The surgeon palpates the radial pulse. The location of the incision is planned (figure 3). A vertical incision is made in the forearm close to the wrist and lateral to the radial pulse (figure 4). Once the incision is carried to the deep subcutaneous tissue, self-retaining retractors are placed. Sharp and blunt dissection is used to identify the cephalic vein. The vein is skeletonized for a distance of 2 to 3 cm. It is encircled with vessel loops proximally and distally. Side branches of the vein are ligated with 4-0 silk (figure 5). The radial artery is then dissected for a distance of 2 to 3 cm. There is a vein on either side of the radial artery that may be ligated or freed from the artery. The artery is encircled with vessel loops proximally and distally. Side branches are ligated as necessary with 4-0 silk. Both vessels must be freely mobilized to enable a tension-free anastomosis. The artery and vein are then encircled with a single vessel loop both proximally and distally to allow alignment of the structures (figure 6).
A longitudinal venotomy is made in the cephalic vein with a number 11 blade and extended for 1 cm with iris scissors. The vein is dilated to size 3.5 mm and a Silastic catheter is passed cephalad to ensure patency of the vein. The vein is irrigated with heparinized saline (figure 7).
The patient is administered intravenous heparin. Fine curved or straight bulldog clamps are placed proximally and distally on the radial artery. A longitudinal arteriotomy of 1 cm is made. In some cases the arterial wall may be much calcified and it will be necessary to probe the artery proximally to ensure patency. Once patency is established, the proximal bulldog clamp is reapplied. The artery and vein are aligned. A side-to-side anastomosis is then created between the cephalic vein and radial artery using running 6-0 nonabsorbable monofilament sutures. The needle on the arterial side must be passed from the endothelial surface outward, ensuring the endothelium is tacked down (figures 8 and 9). Needle B′ (figure 8) is passed back into the lumen and then run continuously on the back wall—always beginning into the arterial intima. At the end, it is tied externally to suture A (figure 10). Needle A′ is passed back into the lumen and then run continuously on the front wall. Once the anastomosis is nearly complete, the proximal bulldog clamp is released transiently to ensure inflow and to flush out any clot. The distal bulldog is likewise released to ensure back bleeding and clear any clot and debris (figure 11). The suture is then tied. The vessel loops are released on the vein and the distal and proximal bulldog clamps are removed from the radial artery. The vein proximal to the anastomosis is then palpated for a thrill to determine patency. Absence of a thrill may indicate a technical problem and the anastomosis should be re-explored. This is done by making a small venotomy in the cephalic vein distal to the anastomosis and a dilator is used to explore the anastomosis as well as the artery and vein. It is important to ligate the cephalic vein distal to the anastomosis, usually with double 2-0 silk (figure 12). After ligation, the vessel is transacted, as this releases any tension on the anastomosis and reduces the incidence of venous hypertension of the hand. The presence of a thrill is reverified. Hemostasis is achieved and the subcutaneous layers are closed with interrupted 4-0 absorbable suture. The skin is closed with a running subcuticular 4-0 absorbable suture. A sterile dressing is then placed.