Figure 54

The brachial-cephalic vein fistula. If a radial-cephalic vein fistula cannot be constructed, the next best choice for vascular access is the brachial-cephalic vein fistula. Accesses that utilize the brachial artery have the advantage of higher blood flow rates than those that use the radial artery. Although this may improve the efficiency of hemodialysis, it is also associated with increased risk of arm edema and steal. A, The native anatomy of the antecubital veins somewhat resembles the letter M. A more complete depiction is seen in B. The medial volar venous flow enters the basilic system; lateral volar flow enters the cephalic system; and the central connector, which includes a deep tributary, connects the brachial (venae comitantes) system at the brachial artery bifurcation. To create an antecubital autogenous site, there are two general approaches; the surgeon either mobilizes the cephalic vein directly into the brachial artery (C) or "anastomoses" the deep connector between the median antecubital vein and the brachial veins directly to the adjacent artery. It is also possible to prepare a native vein arteriovenous fistula in the antecubital fossa by transposing brachial or basilic veins from the deeper compartment of the brachium to the subcutaneous tissue.

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