Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

STEP 3: OPERATIVE STEPS—ANTECUBITAL ARTERIOVENOUS FISTULA

1.INCISION

The patient is placed supine, with the arm placed on an arm board.

Approximately 1 cm below the antecubital crease, a horizontal incision is made, with care taken to preserve the subcutaneous veins (Figure 90-8).

Incision for arteriovenous fistula

FIGURE 90–8

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2. DISSECTION

A suitable antecubital vein is identified and mobilized. The basilic, cephalic, or antecubital bridging veins are typically used. Strategically, flow through the cephalic vein will be easier to access at the dialysis center (Figure 90-9).

The brachial arterial pulse is identified just proximal to the elbow. The bicipital aponeurosis is divided, exposing the artery. Proximal and distal control is obtained. Communicating veins overlaying the artery may need to be divided to allow adequate control. Care must be taken to avoid damage to the nearby median nerve (Figure 90-10).

The vein is divided as distally as possible, flushed with heparinized saline, and dilated manually.

The patient is heparinized, and proximal and distal arterial clamps are placed.

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An end-to-side anastomosis is performed with 6-0 Prolene suture (Figure 90-16).

The clamps are removed, with the distal arterial clamp removed last. The proximal vein is palpated for a thrill. Revision may be necessary if a thrill is not readily palpable. If the vein twisted in the tunnel, the anastomosis may need to be taken down and the vein retunneled. If the fistula is pulsatile without a thrill, a distal obstruction may be present. A venogram can be performed to assess for stenotic lesions.

3. CLOSURE

The wound is closed in two layers with interrupted 3-0 Vicryl subcutaneous sutures and a running 4-0 Monocryl subcuticular layer.

Brachial veins

Basilic vein

Brachial artery

Brachial artery

Basilic vein

FIGURE 90–16

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STEP 3: OPERATIVE STEPS—ARTERIOVENOUS GRAFTS

1.APPROACH AND INCISION

Although primary arteriovenous fistulae are preferred, some patients do not have adequate veins to allow fistula creation. In these cases, artificial conduit, most commonly standard wall 6-mm polytetrafluoroethylene (PTFE), is used. Occasionally, more distal PTFE grafts can bridge to later arteriovenous fistula creation by arterializing the downstream vein.

Incisions are made according to the target vessels. Grafts may be placed in a looped, curved, or straight configuration, based on the availability of arterial inflow and venous outflow, as well as the anatomic position and future ease of access at the dialysis center. Again, the principle of distal placement is followed. Grafts that cross joints or have a sharp turn (e.g., a forearm hairpin turn) may require a short segment of ringed graft. Femoral grafts are avoided if possible, because they may interfere with future kidney transplant

(Figures 90-17 through 90-21).