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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44; </span></p><p class="elsevierStylePara">The most frequent complications of arteriovenous fistula &#40;AVF&#41; type subcutaneous vascular accesses are infections&#44; thrombosis and complications due to low flow&#44; such as steal syndrome and stenosis&#44; both intrinsic to anastomoses and venous return&#46; An infrequent complication&#44; but one that is difficult to treat&#44; is calciphylaxis&#46; It affects small peripheral arteries&#44; causing very painful skin necrosis&#46;<span class="elsevierStyleSup">1-9</span> The case that we present below is unusual because&#44; although it presents some similarities with calciphylaxis&#44; it differs in pathogenesis&#44; treatment and resolution&#44; since it is a surgical complication in a patient with a very calcified arterial bed&#46;</p><p class="elsevierStylePara">The case is a 75 year old man&#44; with a history of stage 5 chronic renal failure of unknown origin&#44; who has been on haemodialysis for 7 years&#46; Other history data of interest&#58; chronic obstructive pulmonary disease&#44; <span class="elsevierStyleItalic">ischaemic </span>stroke without sequelae&#44; high blood pressure&#44; former smoker&#44; chronic atrial fibrillation anticoagulated with acenocoumarol&#44; hypercholesterolemia&#44; erosive duodenitis&#44; appendectomy&#44; several episodes of hyperpotassaemia&#44; intermittent claudication&#44; and femoropopliteal revascularization&#46;</p><p class="elsevierStylePara">Regarding vascular access&#44; haemodialysis was started through a right jugular tunnelised catheter&#44; subsequently a humero-cephalic arteriovenous fistula &#40;AVF&#41; was performed in the left arm&#44; but it did not function&#46; Subsequently a radio-cephalic AVF was performed without problems in the right arm&#44; and the catheter was removed&#46; It functioned without any problems from the beginning&#44; but progressively&#44; during 2008&#44; a very high recirculation index was detected &#40;44&#46;3&#37;&#41;&#44; with the consequent infra-dialysis&#46; After consultation with the vascular surgery department&#44; it was decided to carry out a reconstruction at a more proximal site&#44; since the artery was very calcified&#46; After surgery&#44; there was a significant improvement of recirculation values&#44; as well as analytical values corresponding to urea kinetics &#40;KtV&#41;&#46; On the 7<span class="elsevierStyleSup">th</span> of May 2009&#44; this vascular access suffered thrombosis&#59; therefore a left jugular tunnelised catheter was implanted&#46; Subsequently&#44; on 18<span class="elsevierStyleSup">th</span> August 2009&#44; a new&#44; more proximal&#44; radio-cephalic AVF was performed in the right arm&#46; A surgical complication developed&#44; an expanding haematoma which affected the whole forearm&#46; Progressively&#44; the patient suffered pain and coldness of the right hand&#44; with decreased pulses&#44; compatible with steal syndrome&#46; As to the antebrachial haematoma&#44; its size did not decrease&#44; and an ever greater area of tissue necrosis developed in the region of the surgical wound&#44; reaching a size of 4 cm in length by 4 cm in width&#44; with underlying granulation tissue surrounding the scab&#44; as shown in Figure 1&#46; In view of this situation&#44; an arterial echo Doppler of the right upper limb was performed and a functioning AVF detected&#44; with arterial steal&#44; and a non-encapsulated haematoma&#46; Pain increased&#44; as also coldness and hand functional impotence&#44; so we ligated the AVF on the 10<span class="elsevierStyleSup">th</span> of September 2009&#46; After intervention the symptoms of steal syndrome disappeared&#44; the necrotic scab became detached and the antebrachial haematoma began reabsorption&#46; For 2 months we proceeded to dress the underlying wound beneath the necrotic scab&#44; until complete healing was achieved&#46; Since then&#44; the patient has been asymptomatic&#44; and it was decided to maintain the left jugular tunnelised catheter as a permanent vascular access in view of the failed attempts to obtain other subcutaneous accesses&#46;</p><p class="elsevierStylePara">Differential diagnosis with calciphylaxis is necessary&#44; since the patient&#8217;s risk factors predisposed to this disorder&#44; and the skin lesion had certain similarities&#46; However&#44; since the cause-effect relation with surgery was evident&#44; and hand ischemia caused by the steal syndrome caused the patient intense pain and functional impotence&#44; we opted for AVF ligature&#46; It led to the complete recovery of hand ischemia and the skin necrosis&#44; after opportunely applying dressings&#44; with no sequelae&#46; If the case had not resolved&#44; it would have been necessary to perform a biopsy to rule out calciphylaxis&#46; There are no similar cases described in the scientific literature&#44; the most similar disorders are pressure ulcers&#44; caused by external pressure in bedridden patients or patients with reduced mobility&#46;<span class="elsevierStyleSup">10-15</span>&#160;Pressure in our case was caused from the subcutaneous compartment due to a space impingement on the surgical wound area caused by the expanding haematoma&#44; which&#44; together with defective vascularisation due to severe arterial calcification&#44; caused skin necrosis&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10299&#95;108&#95;7820&#95;en&#95;10299&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10299_108_7820_en_10299_f1.jpg" alt="Skin necrosis"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Skin necrosis</p>"
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