The Brachioradial Artery Variant: A Diagnostic Challenge in the Assessment of Dialysis Access-Associated Steal Syndrome

An 89-year-old woman with end-stage renal disease presented for evaluation of a new right-sided brachial-axillary arteriovenous graft (AVG). Postoperative physical examination revealed a strong, palpable radial pulse and no global hand dysfunction, suggesting adequate distal perfusion. However, duplex ultrasound identified a high-origin radial artery (brachioradial artery) that spared the thumb and index finger from the pressure gradient of the AVG, while the middle, ring, and small fingers exhibited a distinct segmental perfusion deficit. Spectral Doppler and photoplethysmography confirmed total retrograde ulnar flow that reverted to antegrade only with manual AVG compression. This case illustrates the value of duplex scanning for identifying an anatomic variant that affected the clinical presentation of steal physiology after creation of a proximal limb arteriovenous access.