Perioperative management - Hemodialysis access surgery: brachiocephalic fistula ("direct antecubital fistula")

• Decompensated renal failure

• Heart failure NYHA III to IV with massively impaired cardiac ejection fraction
• Infections in the immediate vicinity of the surgical site
• Poorly developed/interrupted arm veins, e.g., following multiple punctures
• Higher-grade PAOD of the upper limb

Medical history

• Prior central venous line? -> central veins patent? -> possibly duplex ultrasound/phlebography
• Prior cardiac pacemaker? -> which vessel was used? occluded cephalic or subclavian vein?
• Prior vascular surgery or arm injury?
• Diabetes mellitus? -> if necessary, primary fashioning of the AV fistula on the upper arm
• Indications of CHD and possibly PAOD in the upper limb? -> possible contraindication for shunt placement
• Anticoagulants? Continue perioperatively?
• Previous vascular access surgery? -> spontaneous occlusion? recurrent shunt thrombosis?

Inspection

• Edematous swelling of the arm? -> central problem?
• Venous collaterals in the shoulder region? -> indicative of occluded subclavian vein
• Inflammatory changes, eczema, cutaneous mycosis? -> local contraindication
• Acral skin colour

Clinical examination

• Palpation of the brachial, radial, and ulnar arteries: palpable pulses?
• Allen test (see below): functional test to assess the blood supply to the hand via the radial and ulnar arteries
• Vein quality assessment by mild compression with a BP cuff

Technical examination

• Arterial and venous duplex sonography (“fistula mapping”)
  • Search for deep-lying veins in obese patients
  • Evaluation of venous diameters
  • Evaluation of arterial vessel walls (arteriosclerosis?)

Allen test

Technique

First, the examiner manually compresses both the radial and ulnar arteries. The patient then repeatedly makes a fist to pump out the venous blood until the palm of the hand turns white.

Selective release of the manual compression of the radial or ulnar artery is used to determine whether the collateral blood supply to the hand provides adequate perfusion. Due to the collateral blood supply of the hand, one of these two arteries normally suffices to supply the entire hand with arterial blood.

Evaluation

If the hand rapidly turns pink (approx. 5–7 sec.) after releasing the compression, the Allen test is normal. If rapid reperfusion is absent or this time is markedly prolonged, the test is pathological and indicates vascular anomalies, occlusion, or arteriosclerotic vascular changes in the artery in question.

• Plan AV fistula/Shunt surgery on day without dialysis!
• If necessary, trim the hair around the surgical site

General risks

• Secondary bleeding, haematoma, possibly reoperation
• Allogeneic blood transfusion, risk of infection (hepatitis, HIV)
• Wound infections, pharmacological or surgical measures
• Allergy/intolerance (latex, medications, contrast agents)
• Thromboembolism
• Skin, tissue, nerve damage
• Keloid

Specific risks

• Infection, thrombophlebitis, possible surgical revision
• Nerve lesion (especially with corrective/repeat procedures)
• Poor limb perfusion → possible fistula exposure or termination, or fashioning of a new AV fistula
• Steal phenomenon
• Chronic arm oedema due to central venous run-off obstruction, possible balloon dilatation or stenting
• Heart failure due to fistula-related increase in cardiac output
• X-ray contrast agents → compromised renal function
• Aneurysm, stenosis → surgical revision