Figure 52

Creation of a Brescia-Cimino (radial-cephalic) fistula. The native vein arteriovenous fistula is the preferred choice for hemodialysis access. This simple and effective procedure, in which an artery is connected to an adjacent vein to provide a large volume of blood flow into the superficial venous system, has become less common in recent years. The ideal artery has minimal wall calcification, so that dilation can occur with time and allow unimpeded flow. In addition, the artery should not be affected by proximal stenosis, the most common site being an ostial lesion in the subclavian artery. Ideally, the outflow vein is subjected to minimal dissection or manipulation during the surgical procedure. Forcible distension of veins and rough handling of arteries leads to formation of neointimal fibrous hyperplasia and localized stenosis.

The first autogenous access site described was radial-cephalic at the level of the radial styloid process. These can be constructed end-vein to side-artery, A and B, or side-to-side, C, between the two vessels. The exposure is conveniently obtained using a transverse incision at the wrist, just proximal to the radial styloid process, where the artery and cephalic vein lie close to one another. In general, the two vessels are just far enough apart so that an end-to-side technique is best. When the vessels overlie each other, some surgeons prefer the side-to-side technique, which allows reversal of blood flow into the dorsum of the hand and then via collaterals into the forearm, theoretically leading to better flow volume over time.

0 0

Post a comment