachial artery transposition arterial dissection duplex ultrasound Figures Figure 1 Figure 2 Figure 3 Background In Japan, superficialization of the brachial artery, also referred to as brachial artery transposition (BAT), has been adopted for selected hemodialysis patients in whom conventional arteriovenous access is difficult [1–7]. However, dissection involving this type of access has seldom been described, and an established management strategy has not been defined. Reliable vascular access is fundamental for safe hemodialysis; however, the available options may be constrained in patients with complex vascular and cardiopulmonary comorbidities. Clinical series have reported acceptable patency and usable dialysis blood flow with SBA/BAT in selected cohorts [1–7]. However, published literature has often focused on complications such as pseudoaneurysm or aneurysmal change; infection; thrombosis or stenosis; and wound-related problems, sometimes necessitating revascularization rather than dissection as a primary event [1, 2, 4, 7, 8]. Duplex ultrasound is widely used for access assessment and cannulation support, and can support clinical management [9, 10]. Against this background, we report a case of SBA dissection detected incidentally during bedside duplex ultrasound during cannulation, managed conservatively with repeat ultrasound assessments during hospitalization, and discuss its diagnostic and management implications in the context of the literature. Case presentation A 76-year-old man with end-stage kidney disease due to diabetic nephropathy had been receiving maintenance hemodialysis three times a week since 2019. After repeated occlusion of the left forearm arteriovenous access, a superficialized right brachial artery was created in 2023 for dialysis cannulation. Routine cannulation was performed using 17-gauge needles. He was not taking any oral antithrombotic agents before admission. His medical history included long-standing hypertension and diabetes mellitus, and he had undergone thoracoscopic subtotal esophagectomy for lower esophageal cancer in 2021. In early 2026, he was admitted for evaluation of gastrointestinal symptoms, he was not tolerating oral feeds. On admission (hospital day 1), he was afebrile and hemodynamically stable (temperature 36.8°C; blood pressure 126/68 mmHg; heart rate 63 beats/min; oxygen saturation 95% on room air). Examination of the SBA revealed no tenderness, erythema, or swelling, and no clinical signs of distal upper limb ischemia. On hospital day 2, he underwent hemodialysis via the SBA without local symptoms or any cannulation-related complications; and arterial dissection was not suspected at that time. Because the lesion was first recognized on hospital day 4, it was not possible to determine the timing of onset or to conclude that the dissection was caused by cannulation on hospital day 2. During routine hemodialysis on hospital day 4, bedside duplex ultrasonography performed at cannulation incidentally revealed findings suggestive of localized arterial dissection despite the absence of local symptoms. Contrast-enhanced computed tomography (CT) revealed focal dilatation of the SBA with an intraluminal thrombus, supporting the suspicion of a localized dissection (Fig. 1 A–C). Bedside duplex ultrasonography was also performed on hospital day 9 to support clinical management; however, formal reports were not available and the stored images are not suitable for publication. A subsequent documented duplex ultrasound examination on day 11 of hospitalization identified a presumed entry site approximately 2 cm proximal to the antecubital fossa. Duplex ultrasound showed an arc-shaped signal arising from the lumen, extending outward, and then turning back toward the lumen near the lesion; suggesting a flap-like structure (Fig. 2 A). Near the antecubital fossa, the artery demonstrated caliber irregularity with a mural thrombus, which was considered compatible with severe underlying atherosclerosis (Fig. 2 B). Re-entry into the true lumen could not be identified, and distal arterial perfusion was preserved. To avoid cannulation at the suspected dissection site, hemodialysis was performed on hospital days 4, 7, and 9 using a right internal jugular venous catheter placed on hospital day 4. On day 11, proximal cannulation away from the presumed entry site was confirmed to be feasible using the superficialized artery, and the catheter was removed. Heparin was used during hemodialysis and maintained at the usual dose throughout this period. The clinical course of hospitalization is summarized in Fig. 3 . The patient was discharged on hospital day 12 and continued hemodialysis at another center using the superficialized artery with an adjusted puncture site approach. Discussion and Conclusions The most important clinical implication of this case is that localized arterial dissection in an SBA does not necessarily require abandonment of access. With careful ultrasonographic evaluation and modification of the puncture strategy, hemodialysis can be safely continued. To place the present case in context, we reviewed the relevant literature on SBA/BAT and related arterial complications. Although superficialization of the brachial artery or BAT has been described as an effective alternative means of access with acceptable patency in selected cohorts [1–6], published series have emphasized adverse events such as wound-related complications (including impaired healing, skin necrosis, infection, and lymphorrhoea), aneurysmal changes (including infective aneurysm), thrombotic or stenotic lesions, access-related bleeding or hematoma, and distal ischemia [1, 2, 4, 7, 8]. Arterial dissection has rarely been reported as a primary complication. This may reflect not only true rarity but also underrecognition, particularly when local symptoms are absent and bedside imaging is not routinely performed at the time of cannulation. Our case therefore adds to the literature by showing that a localized arterial dissection can be detected during routine bedside ultrasound assessment and managed with temporary access diversion and modified recannulation without immediate loss of access. In this patient, the duplex ultrasound demonstrated vessel caliber irregularity and a mural thrombus near the elbow region, suggesting advanced atherosclerotic change, and the presumed entry site was located approximately 2 cm proximal to the antecubital fossa. Although causality cannot be established, repeated puncture-related intimal injury is biologically plausible [11]. Arterial dissection is an uncommon but known complication of invasive arterial procedures, and similar events involving the brachial artery have been described after arterial cannulation [12, 13]. Multiple cannulation attempts are also associated with higher complication rates in arterial catheterization, reflecting cumulative mechanical trauma to the vessel wall [8, 14]. In addition, advanced age and diabetes mellitus may further predispose to arterial wall fragility and adverse vascular remodeling, potentially increasing susceptibility to mechanically induced injury [13, 15]. In superficialization of the brachial artery, the artery is intentionally positioned superficially to permit cannulation [1], and the available puncture zones may be relatively limited, which can concentrate mechanical stress on a narrow segment, particularly when the arterial wall is severely diseased. Needle gauge may also influence puncture-related trauma; however, 17-gauge needles are commonly used in routine hemodialysis cannulation and were therefore not considered a major independent risk factor in this case [16]. Point-of-care duplex ultrasonography is particularly valuable for evaluating superficialized arterial access at the time of cannulation because it provides real-time assessment of both vascular morphology and hemodynamics, enabling detection of access-related abnormalities and guiding safe puncture site selection [9, 10]. Duplex ultrasonography may also raise suspicion of arterial dissection by demonstrating an intimal flap and associated abnormal color and spectral Doppler flow patterns [17]. In our case, bedside ultrasonography identified a focal wall abnormality compatible with a dissection flap or channel and a concomitant mural thrombus, which directly informed avoidance of the affected segment and subsequent modification of the cannulation site. In addition, contrast-enhanced CT can complement ultrasonography by delineating lesion extent, intraluminal thrombus, and surrounding soft tissue changes in a broader anatomical context while helping to evaluate alternative diagnoses and procedural planning [18, 19]. However, duplex ultrasonography remains important for dynamic flow assessment and follow-up during conservative management. Management options for superficialization of the brachial artery or BAT-related complications range from temporary cessation of cannulation with alternative access, (for example, catheter placement) to surgical intervention including arterial repair, segmental resection with interposition grafting, or bypass revascularization, depending on lesion severity and the threat to limb perfusion or access usability [1, 8]. In the present case, conservative management was selected because distal perfusion was preserved, the lesion appeared localized, and there was no obvious flow-limiting lumen compromise on imaging. Duplex ultrasound also suggested interval stability compared with earlier bedside assessments; and hemodialysis could be safely continued after confirming a feasible puncture segment proximal to the presumed entry site while strictly avoiding cannulation of the affected segment. Since the thrombus was mural and distal perfusion was intact without ischemic symptoms, the potential benefit of intensifying anticoagulation was not probable. Therefore, we maintained routine dialysis anticoagulation and prioritized temporary alternative access, repeated ultrasonographic assessments during hospitalization, and a safer cannulation approach. Although no standardized treatment algorithm exists specifically for an SBA dissection; published superficialization of the brachial artery or BAT series indicate that the access artery can remain patent long-term, supporting a strategy that prioritizes access preservation when risk markers are favorable and surveillance is feasible [2–4]. Concepts from the broader iatrogenic peripheral arterial dissection literature further support individualized management: lesions without ischemia or flow limitation may be observed with close imaging assessment, whereas flow-limiting dissections or threatened perfusion generally require endovascular or surgical intervention [11, 12, 20]. Endovascular repair can be technically feasible in peripheral arterial dissections; however, in an SBA repeatedly used for cannulation, stent or stent-graft placement may compromise future puncture strategy, and is therefore not necessarily the preferred option for stable localized lesions. Given that cannulation of an SBA is typically performed in a retrograde direction relative to the arterial flow, we considered retrograde propagation of the dissection. However, the direction of propagation could not be definitively determined on available imaging; therefore, we anticipated a favorable course primarily in the context of a localized, non-flow-limiting lesion with preserved distal perfusion [11, 20]. In conclusion, arterial dissection involving an SBA used for hemodialysis access is rare. Bedside duplex ultrasound can facilitate the early detection of arterial wall pathology at cannulation and support a safer puncture site approach. In selected patients with preserved distal perfusion and a localized non-flow-limiting lesion, an ultrasound-guided conservative approach with repeat ultrasound assessment during hospitalization may allow the continuation of hemodialysis without immediate surgical or endovascular intervention. Abbreviations BAT: brachial artery transposition CT: computed tomography CVC: central venous catheter HD: hemodialysis SBA: superficialized brachial artery US: ultrasonography Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent for the publication of this case report and any accompanying images was obtained from the patient. Availability of data and materials Not applicable. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors’ contributions KY contributed to patient management, data collection, manuscript drafting, and supervised the project, including critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors thank the nursing staff and clinical engineers of the dialysis unit for their support with cannulation management and bedside duplex ultrasonography during hospitalization. We also thank the sonographers and staff of the ultrasound laboratory for their assistance with duplex ultrasound examinations. In addition, we acknowledge the radiology team for their assistance with contrast-enhanced CT acquisition and interpretation. We used an AI-assisted tool for language editing and formatting. The authors reviewed and approved the final content and take full responsibility for the manuscript. Authors’ information Not applicable. References Nakamura T, Suemitsu K, Nakamura J. Superficialization of brachial artery as effective alternative vascular access. J Vasc Surg. 2014;59:1385–92. https://doi.org/10.1016/j.jvs.2013.11.093 Murakami M, Mori K, Hamanoue S, Suemitsu K, Kajiwara K, Miyamoto M, et al. 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Superficialization of the radial artery: an alternative secondary vascular access. J Vasc Access. 2012;13:504–7. https://doi.org/10.5301/jva.5000079 Kukita K, Ohira S, Amano I, Naito H, Azuma N, Ikeda K, et al. 2011 update Japanese Society for Dialysis Therapy guidelines of vascular access construction and repair for chronic hemodialysis. Ther Apher Dial. 2015;19 Suppl 1:1–39. https://doi.org/10.1111/1744-9987.12296 Fujioka S, Sakaki K. Revascularization of the superficialized brachial artery. Ann Vasc Dis. 2025;18:25-00093. https://doi.org/10.3400/avd.oa.25-00093 Teodorescu V, Gustavson S, Schanzer H. Duplex ultrasound evaluation of hemodialysis access: a detailed protocol. Int J Nephrol. 2012;2012:508956. https://doi.org/10.1155/2012/508956 Ko SH, Bandyk DF, Hodgkiss-Harlow KD, Barleben A, Lane J 3rd. Estimation of brachial artery volume flow by duplex ultrasound imaging predicts dialysis access maturation. J Vasc Surg. 2015;61:1521–7. https://doi.org/10.1016/j.jvs.2015.01.036 Funaki B. Iatrogenic flow limiting arterial dissection. Semin Intervent Radiol. 2008;25:437–41. https://doi.org/10.1055/s-0028-1103003 Weinberg L, Abu-Ssaydeh D, Spanger M, Lu P, Li MHG. Case report: Iatrogenic brachial artery dissection with complete anterograde occlusion during elective arterial line placement. Int J Surg Case Rep. 2018;42:269–73. https://doi.org/10.1016/j.ijscr.2017.12.034 Riangwiwat T, Blankenship JC. Vascular complications of transradial access for cardiac catheterization. US Cardiol. 2021;15:e04. https://doi.org/10.15420/usc.2020.23 Sandoval Y, Bell MR, Gulati R. Transradial artery access complications. Circ Cardiovasc Interv. 2019;12:e007386. https://doi.org/10.1161/CIRCINTERVENTIONS.119.007386 Sakellariou XM, Nikas DΝ, Papanagiotou P, Liberopoulos E, Florentin M, Bechlioulis A, et al. Structural radial artery modifications following transradial access: mechanisms, clinical implications, and preventive strategies. World J Cardiol. 2025;17:107772. https://doi.org/10.4330/wjc.v17.i7.107772 Nardinocchi MD, Manocchi K, Traini T. The appropriateness of cannulation devices in the management of arteriovenous fistulae. G Ital Nefrol. 2020;37:2020-vol3 Montorfano MA, Pla F, Vera L, Cardillo O, Nigra SG, Montorfano LM. Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma. Crit Ultrasound J. 2017;9:5. https://doi.org/10.1186/s13089-017-0060-5 Rotzinger DC, Lu TL, Kawkabani A, Marques-Vidal PM, Fetz G, Qanadli SD. Computed tomography angiography in peripheral arterial disease: comparison of three image acquisition techniques to optimize vascular enhancement-a randomized controlled trial. Front Cardiovasc Med. 2020;7:68. https://doi.org/10.3389/fcvm.2020.00068 Jens S, Kerstens MK, Legemate DA, Reekers JA, Bipat S, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial injury due to trauma: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2013;46:329–37. https://doi.org/10.1016/j.ejvs.2013.04.034 Ge BH, Copelan A, Scola D, Watts MM. Iatrogenic percutaneous vascular injuries: clinical presentation, imaging, and management. Semin Intervent Radiol. 2015;32:108–22. https://doi.org/10.1055/s-0035-1549375 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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13:08:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9200914/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9200914/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106382915,"identity":"f015d0ae-9ca9-43d3-8f69-5b8b45dd788b","added_by":"auto","created_at":"2026-04-08 05:31:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41432,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContrast-enhanced CT of localized dissection in a superficialized brachial artery.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A)\u003c/strong\u003e Axial,\u003cstrong\u003e(B)\u003c/strong\u003e oblique coronal, and \u003cstrong\u003e(C)\u003c/strong\u003e oblique sagittal reformatted contrast-enhanced CT images of the right upper arm show focal dilatation of the superficialized brachial artery with an intraluminal thrombus, consistent with localized arterial dissection.\u003c/p\u003e\n\u003cp\u003eAbbreviations: CT, computed tomography.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9200914/v1/78984003ede52944b8abd25d.jpg"},{"id":106404479,"identity":"a776e4c6-49d7-41c1-b192-e2abadee38a4","added_by":"auto","created_at":"2026-04-08 09:16:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55805,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDuplex ultrasound of localized dissection in a superficialized brachial artery.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A)\u003c/strong\u003e Color Doppler imaging shows an abnormal Doppler signal extending outward from the lumen and returning toward the lumen near the lesion, supporting the suspicion of localized arterial dissection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(B)\u003c/strong\u003e B-mode imaging of the superficialized right brachial artery near the elbow region shows caliber irregularity with mural thrombus.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9200914/v1/321d315afe7da47f1ba347bc.jpg"},{"id":106382917,"identity":"4a0f62bf-4799-4f12-98e8-fc93f5c5db07","added_by":"auto","created_at":"2026-04-08 05:31:11","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":38699,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHospital course of superficialized brachial artery dissection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTimeline of the clinical course during hospitalization. On day 4, bedside duplex ultrasonography (US) performed at cannulation of the superficialized brachial artery (SBA) suggested localized arterial dissection, and a right internal jugular central venous catheter (CVC) was placed to avoid cannulation of the suspected lesion. Hemodialysis (HD) was performed via CVC on days 4, 7, and 9. On day 11, proximal cannulation away from the presumed entry site was confirmed feasible using SBA, and the CVC was removed. The patient was discharged on day 12.\u003c/p\u003e\n\u003cp\u003eAbbreviations: CVC, central venous catheter; HD, hemodialysis; SBA, superficialized brachial artery; US, ultrasonography.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9200914/v1/627acb32c8644f90c41d266d.jpg"},{"id":106405867,"identity":"ea7912ff-4e1f-4ffb-b672-ca978ced4f7d","added_by":"auto","created_at":"2026-04-08 09:28:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":655466,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9200914/v1/6b864315-2d17-4548-b7fd-a8d1702e5e88.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dissection in a Superficialized Brachial Artery for Hemodialysis Access: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eIn Japan, superficialization of the brachial artery, also referred to as brachial artery transposition (BAT), has been adopted for selected hemodialysis patients in whom conventional arteriovenous access is difficult [1\u0026ndash;7]. However, dissection involving this type of access has seldom been described, and an established management strategy has not been defined. Reliable vascular access is fundamental for safe hemodialysis; however, the available options may be constrained in patients with complex vascular and cardiopulmonary comorbidities.\u003c/p\u003e \u003cp\u003eClinical series have reported acceptable patency and usable dialysis blood flow with SBA/BAT in selected cohorts [1\u0026ndash;7]. However, published literature has often focused on complications such as pseudoaneurysm or aneurysmal change; infection; thrombosis or stenosis; and wound-related problems, sometimes necessitating revascularization rather than dissection as a primary event [1, 2, 4, 7, 8]. Duplex ultrasound is widely used for access assessment and cannulation support, and can support clinical management [9, 10]. Against this background, we report a case of SBA dissection detected incidentally during bedside duplex ultrasound during cannulation, managed conservatively with repeat ultrasound assessments during hospitalization, and discuss its diagnostic and management implications in the context of the literature.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 76-year-old man with end-stage kidney disease due to diabetic nephropathy had been receiving maintenance hemodialysis three times a week since 2019. After repeated occlusion of the left forearm arteriovenous access, a superficialized right brachial artery was created in 2023 for dialysis cannulation. Routine cannulation was performed using 17-gauge needles. He was not taking any oral antithrombotic agents before admission. His medical history included long-standing hypertension and diabetes mellitus, and he had undergone thoracoscopic subtotal esophagectomy for lower esophageal cancer in 2021.\u003c/p\u003e \u003cp\u003eIn early 2026, he was admitted for evaluation of gastrointestinal symptoms, he was not tolerating oral feeds. On admission (hospital day 1), he was afebrile and hemodynamically stable (temperature 36.8°C; blood pressure 126/68 mmHg; heart rate 63 beats/min; oxygen saturation 95% on room air). Examination of the SBA revealed no tenderness, erythema, or swelling, and no clinical signs of distal upper limb ischemia. On hospital day 2, he underwent hemodialysis via the SBA without local symptoms or any cannulation-related complications; and arterial dissection was not suspected at that time.\u003c/p\u003e \u003cp\u003eBecause the lesion was first recognized on hospital day 4, it was not possible to determine the timing of onset or to conclude that the dissection was caused by cannulation on hospital day 2. During routine hemodialysis on hospital day 4, bedside duplex ultrasonography performed at cannulation incidentally revealed findings suggestive of localized arterial dissection despite the absence of local symptoms. Contrast-enhanced computed tomography (CT) revealed focal dilatation of the SBA with an intraluminal thrombus, supporting the suspicion of a localized dissection (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA–C). Bedside duplex ultrasonography was also performed on hospital day 9 to support clinical management; however, formal reports were not available and the stored images are not suitable for publication. A subsequent documented duplex ultrasound examination on day 11 of hospitalization identified a presumed entry site approximately 2 cm proximal to the antecubital fossa. Duplex ultrasound showed an arc-shaped signal arising from the lumen, extending outward, and then turning back toward the lumen near the lesion; suggesting a flap-like structure (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA). Near the antecubital fossa, the artery demonstrated caliber irregularity with a mural thrombus, which was considered compatible with severe underlying atherosclerosis (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB). Re-entry into the true lumen could not be identified, and distal arterial perfusion was preserved.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo avoid cannulation at the suspected dissection site, hemodialysis was performed on hospital days 4, 7, and 9 using a right internal jugular venous catheter placed on hospital day 4. On day 11, proximal cannulation away from the presumed entry site was confirmed to be feasible using the superficialized artery, and the catheter was removed. Heparin was used during hemodialysis and maintained at the usual dose throughout this period. The clinical course of hospitalization is summarized in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. The patient was discharged on hospital day 12 and continued hemodialysis at another center using the superficialized artery with an adjusted puncture site approach.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThe most important clinical implication of this case is that localized arterial dissection in an SBA does not necessarily require abandonment of access. With careful ultrasonographic evaluation and modification of the puncture strategy, hemodialysis can be safely continued.\u003c/p\u003e\u003cp\u003eTo place the present case in context, we reviewed the relevant literature on SBA/BAT and related arterial complications. Although superficialization of the brachial artery or BAT has been described as an effective alternative means of access with acceptable patency in selected cohorts [1–6], published series have emphasized adverse events such as wound-related complications (including impaired healing, skin necrosis, infection, and lymphorrhoea), aneurysmal changes (including infective aneurysm), thrombotic or stenotic lesions, access-related bleeding or hematoma, and distal ischemia [1, 2, 4, 7, 8]. Arterial dissection has rarely been reported as a primary complication. This may reflect not only true rarity but also underrecognition, particularly when local symptoms are absent and bedside imaging is not routinely performed at the time of cannulation. Our case therefore adds to the literature by showing that a localized arterial dissection can be detected during routine bedside ultrasound assessment and managed with temporary access diversion and modified recannulation without immediate loss of access.\u003c/p\u003e\u003cp\u003eIn this patient, the duplex ultrasound demonstrated vessel caliber irregularity and a mural thrombus near the elbow region, suggesting advanced atherosclerotic change, and the presumed entry site was located approximately 2 cm proximal to the antecubital fossa. Although causality cannot be established, repeated puncture-related intimal injury is biologically plausible [11]. Arterial dissection is an uncommon but known complication of invasive arterial procedures, and similar events involving the brachial artery have been described after arterial cannulation [12, 13]. Multiple cannulation attempts are also associated with higher complication rates in arterial catheterization, reflecting cumulative mechanical trauma to the vessel wall [8, 14]. In addition, advanced age and diabetes mellitus may further predispose to arterial wall fragility and adverse vascular remodeling, potentially increasing susceptibility to mechanically induced injury [13, 15]. In superficialization of the brachial artery, the artery is intentionally positioned superficially to permit cannulation [1], and the available puncture zones may be relatively limited, which can concentrate mechanical stress on a narrow segment, particularly when the arterial wall is severely diseased. Needle gauge may also influence puncture-related trauma; however, 17-gauge needles are commonly used in routine hemodialysis cannulation and were therefore not considered a major independent risk factor in this case [16].\u003c/p\u003e\u003cp\u003ePoint-of-care duplex ultrasonography is particularly valuable for evaluating superficialized arterial access at the time of cannulation because it provides real-time assessment of both vascular morphology and hemodynamics, enabling detection of access-related abnormalities and guiding safe puncture site selection [9, 10]. Duplex ultrasonography may also raise suspicion of arterial dissection by demonstrating an intimal flap and associated abnormal color and spectral Doppler flow patterns [17]. In our case, bedside ultrasonography identified a focal wall abnormality compatible with a dissection flap or channel and a concomitant mural thrombus, which directly informed avoidance of the affected segment and subsequent modification of the cannulation site. In addition, contrast-enhanced CT can complement ultrasonography by delineating lesion extent, intraluminal thrombus, and surrounding soft tissue changes in a broader anatomical context while helping to evaluate alternative diagnoses and procedural planning [18, 19]. However, duplex ultrasonography remains important for dynamic flow assessment and follow-up during conservative management.\u003c/p\u003e\u003cp\u003eManagement options for superficialization of the brachial artery or BAT-related complications range from temporary cessation of cannulation with alternative access, (for example, catheter placement) to surgical intervention including arterial repair, segmental resection with interposition grafting, or bypass revascularization, depending on lesion severity and the threat to limb perfusion or access usability [1, 8]. In the present case, conservative management was selected because distal perfusion was preserved, the lesion appeared localized, and there was no obvious flow-limiting lumen compromise on imaging. Duplex ultrasound also suggested interval stability compared with earlier bedside assessments; and hemodialysis could be safely continued after confirming a feasible puncture segment proximal to the presumed entry site while strictly avoiding cannulation of the affected segment. Since the thrombus was mural and distal perfusion was intact without ischemic symptoms, the potential benefit of intensifying anticoagulation was not probable. Therefore, we maintained routine dialysis anticoagulation and prioritized temporary alternative access, repeated ultrasonographic assessments during hospitalization, and a safer cannulation approach.\u003c/p\u003e\u003cp\u003eAlthough no standardized treatment algorithm exists specifically for an SBA dissection; published superficialization of the brachial artery or BAT series indicate that the access artery can remain patent long-term, supporting a strategy that prioritizes access preservation when risk markers are favorable and surveillance is feasible [2–4]. Concepts from the broader iatrogenic peripheral arterial dissection literature further support individualized management: lesions without ischemia or flow limitation may be observed with close imaging assessment, whereas flow-limiting dissections or threatened perfusion generally require endovascular or surgical intervention [11, 12, 20]. Endovascular repair can be technically feasible in peripheral arterial dissections; however, in an SBA repeatedly used for cannulation, stent or stent-graft placement may compromise future puncture strategy, and is therefore not necessarily the preferred option for stable localized lesions. Given that cannulation of an SBA is typically performed in a retrograde direction relative to the arterial flow, we considered retrograde propagation of the dissection. However, the direction of propagation could not be definitively determined on available imaging; therefore, we anticipated a favorable course primarily in the context of a localized, non-flow-limiting lesion with preserved distal perfusion [11, 20].\u003c/p\u003e\u003cp\u003eIn conclusion, arterial dissection involving an SBA used for hemodialysis access is rare. Bedside duplex ultrasound can facilitate the early detection of arterial wall pathology at cannulation and support a safer puncture site approach. In selected patients with preserved distal perfusion and a localized non-flow-limiting lesion, an ultrasound-guided conservative approach with repeat ultrasound assessment during hospitalization may allow the continuation of hemodialysis without immediate surgical or endovascular intervention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBAT: brachial artery transposition\u003c/p\u003e\n\u003cp\u003eCT: computed tomography\u003c/p\u003e\n\u003cp\u003eCVC: central venous catheter\u003c/p\u003e\n\u003cp\u003eHD: hemodialysis\u003c/p\u003e\n\u003cp\u003eSBA: superficialized brachial artery\u003c/p\u003e\n\u003cp\u003eUS: ultrasonography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for the publication of this case report and any accompanying images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKY contributed to patient management, data collection, manuscript drafting, and supervised the project, including critical revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the nursing staff and clinical engineers of the dialysis unit for their support with cannulation management and bedside duplex ultrasonography during hospitalization. We also thank the sonographers and staff of the ultrasound laboratory for their assistance with duplex ultrasound examinations. In addition, we acknowledge the radiology team for their assistance with contrast-enhanced CT acquisition and interpretation.\u003c/p\u003e\n\u003cp\u003eWe used an AI-assisted tool for language editing and formatting. The authors reviewed and approved the final content and take full responsibility for the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNakamura T, Suemitsu K, Nakamura J. Superficialization of brachial artery as effective alternative vascular access. J Vasc Surg. 2014;59:1385\u0026ndash;92. https://doi.org/10.1016/j.jvs.2013.11.093\u003c/li\u003e\n\u003cli\u003eMurakami M, Mori K, Hamanoue S, Suemitsu K, Kajiwara K, Miyamoto M, et al. Multicentre study on the efficacy of brachial artery transposition among haemodialysis patients. Eur J Vasc Endovasc Surg. 2021;61:998\u0026ndash;1006. https://doi.org/10.1016/j.ejvs.2021.01.038\u003c/li\u003e\n\u003cli\u003eSoma Y, Murakami M, Nakatani E, Sato Y, Tanaka S, Mori K, et al. Brachial artery transposition versus catheters as tertiary vascular access for maintenance hemodialysis: a single-center retrospective study. Sci Rep. 2022;12:306. https://doi.org/10.1038/s41598-021-03860-1\u003c/li\u003e\n\u003cli\u003eMorita K, Murakami M, Akagi R, Nagai K. Outcomes of brachial artery transposition in hemodialysis patients. J Vasc Surg. 2024;80:855\u0026ndash;63. https://doi.org/10.1016/j.jvs.2024.05.008\u003c/li\u003e\n\u003cli\u003eYasunaga C, Nakamoto M, Fukuda K, Goya T. Superficial repositioning of the artery for chronic hemodialysis: indications and prognosis. Am J Kidney Dis. 1995;26:602\u0026ndash;6. https://doi.org/10.1016/0272-6386(95)90596-0\u003c/li\u003e\n\u003cli\u003eWeyde W, Kusztal M, Gołębiowski T, Letachowicz K, Letachowicz W, Wątorek E, et al. Superficialization of the radial artery: an alternative secondary vascular access. J Vasc Access. 2012;13:504\u0026ndash;7. https://doi.org/10.5301/jva.5000079\u003c/li\u003e\n\u003cli\u003eKukita K, Ohira S, Amano I, Naito H, Azuma N, Ikeda K, et al. 2011 update Japanese Society for Dialysis Therapy guidelines of vascular access construction and repair for chronic hemodialysis. Ther Apher Dial. 2015;19 Suppl 1:1\u0026ndash;39. https://doi.org/10.1111/1744-9987.12296\u003c/li\u003e\n\u003cli\u003eFujioka S, Sakaki K. Revascularization of the superficialized brachial artery. Ann Vasc Dis. 2025;18:25-00093. https://doi.org/10.3400/avd.oa.25-00093\u003c/li\u003e\n\u003cli\u003eTeodorescu V, Gustavson S, Schanzer H. Duplex ultrasound evaluation of hemodialysis access: a detailed protocol. Int J Nephrol. 2012;2012:508956. https://doi.org/10.1155/2012/508956\u003c/li\u003e\n\u003cli\u003eKo SH, Bandyk DF, Hodgkiss-Harlow KD, Barleben A, Lane J 3rd. Estimation of brachial artery volume flow by duplex ultrasound imaging predicts dialysis access maturation. J Vasc Surg. 2015;61:1521\u0026ndash;7. https://doi.org/10.1016/j.jvs.2015.01.036\u003c/li\u003e\n\u003cli\u003eFunaki B. Iatrogenic flow limiting arterial dissection. Semin Intervent Radiol. 2008;25:437\u0026ndash;41. https://doi.org/10.1055/s-0028-1103003\u003c/li\u003e\n\u003cli\u003eWeinberg L, Abu-Ssaydeh D, Spanger M, Lu P, Li MHG. Case report: Iatrogenic brachial artery dissection with complete anterograde occlusion during elective arterial line placement. Int J Surg Case Rep. 2018;42:269\u0026ndash;73. https://doi.org/10.1016/j.ijscr.2017.12.034\u003c/li\u003e\n\u003cli\u003eRiangwiwat T, Blankenship JC. Vascular complications of transradial access for cardiac catheterization. US Cardiol. 2021;15:e04. https://doi.org/10.15420/usc.2020.23\u003c/li\u003e\n\u003cli\u003eSandoval Y, Bell MR, Gulati R. Transradial artery access complications. Circ Cardiovasc Interv. 2019;12:e007386. https://doi.org/10.1161/CIRCINTERVENTIONS.119.007386\u003c/li\u003e\n\u003cli\u003eSakellariou XM, Nikas D\u0026Nu;, Papanagiotou P, Liberopoulos E, Florentin M, Bechlioulis A, et al. Structural radial artery modifications following transradial access: mechanisms, clinical implications, and preventive strategies. World J Cardiol. 2025;17:107772. https://doi.org/10.4330/wjc.v17.i7.107772\u003c/li\u003e\n\u003cli\u003eNardinocchi MD, Manocchi K, Traini T. The appropriateness of cannulation devices in the management of arteriovenous fistulae. G Ital Nefrol. 2020;37:2020-vol3\u003c/li\u003e\n\u003cli\u003eMontorfano MA, Pla F, Vera L, Cardillo O, Nigra SG, Montorfano LM. Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma. Crit Ultrasound J. 2017;9:5. https://doi.org/10.1186/s13089-017-0060-5\u003c/li\u003e\n\u003cli\u003eRotzinger DC, Lu TL, Kawkabani A, Marques-Vidal PM, Fetz G, Qanadli SD. Computed tomography angiography in peripheral arterial disease: comparison of three image acquisition techniques to optimize vascular enhancement-a randomized controlled trial. Front Cardiovasc Med. 2020;7:68. https://doi.org/10.3389/fcvm.2020.00068\u003c/li\u003e\n\u003cli\u003eJens S, Kerstens MK, Legemate DA, Reekers JA, Bipat S, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial injury due to trauma: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2013;46:329\u0026ndash;37. https://doi.org/10.1016/j.ejvs.2013.04.034\u003c/li\u003e\n\u003cli\u003eGe BH, Copelan A, Scola D, Watts MM. Iatrogenic percutaneous vascular injuries: clinical presentation, imaging, and management. Semin Intervent Radiol. 2015;32:108\u0026ndash;22. https://doi.org/10.1055/s-0035-1549375\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"superficialization of the brachial artery, brachial artery transposition, arterial dissection, duplex ultrasound","lastPublishedDoi":"10.21203/rs.3.rs-9200914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9200914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSuperficialization of the brachial artery is an alternative vascular access strategy for selected hemodialysis patients for whom conventional access options are limited. Dissection of a superficialized brachial artery (SBA) used for dialysis access has rarely been described, and its management is not well established.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 76-year-old man with end-stage kidney disease due to diabetic nephropathy underwent right brachial artery superficialization and maintenance hemodialysis via the superficialized artery. During routine cannulation, bedside duplex ultrasonography incidentally suggested a localized arterial dissection, despite the absence of local symptoms. Contrast-enhanced computed tomography revealed a focal dilatation of the SBA with an intraluminal thrombus. Hemodialysis was temporarily performed using a right internal jugular venous catheter to avoid cannulation of the suspected lesion. Duplex ultrasound showed preserved distal perfusion, and a flap-like structure with a mural thrombus and caliber irregularity near the antecubital fossa; the presumed entry site was approximately 2 cm proximal to the antecubital fossa. After confirming the feasibility of proximal cannulation under ultrasound guidance, the catheter was removed, and hemodialysis was continued using an adjusted puncture site approach.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case suggests that bedside duplex ultrasound can be used in the early detection of arterial wall pathology in SBA access; and in selected patients with preserved distal perfusion and non-flow-limiting localized lesions, an ultrasound-guided conservative approach with repeat ultrasound assessment during hospitalization may allow the safe continuation of hemodialysis.\u003c/p\u003e","manuscriptTitle":"Dissection in a Superficialized Brachial Artery for Hemodialysis Access: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-08 05:31:05","doi":"10.21203/rs.3.rs-9200914/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e540f23-8004-46d7-bf0e-af372d7774cc","owner":[],"postedDate":"April 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-10T02:55:11+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-08 05:31:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9200914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9200914","identity":"rs-9200914","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}