Revascularization using distal inflow via a native retrograde cephalic vein branch for high-flow brachiocephalic arteriovenous fistula

We present a 62-year-old male with end-stage kidney disease and a high-flow brachiocephalic arteriovenous fistula (3.3 L/min). Revascularization using distal inflow was performed with a naturally developed retrograde cephalic vein branch in the ipsilateral arm anastomosed to the distal radial artery. The original anastomosis was ligated. The patient could use the revised forearm portion of the autogenous moderate-flow fistula at 2-month follow-up. This case demonstrates the use of naturally augmented veins to facilitate revascularization using distal inflow rather than a prosthetic graft or saphenous vein conduit, offering a unique approach to flow reduction and creation of autogenous forearm conduits for cannulation.