Hemodialysis access surgery: brachiocephalic fistula ("direct antecubital fistula")

Oblique skin incision in the region of the right cubital fossa with transection of the subcutaneous tissue.

Tip:

Spare the median cubital and basilic veins. They may come into play if the further course of the cephalic vein reveals a problem and it is unsuitable for fashioning a dialysis access fistula. In such a situation, a basilic fistula may be a suitable alternative, for example.

Locate and dissect the cephalic vein, which is encircled centrally with a vessel loop. Peripherally, ligate the vein by simple ligation approximately 1 cm distal to the junction of the entering side branch. Occlude the vein centrad with a soft bulldog clamp and take down both the vein and its lateral branch peripherally. Carry the incision of the vein into the lateral branch, resulting in a so-called flared shape.

After careful dilation, probe the cephalic vein centrad with a Fogarty catheter to verify vessel patency along the course of the upper arm. Delicately dilate the vein when withdrawing the catheter. This is followed by instillation of 1,000 IU of heparinised saline into the central vessel segment.

Tips:

1. Do not bruise the vein with the forceps.

2. If a suitable collateral branch supplies the vein peripherally, use it to fashion a flared anastomosis. This will facilitate the anastomosis.

3. In case of small vein caliber, carefully dilate the cephalic vein and delicately dilate it with a balloon catheter along its entire course on the upper arm.