The ulnarcephalic fistula is appropriate when the radial artery is not an acceptable site for arterial inflow, but the cephalic vein is of good size and quality. Care must be taken in these situations to ensure adequate perfusion to the hand. An arteriogram is usually necessary to define the arterial anatomy of the forearm and hand. Correctable problems with arterial inflow should be addressed. It is the authors’ preference to perform angiographic assessment of the hand perfusion. Perfusion to the hand should be documented with and without ulnar compression since ulnar flow will be diverted through the fistula. Inadequate perfusion of the hand through the ulnar artery or a lack of collateral perfusion is a relative contraindication to creation of an ulnarcephalic fistula.

Similarly to the previously described radiocephalic transposition, the cephalic vein is dissected free from the antecubital fossa to the wrist using a single incision or multiple skip incisions. All venous branches are ligated. The ulnar artery is dissected using a longitudinal incision. The ulnar artery tends to be deeper than the radial artery and is in intimate proximity to the ulnar nerve. A meticulous dissection should be performed taking care to avoid crossing veins and small branches of the artery. The artery is encircled with vessel loops. The cephalic vein is transected, flushed, marked, and tunneled toward the ulnar artery. Heparinization is performed after tunneling to prevent excessive bleeding. An arteriotomy is made, and an end-to-side anastomosis is made with the ulnar artery.

When the cephalic vein is of inadequate size or quality but the basilic vein is adequate, a transposed radiobasilic fistula can be considered. The basilic vein runs deeper than the cephalic vein and runs along the ulnar aspect of the forearm, making its native position inappropriate for dialysis access. The basilic vein in the forearm always must be transposed to a more accessible location. Duplex ultrasound is a useful adjunct for localization of the vein along its course. Side branches can be marked at the same time. Either a single continuous or a series of skip incisions can be made along the course of the vein, dissecting along its entire course in the forearm back toward the antecubital fossa. The radial artery is dissected at the wrist using a longitudinal incision as previously described. The basilic vein is transected, flushed, marked, and tunneled toward the distal radial artery (Figs. 16.6, 16.7, and 16.8). The more radially the vein can be tunneled, the less supination of the wrist will be necessary during dialysis sessions. An arteriotomy is made and an end-to-side anastomosis is made with the radial artery (Fig. 16.9). An example of this fistula after maturation created by the authors is shown in Image 16.1.