The most common indication for creation of an arteriovenous (AV) fistula is renal failure requiring chronic hemodialysis. It is preferable to create a native fistula, although prosthetic material may be needed if a suitable vein is not available.
The goal is to place an AV fistula prior to the patient starting dialysis. The day of surgery, electrolytes should be checked to verify the absence of hyperkalemia. Many of the patients are diabetic and close monitoring of blood glucose levels during the procedure is warranted. Antibiotic prophylaxis is administered within 1 hour of the incision. A single dose is usually sufficient. In patients with a poorly defined superficial venous system, venous mapping may be done preoperatively to define the anatomy.
The patients requiring chronic hemodialysis are poor risks for general anesthesia. An axillary block on the side that is to be used provides excellent regional anesthesia. If regional anesthesia cannot be done, local anesthesia is a valid option.
The patient is placed in the supine position. The arm to be used for the fistula is placed on an arm board (figure 1). The opposite arm may be tucked with a sheet or placed on an arm board.
Hair is removed with clippers. The arm is prepped circumferentially from the fingers to the axilla. After draping, a sterile knit stocking is placed over the arm. This covers the fingers and arm to the axilla (figure 2).
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 ...