The patient is administered intravenous heparin. Fine curved or straight bulldog clamps are placed proximally and distally on the radial artery. A longitudinal arterotomy of 1 cm is made. In some cases the artery 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 the 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 one arm of suture A (Figure 10). 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 re-verified. Hemostasis is achieved and the subcutaneous layers are closed with interrupted 3-0 absorbable suture. The skin is closed with a running subcuticular 4-0 absorbable suture. A sterile dressing is then placed.