Brachiocephalic fistula


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Brachiocephalic fistula

  1. 1. Brachiocephalic Fistula
  2. 2. 1. Preop <ul><li>Vascular lab </li></ul><ul><ul><li>Vein </li></ul></ul><ul><ul><ul><li>Diameter ≥3 mm without evidence of significant stenosis </li></ul></ul></ul><ul><ul><ul><li>Suitable segment from wrist to antecubital fossa (forearm access) or antecubital fossa to axilla (upper arm access) </li></ul></ul></ul><ul><ul><ul><li>  Absence of significant central vein stenosis in the ipsilateral extremity </li></ul></ul></ul><ul><ul><li>Artery </li></ul></ul><ul><ul><ul><li>Diameter ≥2 mm </li></ul></ul></ul><ul><ul><ul><li>Absence of hemodynamically significant inflow stenosis </li></ul></ul></ul><ul><ul><ul><li>Nondominant radial artery for wrist access </li></ul></ul></ul>
  3. 3. 2. Position <ul><li>Supine with arm abducted 90 deg </li></ul><ul><li>supported on arm board </li></ul><ul><li>Avoid hyperextension of shoulder to avoid brachial plexus injury </li></ul><ul><li>Pre-op abx – consider vanc </li></ul><ul><li>Regional and local anesthesia </li></ul>
  4. 4. 3. Prep and Drape <ul><li>Prep axilla, brachium and hand </li></ul><ul><li>Cover hand with stockinette </li></ul>
  5. 5. 4. Exposure and Dissection <ul><li>sigmoid incision is started over the brachial artery in the proximal arm and extended across the antecubital crease and along the forearm, incorporating the previously marked cephalic vein </li></ul><ul><li>cephalic/median antecubital veins are very superficial </li></ul><ul><li>The cephalic vein is dissected free for approximately 4 cm by creating superior and inferior skin flaps </li></ul>
  6. 6. 4. Exposure and Dissection <ul><li>The cephalic/median antecubital vein bifurcates or trifurcates in the antecubital fossa. It can be helpful to preserve the proximal aspects of these branches to help create a generous hood for the anastomosis </li></ul><ul><li>The large, deep branches of the vein should be suture-ligated because they tend to retract into to muscle/soft tissue </li></ul><ul><li>brachial artery is exposed by incising the overlying bicipital aponeurosis and approximately 2 to 3 cm of the artery is dissected free. A pair of deep brachial veins flanks the artery and they communicate via crossing branches that overlie the artery. These delicate branches must be dissected to allow exposure of the artery </li></ul><ul><li>vein is distended with saline using an olive-tipped catheter, spatulated, and all defects are repaired </li></ul>
  7. 7. 4. Exposure and Dissection
  8. 8. 5. Heparin <ul><li>5,000 units of heparin intravenously and the brachial artery is occluded proximally and distally </li></ul>
  9. 9. 6. Arteriotomy <ul><li>1-cm longitudinal incision is created in the artery using an 11 blade and potts scissors </li></ul>
  10. 10. 7. Anastomosis <ul><li>6-0 running prolene suture end-to-side anastomosis </li></ul>
  11. 11. 8. Examine Fistula for thrill and hand for ischemia <ul><li>the fistula and the arterial signals at the wrist are interrogated with the continuous wave Doppler. </li></ul><ul><li>thrill should be detected in the proximal aspect of the fistula </li></ul>
  12. 12. 9. Closure <ul><li>wound edges are reapproximated with interrupted 3-0 vicryl </li></ul><ul><li>skin closed with interrupted 4-0 monocryl or staples </li></ul>
  13. 13. 10. Postop <ul><li>Motor-sensory exam prior to discharge </li></ul>