Perioperative management - Dialysis access surgery: Brachiocephalic fistula (“direct antecubital fistula”) - Vascular Surgery

• Decompensated renal failure

• Heart failure NYHA III to IV with massively impaired cardiac ejection fraction
• Infections in the immediate vicinity of the surgical site
• Poorly developed/interrupted arm veins, e.g., following multiple punctures
• Upper limb with higher-grade PAOD

Medical history

• History of prior central venous line? -> central veins patent? -> possibly duplex ultrasonography/phlebography
• History of cardiac pacemaker? -> which vessel was used? Occlsusion of the cephalic or subclavian vein?
• Prior vascular surgery or arm injury?
• Diabetes mellitus? -> if necessary, fashion AV fistula on the upper arm
• Indications of CHD and possibly PAOD in the upper limb? -> possible contraindication for access fistula
• Anticoagulants? Continue perioperatively?
• Previous vascular access surgery? -> spontaneous occlusion? recurrent fistula thrombosis?

Inspection

• Edematous swelling of the arm? -> central problems?
• Venous collaterals in the shoulder region? -> indicative of occluded subclavian vein
• Inflammatory changes, eczema, cutaneous mycosis? -> local contraindication
• Acral skin color

Clinical examination

• Palpation of the brachial, radial, and ulnar arteries: Palpable pulses?
• Allen test (see below): Function testing of the blood supply to the hand via the radial and ulnar arteries 
• Vein quality assessment by mild compression with a BP cuff

Technical examination

• Arterial and venous duplex ultrasonography (“fistula mapping”)
  • Search for deep-lying veins in obese patients
  • Evaluation of venous diameters
  • Evaluation of arterial vessel walls (arteriosclerosis?) 

Allen test

Surgical technique

First, the examiner manually compresses both the radial and ulnar arteries. The patient then makes a fist several times to pump out the venous blood until the palm of the hand turns white.

Selective opening of the manually compressed radial or ulnar artery is used to determine whether the collateral blood supply to the hand provides adequate perfusion. Due of the collateral blood supply of the hand, one of these two arteries normally suffices to supply the entire hand with arterial blood. 

Evaluation

If the hand rapidly (approx. 5–7 sec.) turns pink after releasing the compression, the Allen test is normal. If rapid reperfusion is missing or if this time is significantly prolonged, the test is pathologic and indicates vascular anomalies, occlusion, or arteriosclerotic vascular changes in the artery in question. 

• Plan AV fistula surgery on day without dialysis!
• If necessary, trim the hair around the surgical site               

General risks

• Secondary bleeding, hematoma, possibly reoperation
• Allogeneic blood transfusion, risk of infection (hepatitis, HIV)
• Wound infections, pharmacological or surgical measures
• Allergy/intolerance (latex, medications, contrast agents)
• Thromboembolism
• Skin, tissue, nerve damage
• Keloid

Specific risks

• Infection, thrombophlebitis, possible surgical revision
• Nerve lesion (especially with corrective/repeat procedures)
• Poor limb perfusion -> possible fistula exposure or termination, or fashioning of a new AV fistula
• Steal phenomenon
• Chronic arm edema due to central venous run-off obstruction, possible balloon dilation or stenting
• Heart failure due to fistula-related increase in cardiac output
• X-ray contrast agents → compromised renal function
• Aneurysm, stenosis → surgical revision