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  • End-stage renal disease; recommendations from the Kidney Dialysis Outcomes Quality Initiative:
    • Creatinine clearance < 25 mL/min.
    • Serum creatinine > 4.0 mg/dL.
    • Dialysis anticipated within 1 year.
  • Long-term plasmapheresis.

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  • Ipsilateral proximal venous and arterial occlusion or stenosis.
  • Systemic or local infection.
  • Multiple comorbidities precluding safe intervention.

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Expected Benefits

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  • Provides access for dialysis.

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Potential Risks

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  • Clotting, narrowing, or scarring of the graft requiring surgical or radiologic revision.
  • Infection of the graft requiring surgical excision and replacement.
  • Wound infection.
  • Injury to the neurovascular structures of the arm.
  • Bleeding.
  • Failure of the fistula to mature for adequate dialysis access.
  • Pain or numbness.
  • Development of arterial "steal," resulting in decreased blood flow to the hand.

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  • No. 10 or 15 blade scalpel for skin incision.
  • Electrocautery unit.
  • Heparinized saline solution.
  • Prosthetic expanded polytetrafluoroethylene (ePTFE) graft (frequently tapered 4–7 mm) for forearm loop grafts or brachial artery to axillary vein arteriovenous grafts if arteriovenous fistula is not possible.
  • Tunneling device if needed.
  • Small vascular clamps or vessel loops.
  • No. 11 blade scalpel and Micro-Potts scissors.
  • Double-armed polypropylene suture.
  • Doppler ultrasound unit.

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Preoperative History

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  • Specific focus on history of indwelling catheters, pacemaker, internal automatic cardiac defibrillator, or extremity trauma.
  • Dominant extremity should be documented.
  • Patients with severe congestive heart failure may not tolerate the additional cardiac output required to circulate blood through the fistula.

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Physical Examination

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  • All pulses should be palpated.
  • The Allen test should be performed to evaluate perfusion to the hand.
  • Blood pressure should be obtained in both arms to evaluate proximal arterial disease.
  • Veins of the wrist, forearm, elbow, and upper arm should be evaluated with or without a tourniquet.
    • Repetitive hand squeeze may make veins more prominent.
    • Visible veins can be considered for access.

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Ultrasonography

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  • Doppler: to assess arterial flow.
  • B-mode: to image and size potential veins.
    • Vein segments < 2.5 mm may be technically difficult to use for anastomosis and are associated with higher rates of failure.

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Indications for Venography

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  • Edema in the extremity in which access is planned.
  • Collateral vein development in the planned access site.
  • Differential extremity size of the considered limb.
  • Current or previous central access or transvenous catheter in the ipsilateral limb.
  • Previous arm, neck, or chest trauma on the same side as the planned access site.
  • Prior failed attempts to establish access in the ipsilateral extremity.

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  • The patient should be supine with the operative arm extended on an arm board and supinated.
  • The arm should be prepared circumferentially from the fingers to the axilla, and the hand covered with a sterile towel.

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  • Figure 33–1: Vascular anatomy of the upper extremity.
    • The basilic vein courses medially down the arm and is found in the deeper subcutaneous tissues.
    • The cephalic vein courses laterally and is very superficial, running under the skin layer.
    • The cephalic vein runs posteriorly and laterally, proximal to the antecubital fossa.

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