Creation of a Radial-Cephalic Arteriovenous Fistula
,
Massachusetts General Hospital
Main Text
Table of Contents
End-stage renal disease is common in the United States. It is most commonly caused by diabetes and hypertension. Renal function progressively declines over an unpredictable period of months to years, such that the kidneys are no longer able to perform their function. If failing renal function is not corrected or aided, premature demise is certain. Fortunately, several reliable techniques exist for establishing durable vascular access to aid in renal replacement therapy, specifically hemodialysis. Here we present the case of a middle-aged male with progressive renal failure who underwent arteriovenous fistula creation for the purposes of aiding in renal replacement. We outline the scope of the problem, its natural history, preoperative care, selected intraoperative techniques, and relevant postoperative considerations for this process.
The world has seen an alarming rise in the number of patients with chronic kidney disease (CKD), with tens of millions of cases in the United States alone. In the United States, the easy availability of chronic hemodialysis (HD) as renal replacement therapy (RRT) enables it to serve as a safe and viable destination therapy for some, and as a bridge to transplant for others. Surgical hemodialysis access in the form of an arteriovenous fistula (AVF) provides the best conduit for HD.1
AVFs are surgically created connections between the native arteries and veins, allowing for reliable HD access capable of achieving the necessary blood flow rates for effective filtration. Here we will discuss the necessary steps in preoperative evaluation, as well as the surgical technique for creating a common type of AVF.
A thorough history and physical examination are part of the evaluation for AVF creation.
In particular, hand dominance and work history should be established. Evaluators should also assess for concomitant illnesses that may reduce the success of HD access creation.2, 3 Furthermore, a history of stroke, extremity incapacitation, chronic infections, skin diseases, and immunosuppression are important as these may affect the choice of procedure. Lastly, past surgical history should focus on access procedures, the venous system, and chest surgery.
Our patient is a 56-year-old right-hand dominant male with a history of obesity, type II diabetes, hypertension, hyperlipidemia, heart failure, and progressive renal failure. He has had no previous surgeries. Notable medications include aspirin, atorvastatin, isosorbide mononitrate, metoprolol succinate, and furosemide. Family history is notable for a sister with type II diabetes induced end-stage renal disease (ESRD) requiring renal transplantation. Our patient is retired, a social drinker, and a previous five pack-year smoker who quit 17 years prior.
Physical manifestations of chronic kidney disease (CKD) are often protean and may not appear until very late in the course of the disease. A comprehensive physical exam is important to assess suitability for surgery.
The preferred first site of fistula creation is the non-dominant arm. If this is not possible, the exam can be extrapolated to an alternate location. Examine for nearby edema, skin disease, scars, or extensive venous collaterals. Distal to the proposed site of AVF creation, the extremity should be free from neurovascular compromise.
Relevant arterial vasculature should be palpable, soft, easily compressible, and symmetric. Bilateral blood pressures should be obtained to ensure there are no obvious asymmetries, and Allen’s test should be performed to establish the presence of collateral flow distal to the proposed site of AVF creation. Alternatively, the Barbeau test has been noted to be more accurate and less subjective.4
In our case, the preoperative examination reveals an obese male. His heart rate is 51 beats per minute, and his left and right arm blood pressures are 139/66 mmHg and 152/72 mmHg, respectively. His heart is regular with a grade II/VI systolic murmur. His lungs have rales in the bases. He has 1+ pitting bilateral lower extremity edema, and his jugular venous pulsation is 2 cm above the clavicle when reclining at 45°. His left arm is free from skin abnormalities and demonstrates a normal Allen's test and a palpable cephalic vein in the forearm.
In preparation for AVF creation, ultrasound (US) mapping of the relevant arteries and veins is of the utmost importance. US imaging provides information about vein diameter, patency, distensibility, depth, congenital variations, and unsuspected pathology.1 Although it is operator dependent, the US has the advantage that it is non-invasive, evaluates both the arteries and veins in one setting, and does not require administration of nephrotoxic iodinated contrast. Moreover, it can be performed safely and quickly in the physician’s office and is easily repeated in the preoperative holding area.
If there are further questions concerning vascular disease, additional studies including contrast venography, arteriography, computed tomography, or magnetic resonance angiography are available as the adjunctive imaging techniques. These modalities must be utilized carefully given the toxic effects of various contrast media in the CKD patient.
The suggested minimum arterial diameter for successful AVF creation is 1.5–2 mm, but we prefer a minimum diameter of 2 mm.5, 6 With regard to venous anatomy, it is important that the lumen be ≥ 2.5 mm with the unobstructed flow. Additionally, it is ideal, though not imperative, that the selected segment be straight and < 1 cm from the skin surface. Many of these characteristics can be assessed by clinical examination, but the “2009 Kidney Disease: Improving Global Outcomes” guidelines recommend preoperative imaging.7
In our case, preoperative upper extremity vascular imaging is notable for a 3.8-mm cephalic vein and a 2.6-mm radial artery in the lower forearm. Both vessels are patent and without pathology.
Signs and symptoms of progressive renal dysfunction are insidious in onset and heterogeneous from patient to patient, and the determinants of progression are poorly understood.8 Factors such as HTN, diabetes, and proteinuria are known; however further investigation is ongoing to elucidate additional influences.9 As the disease progresses, patients will manifest symptoms of increasing morbidity and declining renal filtration, excretion, and endocrine function. It is known that CKD is strongly associated with poor outcomes, increased morbidity, and up to a 50% 5-year mortality rate.8
Patients with advanced CKD (a glomerular filtration rate of < 25 ml/min) should be referred to an access surgeon for evaluation for HD access.10 AV access should be created as soon as possible to allow proper “maturation” and to perform any additional procedures prior to HD initiation.1, 11 Evidence suggests that access construction 4–6 months prior to HD initiation is associated with fewer complications including death and sepsis.1, 11
There are three types of vascular access that are commonly utilized for performing HD12-15:
- Tunneled central venous catheters
- Arteriovenous grafts
- Arteriovenous fistulae
Autogenous arteriovenous access, created by anastomosing a native artery and vein to create a fistula, is the preferred method of HD access creation (AVF). This is due to its superior results in preventing failure and infection relative to other modalities.12-15
If the patient’s arterial or venous beds are not suitable for autogenous fistula creation, an arteriovenous fistula can be created with the aid of an interposed synthetic or biologic material (AVG). Its use is limited due to increased rates, relative to AVF, of both stenosis at the venous anastomosis, causing graft closure and of graft infection.12
Lastly, tunneled venous catheters provide immediate, short term HD access. However, they are fraught with acute and chronic complications such as thrombosis, infection, and central venous stenosis and generally should not be used in the long term.16
Of the commonly used methods, HD performed via autogenous AV access is superior with regard to patient morbidity and mortality with the possible exception in the elderly population (>75 years of age).13-15 Autogenous access is also associated with lower rates of patient death and infection and higher rates of graft patency.17 Additionally, initial AVF access should ideally be located as far distally in the upper extremity as possible in order to preserve more proximal locations for any future procedures.
In our case, the thorough preoperative evaluation revealed satisfactory arterial and venous conduits for the creation of a radio-cephalic AVF in the patient’s non-dominant forearm.
In preparation for AVF creation, it is important to ensure that the patient is healthy enough to undergo surgical intervention as this patient population can be quite ill at baseline.1 It is also important to ensure that there is no overlying skin or soft tissue infection at the proposed site.17
The preferred arterial conduit is the radial artery given its proximity to the cephalic vein relative to the ulnar artery.1 Furthermore, the cephalic vein is preferred to other veins given its ease of access and dissection. Lastly, the surgeon ideally utilizes standard surgical magnification while operating.
There is a growing burden of kidney disease worldwide. In the United States alone there are an estimated 20 million adults with CKD.10 The incidence of the disease has doubled since the beginning of the twenty-first century, growing most rapidly in adults older than sixty. The course of kidney disease is unpredictable with many sufferers progressing to ESRD and requiring dialysis. As of 2009, there were an estimated 871,000 people receiving treatment for ESRD.10
A patient with ESRD will require RRT in the form of hemodialysis, peritoneal dialysis, or renal transplant, to sustain life. The demand for donor kidneys is high; there are currently 100,791 people waiting for kidney transplants in the United States with 3,000 new patients being added to the waiting list each month. The median wait time is 3.6 years, and while awaiting transplantation, many patients become too ill to survive transplantation or pass away prior to being offered an allograft.18 Alternatively, there are 398,861 individuals in the United States receiving HD for their ESRD.10
In this article, we presented the case of a 56-year-old male with type II diabetes leading to ESRD. He underwent an uncomplicated left forearm radio-cephalic AVF creation and recovered without complication. He was seen in follow-up eight weeks after surgery and found to be in satisfactory health, but his GFR has continued to decline such that he is requiring increasing doses of furosemide to maintain a euvolemic state. On exam, the site of the AVF had a strongly-palpable thrill. A bruit was auscultated, but it had not yet matured to the point that could be accessed for HD. He will continue to meet with his outpatient nephrologist to assess the maturation of the fistula and plan for the eventual initiation of HD.
Over the past ten years, more than one million patients in the United States have initiated HD. This process has almost become routine and is now considered a “minor” procedure. This has been made possible through improved safety and refinement of vascular access creation techniques, and it is no small feat when considering the far-reaching effects of ESRD and that the patient population inherently has a diminished baseline secondary to comorbid disease.19
When chosen appropriately and monitored carefully, it is possible to safely perform HD access creation with a relatively low risk of complication. Of the available methods, AVF creation remains the most reliable method for providing RRT in patients with ESRD.12-15 However, outcomes studies of AVF creation note that primary failure of the fistula remains a major issue.20 There is no clear consensus on the predictors of this phenomenon, but it is thought that arterial diameter is most strongly associated with success or failure. Schinstock et al. found that the mean initial arterial diameters for patent brachiocephalic, brachiobasilic, and radiocephalic AVFs were 4.7 ± 1.0, 4.4 ± 1.2, and 2.9 ± 1.2 mm, respectively.20
When compared with other means of obtaining vascular access, AVFs present lower risks of morbidity in the form of infection and technical complications.19, 21 Additionally, the rate of cardiovascular and infection-related mortality after AVF creation is 3.1% versus 9.7% after catheter placement or 4.8% after graft placement.19 These estimates are amplified in the older and increasingly more comorbid patients. These morbidity and mortality risks are not trivial when considering the large number of people who will require RRT as a bridge or destination therapy.
With this burden in mind, multiple studies are underway to further refine the process of AVF creation and further optimize patient outcomes. It will be important to define testing modalities to ensure adequate extremity perfusion after fistula creation. In an effort to minimize burdensome complications, work is being done to refine alternative techniques of access creation such as a tunneled central venous catheter or AVG placement. Most importantly, work continues to better characterize biologic determinants of renal failure, as well as its progression towards ESRD requiring RRT.
We have nothing to disclose.
Consent for the use of clinical history, radiology, and the intraoperative video was obtained from the patient and providers involved in the compilation of this case report and filming.
Citations
- Sidawy AN, Spergel LM, Besarab A, et al. The Society for Vascular Surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg. 2008;48(5)(suppl):S2-S25. doi:10.1016/j.jvs.2008.08.042.
- Miller PE, Tolwani A, Luscy CP, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int. 1999;56(1):275-280. doi:10.1046/j.1523-1755.1999.00515.x.
- Astor BC, Coresh J, Powe NR, Eustace JA, Klag MJ. Relation between gender and vascular access complications in hemodialysis patients. Am J Kidney Dis. 2000;36(6):1126-1134. doi:10.1053/ajkd.2000.19816.
- Barbeau GR, Arsenault F, Dugas L, Simard S, Larivière MM. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen's test in 1010 patients. Am Heart J. 2004;147(3):489-493. doi:10.1016/j.ahj.2003.10.038.
- Malovrh M. Approach to patients with end-stage renal disease who need an arteriovenous fistula. Nephrol Dial Transplant. 2003;18(suppl 5):v50-v52. doi:10.1093/ndt/gfg1047.
- Silva MB Jr, Hobson RW II, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg. 1998;27(2):302-308. doi:10.1016/S0741-5214(98)70360-X.
- Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2009;76(suppl 113):S1-S130. doi:10.1038/ki.2009.188.
- Jennings WC, Kindred MG, Broughan TA. Creating radiocephalic arteriovenous fistulas: technical and functional success. J Am Coll Surg. 2009;208(3):419-425. doi:10.1016/j.jamcollsurg.2008.11.015.
- Stringer S, Sharma P, Dutton M, et al. The natural history of, and risk factors for, progressive Chronic Kidney Disease (CKD): the Renal Impairment in Secondary care (RIISC) study; rationale and protocol. BMC Nephrol. 2013;14:95. doi:10.1186/1471-2369-14-95.
- Kidney disease statistics for the United States 2016. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.niddk.nih.gov/health-information/health-statistics/Pages/kidney-disease-statistics-united-states.aspx. Accessed August 1, 2017.
- Jindal K, Chan CT, Deziel C, et al; Canadian Society of Nephrology Committee for Clinical Practice Guidelines. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol. 2006;17(3)(suppl 1):S1-S27. doi:10.1681/ASN.2005121372.
- Bachleda P, Utikal P, Kocher M, Cerna M, Fialova J, Kalinova L. Arteriovenous graft for hemodialysis, graft venous anastomosis closure - current state of knowledge. Minireview. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015;159(1):27-30. doi:10.5507/bp.2014.027.
- Onuigbo MAC. The natural history of chronic kidney disease revisited—a 72-month Mayo Health System Hypertension Clinic practice-based research network prospective report on end-stage renal disease and death rates in 100 high-risk chronic kidney disease patients: a call for circumspection. Adv Perit Dial. 2009;25:85-88. https://www.advancesinpd.com/adv09/306-Onuigbo-Final.pdf.
- Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int. 2001;60(4):1443-1451. doi:10.1046/j.1523-1755.2001.00947.x.
- Allon M, Daugirdas J, Depner TA, Greene T, Ornt D, Schwab SJ. Effect of change in vascular access on patient mortality in hemodialysis patients. Am J Kidney Dis. 2006;47(3):469-477. doi:10.1053/j.ajkd.2005.11.023.
- Vats HS. Complications of catheters: tunneled and nontunneled. Adv Chronic Kidney Dis. 2012;19(3):188-194. doi:10.1053/j.ackd.2012.04.004.
- Tordoir JHM, Bode AS, Peppelenbosch N, van der Sande FM, de Haan MW. Surgical or endovascular repair of thrombosed dialysis vascular access: is there any evidence? J Vasc Surg. 2009;50(4):953-956. doi:10.1016/j.jvs.2009.06.058.
- Organ donation and transplantation statistics 2017. National Kidney Foundation website. https://www.kidney.org/news/newsroom/factsheets/Organ-Donation-and-Transplantation-Stats. Accessed August 7, 2017.
- Stolic R. Most important chronic complications of arteriovenous fistulas for hemodialysis. Med Princ Pract. 2013;22(3):220-228. doi:10.1159/000343669.
- Schinstock CA, Albright RC, Williams AW, et al. Outcomes of arteriovenous fistula creation after the Fistula First Initiative. Clin J Am Soc Nephrol. 2011;6(8):1996-2002. doi:10.2215/CJN.11251210.
- Lok CE, Foley R. Vascular access morbidity and mortality: trends of the last decade. Clin J Am Soc Nephrol. 2013;8(7):1213-1219. doi:10.2215/CJN.01690213.
Cite this article
Nahel Elias, MD, FACS, Sahael Stapleton, MD. Creation of a radial-cephalic arteriovenous fistula. J Med Insight. 2020;2020(110). https://doi.org/10.24296/jomi/110Procedure Outline
- Initiate Anesthesia
- This procedure is regularly performed under general anesthesia or monitored anesthesia care (MAC) with or without intravenous sedation. The choice of approach is based on the patient's baseline risks and ability to tolerate anesthesia. If performed under MAC, either local anesthesia or a peripheral nerve block is obtained in the holding area.
- Position Patient
- The patient is positioned supine with the operative arm abducted and resting comfortably on a specialized wide arm board designed for hand surgery. If this is not available, it is possible to have two standard-sized arm boards placed next to each other.
- Mark Incision and Inject Local Anesthetic
- Use preoperative US and manual palpation to determine the location of the cephalic vein and radial artery.
- If the artery and vein are near to each other, a single curvilinear incision is acceptable. If the vessels are separate from each other, it is better to perform two parallel longitudinal incisions and create a subcutaneous tunnel through which to position the cephalic vein at the time of anastomosis. In our case the artery and vein were in close proximity.
- Incise and Dissect to Vein
- Make a 5-cm curvilinear incision over the artery and vein with the proximal end of the incision closest to the vein or directly superficial to it.
- Carefully dissect the subcutaneous tissues and fat with a combination of sharp dissection and electrocautery.
- Mobilize Vein and Retract with Vessel Loop
- Identify the cephalic vein in the radial groove and dissect it proximally and distally to expose a 4-cm segment that is of an appropriate diameter.
- Ligate vein branches with braided suture.
- Locate and Mobilize Artery
- Identify and palpate the radial artery (it courses parallel to the cephalic vein) and sharply dissect a 4-cm portion that is of adequate caliber.
- Place vessel loops proximally and distally along the artery. These should be double looped and used for retraction and occlusion of the artery. This is less disruptive to the artery than vascular clamps, and does not crowd the small surgical field.
- Tie and Ligate Vein
- Ligate the cephalic vein at the distal most end of its course. Be sure to mobilize an adequate length of the vein proximally, such that it will anastomose with the artery in a tension-free manner.
- Spatulate the vein at an oblique angle to perform a larger anastomosis.
- Dilate Vein
- Flush the proximal end of the vein with heparinized saline solution; this will enable evaluation of vessel caliber as well as any side branches or iatrogenic vein injuries that may need repair.
- Place a Bulldog clamp proximal on the vein.
- Incise Artery
- After proximal and distal control of the artery (with vessel loops), an arteriotomy is created, the length of which should be limited to 4–6 mm to limit the risk of creating a vascular steal phenomenon. This is especially important with a small diameter artery. The size of the arteriotomy should roughly correspond to the spatulated diameter of the vein.
- Suture Anastomosis
- Create an end-to-side anastomosis between the cephalic vein and radial artery using 6-0 or 7-0 polypropylene suture in a continuous running fashion, as this will prevent enlargement of that anastomosis, which may also lead to steal phenomena.
- Inspect and Adjust
- Release the clamp on the vein and then the vessel loops on the proximal and distal portions of the artery.
- Test Flow with Palpation and Doppler Probe
- Palpate the newly-created fistula to ensure that there is a palpable thrill indicating appropriate flow. As an adjunct to palpation, the surgeon can use a Doppler probe to listen for appropriate arterial signal at the site of the anastomosis.
- Close the subcutaneous tissue over the fistula using a running 3-0 braided stitch. Close the skin in a single layer using a 4-0 monofilament stitch. Single-layer skin closure is also adequate in cases with minimal subcutaneous tissue.
- Immediate Postoperative Care
- Place a standard postoperative occlusive dressing. Some pressure dressing may be necessary in the event that the patient is at elevated risk of raw surface or other postoperative venous bleeding. This should not be placed proximal to the incision to avoid pressure on the proximal vein and occlusion of it.
- Postoperative pain should be minimal; patients often do not require opiate pain medication.
- Upon discharge the patient should receive instructions for hand exercises to start 1–2 days postoperatively. These exercises should increase blood flow through the venous system, which in turn will aid in maturation of the AVF.
- Postoperative Restrictions and Plan for Follow-up
- Postoperatively activity is minimized for the immediate postoperative period (specifically, avoid lifting heavy objects for 14 days).
- Patients are instructed to palpate their newly created fistula every day and should contact their surgeon immediately if a thrill is absent.
- The patient will follow up in the surgical clinic approximately two weeks postoperatively to assess healing and fistula patency, and again 6–8 weeks postoperatively to evaluate for fistula maturation.
Transcription
CHAPTER 1
Hello my name is Nahel Elias. I'm a transplant surgeon at Massachusetts General Hospital. The procedure today is an arteriovenous fistula at the wrist, so it's a radial artery to cephalic vein or radiocephalic AV fistula creation. The procedure consists of dissecting through the skin, identifying the cephalic vein, and dissecting it for an adequate distance. Then mobilizing it towards the artery, identifying the radial artery, and- also dissecting it for an adequate distance. Ligating the vein distally and cutting it just proximal to the ligature. then mobilizing the vein towards the artery, and performing the anastomosis between the vein to the artery in an end-to-side fashion. Following that, we'll close the skin after assuring hemostasis, and that's the end of the procedure.
CHAPTER 2
Left wrist AV fistula- he’s positioned - he’s marked. So this is the- cephalic vein as identified by palpation. This is the radial artery. And we’re going to make an incision curvilinear to extend it if we need an extra length on the cephalic vein to get to the artery. This is the numbing medicine. A pinch and a burn.
We’re making an incision through the skin. You can go down to 25 on the Bovie, please. A straight. J please. DeBakey? No, J, a straight J. So I don’t know if you can see the vein- it’s over here. I'll take an Ohms retractor, please.
And Debakey's, please. So now that we identified the cephalic vein, we're going to encircle it and mobilize it for an adequate distance to bring it over to the artery. Can I have a vessel loop please? So this is the cephalic vein of the wrist. We’re going to mobilize it for- a good length, so we can get it down to the artery. Stay closer to the vein. Yes. Mobilize a little further distal, on top of the vein. Or superficial to the vein. Yes. If you turn your tips away from the vein, it's a bit safer. It may be easier for you if you retract the vein with this, and then use your scissors, so that will be your counter-traction. This looks good enough. Alright, let me just get- there's a little bit of a bleeder right here. Right here. We'll need a quick buzz. Let me just retract this, and if you can retract… Let's grab that tissue there. Perfect. So getting a good length on this vein is essential to mobilize it to the artery, and not have it under tension- when it's under tension tends to- narrow or occlude. So if you hold this for a sec. That's the reason I make my incision curvilinear, this way if you want to get more length on it, you can extend it that way. Do you ever have to superficialize these ones? Very rarely on the forearm. In the upper arm, patients with a larger-size arm, and they- they may have to have that. Sometimes there's- a thin layer of fascia within the subcutaneous tissue holding the vein down, and then you definitely have to superficialize it. But the cephalic vein in the forearm tends to be superficial.
Let's go deep through the tissue here. So if you hold this up, you'll just go straight down. Yes, and this is where you go, kind of- longitudinal. Okay. So a curvilinear for the cephalic, and a longitudinal for the radial? Yes. Well essentially, for the subcutaneous tissue, you’re going longitudinal for both, right? Along the vessel. This way it’s less likely that you’re injuring any structures in there. It's more comfortable when the patient is under local anesthesia. You can divide this a little more. So the artery is over here. I'm feeling it underneath this. Yep, here it is. So if you grab this. See the artery? Yes. So go through there. Quick buzz right there. Can I have the other forceps, the right angle forceps? So grab the tissue opposite to me. So similarly, you want to dissect the vessel for an adequate distance. Now we don't need to mobilize it as much, so the dis- careful of the skin- we don't need to mobilize as much of a distance, but- Hold on to this. A good distance will make it easier to- clamp it. So we'll take another vessel loop please. See this artery is relatively smallish in size. And a SNaP. And that's an important reason to do the Allen's test before you do this because you could be mobilize- taking away significant amount of the blood flow into this artery- diverting it into the vein. I'll take another vessel loop please? Actually, why don't you dissect this. Tie that off, or? Yeah, there's a small branch, why don't we tie it off. I'll take a 3-0 tie, please, or do you... 4-0 or smaller, please. 4-0 tie, please. So with a vessel this small, very little tension on this- on the tie. When you're tying, but also when you're cutting. Scissors. Okay, bring the knot down. Don't retract the vessel too much when you’re tying. So use 2 vessel loops on the artery. And depending- SNaP, please. Depending on the size of the artery, you may have to double loop these vessel loops, but this is a smaller artery that I think just retracting it like will do. And I use these to occlude it and retract it. This way you have minimal trauma to the artery when you're doing this. Okay. We’ll tie it over here, we should be fine.
3-0 silk tie, please. Let me just retract for you. This way you get all the length you can on the vein. Yes.
So at this point, important things to think of is make sure the vein is not twisted. So an easy way to do that is to dilate the vein. We flush it with hep-saline, which is also useful to dilate the vein. So I start with a forceps or a SNaP to dilate the vein. Hep-saline, please? So why don't you occlude the- just kind of almost like a tourniquet on the arm. This is a straight enough - short enough cord? Yes. So you don’t mark it or anything with a marker? Yeah, yeah we don't need to. Doesn't look like it's done. So this is what you want to make sure is not twisted in here. Looks pretty good. Schwartz clip please. The other thing about the length of the vein, when you have this much length on it, a little bit of a twist- you know if you have like 45 or even up to 90 degrees- not a big problem. Okay. Make sense? And we see how dilating it makes it really have a good size. I like to do this so we don't have to put a retractor underneath, but it looks like we will need it. I'll take the Ohm's retractor please. This is going to be a bit in our way.
CHAPTER 3
So I'm going to cut it at an angle to spatulate- you got the iris scissors? So we're going to make an arteriotomy over here and anastomose these 2 together. I'll take the beaver blade- white towels actually first. And one more. So you see the length of this. Once you see the flash of blood, that means you're in the lumen. Okay. Knife down. We’ll take the iris scissors next. I'm going to make sure it's not bleeding, so that means your vessel loops are holding- properly. Then extend the- arteriotomy, only on the- one side, make sure you don’t get the back wall. Hep-saline please. Oh, there’s a little bit of bleeding from the distal end, so I'm going to retract this a little bit tighter. This is where sometimes double looping the vessel loop is beneficial. It looks like we got it. And you know it’s the distal end, you just saw it coming from that direction? Yeah, so when you dry it, you see where the blood is coming from. The other- helpful thing you can do is flush it with hep-saline, and then you'll see where it's coming from. Okay. And either way, when you retract one end, you're putting traction on both in a way. Okay. This looks like a long enough anastomosis.
So this is long enough that we can actually sew it from outside. Sometimes I sew the back wall from inside, but we can do it either way with this one because we have enough length on the vein. Yeah, just grab the other end. Now opposite to me, I'm going to do the heel first. And you know we’ll- we’ll take another stitch like this please. You want to tie it or snap it first? I'm just going to snap it. And what we’re going to do is we’ll have you start the back wall. I'll take a shod please. So you can take it outside in, in the 2. Have the vein inside out on the artery. Yes. Take the same needle. Take it inside out on the artery. You can almost do it forehand I think better. Yep. So you noticed on my side, I did inside-out then inside-out with the other needle, but if you go outside-in on one side, you can do inside-out with the other. So you see this is a small artery. So just be careful in the size of the bite you take. Yes, perfect- take it. So we can tie that. Wet my hands please. My left. More, more, more, more, more, more, more, more, more- thank you. Shod please. I always put a sliding knot in my first 2, so- you get it all the way down. Shod this, then we're going to sew with this. So you're going to swing this on the other side of the vein. This way you can see your loop holes nice. Outside-in on the vein, inside-out on the artery. Straightforward vascular anastomosis. First corner stitch especially if you’re not at the- the corner, you do it in 2, which makes a lot of sense. Freer in the lumen. I got it - just got to get the wall open without the… So one thing you can do is just put a- one of your jaws like that, and then- go ahead, try that. I can do it from here for you if you want. It's maybe easier. Yep. Yes, nice. Your next stitch or the next one, you should be able to start taking it in one. And as we go further from the corner, I will be retracting. By me retracting, I will be opening the artery for you. There’s a little cuff, is that okay? Yeah, that's fine. We have a long vein - we have a… yes. Nice. Take slightly bigger bites on the artery is okay. Okay. Remember we did a linear arteriotomy, and we’re replacing it with a cylinderic structure, right, the vein. So the artery is going to be bigger, in diameter, so if you take some of the- diameter out by your suture, it's not a compromise. Nope, you're good. Can you see what I'm doing? I'm pushing the wall of the vein into the lumen. So my forceps is essentially preventing you from back-walling right now. Don’t move your hand, please. Yes. Straight through across. The less you manipulate the vessels, the better. Do you find that for the vein as well, or is it more… More for the artery, but yeah, veins can take it. Corner in two. So because we haven't tied it down, you could almost take it in one, it's not that much more of a problem. One thing may be easier is for me to take it this way, but see how your angle is? Try to take it. Okay, I think we can swing it back. We'll start with the vein, with the the corner stitch first. We'll take this one underneath, or? Yes. So take the end of it, and pass the end of it. Hold onto this needle. Just going to check the vessels, make sure- so, I don't think we took the back wall. The other important thing to check is we didn't narrow the lumen coming down. Okay. So if you grab the vein open. That's good. And this is nice and wide. It's good. Now, if I tie this… So if you grab the vein under tension. Just a minimum amount. So if the vein is shorter and you don't have the ability to twist it over and sew it from outside, you could sew it from inside the lumen, so I'd be sewing both sides from my side, but in that situation, I usually do the corner stitch as a U-stitch, and not tie it down. Tend to be tougher too, if you tie it down to be able to- take that all the way. If you're doing one stitch, and you're not doing a U-stitch at the, and you're not tying it down, you want to make sure when you tie it at the end, you don't tie it too tight because you could purse-string it, and minimize the flow in the vein Okay. Kind of like- I was watching that liver transplant. Yes, when we do the venous anastomosis on the portal vein, we leave it loose. I was surprised how loose it actually was. Yes. You can always make it tighter, right? You can take stitches in it and narrow it, but you don't want to loosen it, and you don’t want it too tight, then you have to redo it. So again, I’m taking the corner in two. Don’t move your hand, please. He's helping me sewing. You want the jewelers there? Yes, I've got them right here. Just at the corner, I don't mind using the- the right angle so I can- put it in the lumen. Put the tip in the lumen, and- see it a little better. Wet my hands, please. You can cut your corner stitch.
So first you open the vein, but as you saw, the vein didn't have back bleed because of valves- Schwartz clip back to you. So we will take the distal corner, which still has arterial flow, we'll see how it- the vein… So we have a nice distal- the distal is open, the proximal is open. By doing that, it kind of like gently refills it as opposed to forcefully? Yeah, it’s still- I mean an arterial- the radial artery has good flow from, you know when you have a normal Allen’s test from both sides. And you can feel a nice thrill to it. And you see, we retracted the artery quite a bit that now, I mean the vein is not under tension, and it's straightened out. Maybe we can take out this band to minimize- the angulation there. Do you have the doppler probe open? I want to make sure there's no major bleeding here. I'll then have the patient move his wrist, and that will get the artery back to where it's supposed to be. And it feels nice. And see by occluding it proximally, you lose the thrill, which means that it's a single outflow, which is essential for these. The longer the distance of the vein with single outflow, without branching, the better the fistula will be, the better it will mature. Okay. Vessel loops back.
See when I occlude it. You lose the diastolic flow. You will have some systolic flow- which means there's no flow in it. Okay. Perfect.
CHAPTER 4
This looks hemostatic. Looks pretty good. Good. So, I usually- the trouble with these, if you have any bleeding, is the vein is so thin that it will be occluded by hematoma that I prefer not to close it completely watertight with two layers or anything like that, so I just do interrupted, deep dermals in the skin. Okay. I use Vicryl, with a small needle, and just do them about 3 to 4 mm apart- inverted, deep dermals. Do you have the 4-0 popoffs? and Adsons with teeth? Do you do like a Histoacryl closure then? No, I just do Steris, and this way- and don’t put the Steris all the way. Sutures scis please. So essentially a deep dermal. just approximating and leaving a little bit of a- separation in between the sutures. Still, look at the skin. It comes together nicely. Yep. At least if it bleeds tonight, it won’t compress and clot the fistula- that’s the point. And sometimes you have little bleeding from the skin or the sub-Q, Some patients who are uremic, their platelets aren’t working well - all that factors in. So you see how I separate them? So if there’s a hematoma, I will escape through. Release our popoff. Needle down. And you just do the same thing from your end. Sure- I'll take another stitch, please. And now we feel the thrill very nicely over here. So the deep dermal inverted- you're starting the sub-Q essentially, get some of the deep dermis. Yep, leave the epidermis apart. And then cross-over superficial and come deep. And it's important to avoid the vein when you're sewing these. That would be a problem. The attending would be frustrated. A little bigger bite. I find it easier to do subcuticular or deep dermal, when you're pulling the opposite side, when you're everting the stitch, it's easier for you to- let me just make sure this is on the right… So you see we got both ends, one on each side of the loop- that's not right, so we got to bring this underneath. Yep. Perfect. I intentionally did that to show it on the video. Oh. So you see, your side, when you pull it- that's perfect, you evert it nicely, and now you sew through it. The opposite side, instead of grabbing the epidermis, try to evert it as you were trying to do. Grab the dermis? Grab deep dermal and pull it out, and you can grab it underneath this. So grab it here and pull it. So this was the arteriovenous fistula creation- radiocephalic, the radial artery to the cephalic vein at the wrist. The case went smoothly, nothing unusual. The artery was a bit on the smaller size, relatively speaking, but it was still had good flow, and it had nice thrill at the end. The vein was a reasonable size, and dilating it gave us a little extra diameter that was- that improved the flow. The length of the vein was also adequate, we got a nice length on it, so… It went smoothly, nothing unusual, standard arteriovenous fistula.