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The elevation procedure of the arterialized vein was originally introduced as a surgical revision for the purpose of facilitating AVF cannulation. Adequate maturation of the fistula is required for the successful implementation of repeatable, safe cannulation in clinical practice. The updated NKF-K/DOQI guideline proposes the following parameters associated with maturity of a newly created AVF, famously known as “the rule of 6s:” flow of > 600 mL/min, diameter of ≥0.6 cm, depth of ≤0.6 cm, and discernible margins [2].

In general, the rate of initial or early non-maturation AVF failure ranges from 20 to 60% [19]. Moreover, according to a study by van Loon et al. [20], during the first 6 months of a newly placed VA, a substantial proportion of patients encounter cannulation-related complications resulting in the need for temporary VA methods such as single-needle dialysis (33%) and catheter dialysis (22%). Cannulation-related complications of VA, such as hematoma formation, infection, and aneurysms, might lead to morbidity, hospitalization, access revision, loss of the VA, and the consecutive occurrence of other serious adverse events potentially attributable to the temporary VA [20, 21]. Ultrasound-guided needling may facilitate successful cannulation of arterialized veins with inaccessibility. However, a fundamental resolution regarding the clinical value of this technique has not yet been reached, and a certain risk of mis-cannulation and patient burden inevitably remains. Additionally, ultrasound guidance requires advanced technical skill. Given these facts, adjunctive elevation should be used to improve the accessibility by decreasing the depth and lengthening the accessible segment of the arterialized vein, which will in turn minimize the incidental risk of mis-cannulation and its related complications.

The elevation technique was recently adapted to one- or two-stage TBBAVF construction as an alternative combined superficialization procedure of tunnel transposition, as mentioned earlier (Figs. 1, 2). Furthermore, several reports have suggested the practical feasibility of AVF creation combined with the elevation of deeply located forearm and upper arm cephalic veins in a one- or two-stage procedure [10, 22, 23].

The outcomes of various elevation procedures were evaluated in a retrospective study conducted by Bronder et al. [10]. The authors assessed 295 cases of vein elevation (172 brachiocephalic fistulas, 70 brachiobasilic fistulas, 46 radiocephalic fistulas, and 7 superficial femoral vein fistulas) performed in a one- or two-stage procedure. The two-stage procedure included revisional elevation implemented within certain terms after fistula construction. The authors demonstrated that these elevations provided acceptable functional primary and secondary patency as a whole and found no significant differences in any outcomes based on the anatomic site of elevation or whether the procedure was performed in one or 2 stages [10].