A 3-cm longitudinal incision is made in the distal forearm midway between the radial artery and the cephalic vein. Alternatively, the artery and vein can be exposed using an incision in the anatomic snuffbox, although, as noted above, the vessels are smaller at this location. A small skin flap is raised toward the vein side, the cephalic vein is dissected free, and two small spring retractors can be oriented diagonally across the wound to aid exposure. The vein is then dissected until a length of 3 cm or more is mobilized, allowing for transposition onto the radial artery. A skin flap is then raised toward the radial artery side, and approximately 2–3 cm of the artery is exposed by excising the investing soft tissue. It is important to ligate any branches of the artery at this level. Vessel loops should be placed for proximal and distal control. The vein is then transected, distended with saline, and spatulated. Prior to occluding and opening the radial artery, heparin can be given intravenously. The artery is occluded with two small microvascular clamps, and a 0.75-cm arteriotomy is created using a #11 scalpel blade and fine arteriotomy scissors (e.g., Pott’s scissors). The anastomosis is performed end-to-side using a running 6–0 monofilament polypropylene suture. Other anastomotic configurations have been reported (i.e., side-side, end artery-end vein, end artery-side vein), although it is the general impression that the end vein-side artery is associated with the greatest long-term patency and the lowest incidence of venous hypertension in the hand. After the creation of the anastomosis, the fistula and hand perfusion should be checked with intraoperative Doppler. The fistula should have, at the minimum, continuous signal throughout systole and diastole. Optimally, a thrill should be felt but this can take time to develop. Pulsatile flow in the cephalic vein is not normal and indicates an outflow obstruction. It warrants inspection of the anastomosis with possible revision or further mobilization of the cephalic vein proximally in order to better orient the vein to the artery. The incision is closed in two layers – the deep dermis and subcuticular layer. The deep dermis is closed using an interrupted 3–0 braided, absorbable suture and the skin closed using a running 4–0 monofilament, absorbable suture.

After creation, the radiocephalic fistula is given 6–8 weeks to mature before accessing it for hemodialysis. Prior to the first access for hemodialysis, the fistula should be examined for maturation. In order for a fistula to mature, the vein wall must remodel and thicken in response to higher pressures. This allows it to sustain the repetitive cannulations. A minimum fistula diameter of 0.4 cm combined with a minimum flow volume of 500 mL/min predicts a high level of fistula usability (Fig. 15.1c) [6]. The fistula must also be accessible and within 1 cm of the skin surface with a straight segment that is ideally 6–10 cm in length [6]. More criteria and recommendations for maturation are listed in a following section.

The brachial artery to cephalic vein fistula is the next anatomic level autogenous fistula. It consists of an anastomosis between the side of the brachial artery and end of the cephalic vein in the antecubital fossa or upper arm. It has excellent flow and maturation rates but has been associated with higher rates of “steal” phenomenon due to the larger arterial caliber than in the forearm [7]. It also eliminates the forearm for consideration of future access. If the radiocephalic fistula fails, the brachiocephalic fistula is a possibility. In patients with small vessels in the forearm, the brachiocephalic fistula becomes the first-line fistula in most cases when the upper arm vein is of sufficient size.

The incision for this access varies due to the specific location of the cephalic vein, the more distal median antecubital vein, the brachial artery, and the body habitus of the patient. Three incisions are described: the first is a transverse incision across the antecubital fossa (Fig. 15.3); the second is a sigmoid incision from medial in the upper arm across the antecubital fossa and down along the cephalic vein in the forearm; and the third option is actually two separate incisions – one over the brachial artery and the other over the cephalic vein in the upper arm. There is no superior approach of these three – above all else is adequate exposure to the vessels in the forearm.

We prefer to perform this access in the following way: The brachial artery is palpated in the upper arm just above the antecubital fossa and its course marked on the skin. The cephalic vein is found crossing the antecubital fossa and its course marked as well. Using a sigmoid incision, the skin is incised starting at this point and extended across the antecubital crease and down the forearm, incorporating the marked cephalic vein, and with care not to deeply incise and injure the cephalic vein or its distal continuation, the median antecubital vein. It can be helpful to place marks transversely across the course of the planned incision to aid in skin alignment at closure. Just as in the radiocephalic operation, exposure can be facilitated with two large spring retractors. The cephalic vein is dissected and mobilized for approximately 4 cm with superior and inferior skin flaps. The cephalic vein and its distal continuation as the median antecubital vein typically bifurcates or trifurcates in the antecubital fossa. The proximal trunk of these branches can be preserved and incorporated to create a larger hood for the anastomosis. The large, deep branches of the vein should be suture ligated to prevent uncontrolled bleeding as they can retract into the muscle and soft tissue. After exposure of the cephalic vein, attention is turned to the brachial artery by incising the overlying bicipital aponeurosis. Approximately 2 to 3 cm of the artery is dissected and mobilized. A pair of deep brachial veins flanks the artery and communicates via delicate crossing branches that overlie the artery. These branches must be dissected to allow exposure. The vein is distended with saline and spatulated and any defects repaired. The patient is given 5000 units of heparin systemically, and the brachial artery is occluded proximally and distally with vascular clamps. A 0.75-cm longitudinal arteriotomy is created with a #11 scalpel blade and arteriotomy scissors. The anastomosis is performed in a running fashion using a 6–0 monofilament vascular suture (Fig. 15.4). Upon completion, as in the radiocephalic fistula, the fistula and the arterial signals at the wrist are investigated with the continuous wave Doppler. Unlike the radial artery-based autogenous access, a thrill should be detected immediately at the proximal end of the fistula. As above, the absence of a thrill or a pulsatile Doppler signal mandates further inspection. The solution may be as simple as mobilizing the vein proximally to straighten its course or undoing the anastomosis and redoing it due to technical error. A diminished or monophasic Doppler signal at the wrist suggests that the hand may be ischemic. It is impossible to determine at this point whether this is due to reversible vasospasm or frank hand ischemia. All patients with suspected hand ischemia require close observation throughout the postoperative period with treatment as required, including revision of the anastomosis. The wound edges are re-approximated with an interrupted 3–0 braided, absorbable suture, and the skin is closed with a subcuticular stitch (e.g., 4–0 monofilament, absorbable).