**5. Surgical technique**

We use the two-stage approach in creating a functional brachio-brachial fistula. Although a single-stage approach has been described by Bazan and Schanzer (Bazan & Schanzer, 2004), we found the two-stage procedure to be safer as mobilization of the arterialized vein is easier than the thin-walled initial vein (Dorobanţu et al., 2010).

The first stage involves anastomosing the brachial vein to the brachial artery. The upper extremity is circumferentially prepared up to the axilla and is placed in extension and abduction, with the hand in supination. Local anesthesia is used, infiltrating 1% Lidocaine in the cutaneous and subcutaneous tissue. A 4-5 cm longitudinal incision is made in the antecubital fossa, following the medial border of the biceps muscle. The muscle is retracted slightly laterally in order to allow access to the thin aponeurotic sheath which contains the neuro-vascular bundle. The sheath is opened and the artery is dissected clear of the median nerve, passing a loop tape underneath it. With the arteries are two venae comitantes, connected by fragile transverse and oblique branches. The vein with the greater diameter is chosen for the AVF. All of its branches are ligated and a longitudinal venotomy is performed. Flushing the vein with a heparinated saline solution (2500 units in 250 ml of

2001). Prosthetic and autologous AVF have similar patency rates for the first 4 postoperative weeks. After this period of time, synthetic bridge grafts require further interventions for angioplasty. Even with newer types of grafts, such as the Vectra Vascular Access grafts, the primary assisted rate of the prosthetic AVF is lower that of the autogenous AVF at 18 months of follow-up (58% vs 78%, respectively) (Kappos, 2007). The same study shows an overall access thrombosis rate of 17% for autogenous AVF and 34% for the Vectra graft. This

Most complications can be treated conservatively, without compromising the fistula (Matsuura et al., 1998). Severe hand ischemia, necessitating surgical treatment, occurs in 1% of patients with AVF and 2.7-4.3% of patients with graft AVF (Porter et al., 1985). Also, steal syndrome occurs in 73% of autogenous AVF and in 91% of graft AVF, as demonstrated by hemodynamic studies. Therapeutic options for hand ischemia always involve surgical interventions and include banding of the AVF (which is sometimes impractical, especially

Infection is a rare complication of the autogenous AVF; because there is no foreign body, it responds well to drainage and antibiotics. On the other hand, an infected prosthetic graft is a potentially lethal complication. The presence of foreign material makes this complication very difficult to treat. Prophylactic antibiotics are given before constructing the prosthetic AVF. Treatment requires removal of the whole prosthetic segment, debridement and

Perigraft seroma is a very rare complication of the autogenous AVF (Blumenberg et al., 1985). It is more common with prosthetic grafts, because of changes in the structure of the ePTFE and of certain biological alterations in the host (Sladen & Mandl, 1985; Ahn & Machleder, 1986). Minimally invasive treatment is often unsuccesful, so more aggressive

There is also a decreased risk of intimal hyperplasia because the anastomosis is much smaller compared to the one used with a prosthetic graft (Lumsden & Chen, 1997). In the rare case of fistula failure, the surgeon still has the backup possibility of creating a synthetic bridge fistula,

We use the two-stage approach in creating a functional brachio-brachial fistula. Although a single-stage approach has been described by Bazan and Schanzer (Bazan & Schanzer, 2004), we found the two-stage procedure to be safer as mobilization of the arterialized vein is

The first stage involves anastomosing the brachial vein to the brachial artery. The upper extremity is circumferentially prepared up to the axilla and is placed in extension and abduction, with the hand in supination. Local anesthesia is used, infiltrating 1% Lidocaine in the cutaneous and subcutaneous tissue. A 4-5 cm longitudinal incision is made in the antecubital fossa, following the medial border of the biceps muscle. The muscle is retracted slightly laterally in order to allow access to the thin aponeurotic sheath which contains the neuro-vascular bundle. The sheath is opened and the artery is dissected clear of the median nerve, passing a loop tape underneath it. With the arteries are two venae comitantes, connected by fragile transverse and oblique branches. The vein with the greater diameter is chosen for the AVF. All of its branches are ligated and a longitudinal venotomy is performed. Flushing the vein with a heparinated saline solution (2500 units in 250 ml of

an option that he would lose should he employ a prosthetic fistula in the first place.

rate is higher for other materials, such as ePTFE (Segal et al., 2003; Choi et al., 2003).

with prosthetic AVFs) and complex revascularization procedures.

measures must be taken, leading even to replacement of the graft.

easier than the thin-walled initial vein (Dorobanţu et al., 2010).

systemic antibiotics.

**5. Surgical technique** 

saline) verifies the vein's permeability. The entire length of the catheter is inserted into the vein. Now the brachial artery is cross-clamped proximally and distally to the proposed site of anastomosis and a longitudinal arteriotomy is performed. An end-to-side anastomosis is performed using a running nonabsorbable 7-0 polypropilene suture. The posterior wall is performed first and the brachial vein is divided distally before completing the anastomosis. Before tying the suture, the permeability of the fistula, as well as of the brachial artery should be evaluated. The vein should be inspected for a thrill; its absence indicates poor outflow and the surgeon must look for a potential problem and correct it (figure 3). All bleeding sources should be controlled and the skin is closed using interrupted simple sutures, without drainage (Ştiru, 2006; Iliescu, 2007).

Fig. 3. The brachio-brachial fistula – intraoperative view

After 4 weeks, the vein is evaluated using Duplex scanning and, if its diameter is greater than 4 mm, it is transposed in a superficial plane in order to ease access for punctures. A longitudinal incision is performed on the antero-medial side of the arm, from the antecubital fossa to the axillary region. The neuro-vascular bundle is exposed, with the vein on the lateral side, the artery in the middle and the median nerve on the medial side. All of the venous collaterals are ligated, thus mobilizing the vein so that the aponeurosis can be closed underneath the vein with interrupted sutures (figure 4). A drainage tube is inserted and kept in place for 24 hours. The skin is closed with interrupted sutures, making sure that there is a 1.5 cm layer of tissue between the vein and the skin's surface to allow healing between needle punctures. The fistula can be used for hemodialysis after 3 weeks (Schanzer, 2004; Ştiru, 2006).

The Brachio-Brachial Arteriovenous Fistula 41

level of the brachio-brachial fistula, and numerous collaterals between the two brachial veins. In nearly all the patients we noted the presence of a collateral superficial venous network, as an adaptive reaction to the greater pressure in the deep venous system. After the superficialization and the ligation of the collaterals between the two brachial veins, this edema disappeared. We noted only one important edema of the arm, which regressed after the transposition in the subcutaneous tissue of the arterialized brachial vein. We believe that the absence of other complications like persistent forearm edema, ischemic lesions, etc, was related to the presence of two satellite brachial veins; therefore, the remaining brachial vein sustains the deep venous drainage. Other groups have reported a higher number of complications, including hematomas, wound infections (Casey, 2008) and steal syndrome

**Casey Angle Elwakeel Dorobanţu** 

0

which required reintervention and revascularization of the upper extremity.

At 12 months 40% 75.89% At 24 months 55.39%

**Mean follow-**

**Maturation** 

**Patency rate** 

**complications**  Hematoma Infection Steal sdr. Aneurysm

good results achieved with this technique.

the non-maturation problem (Pisoni et al., 2002).

related causes and another three patients were lost at follow-up.

**Major** 

**No. of patients** 17 20 21 49

**up (months)** 8 14 ± 4 15.85 ± 9 18 ± 11.1

**rate at 4 weeks** 47% 100% 66.6% 79.6%

At 37 months 82.1%

Table 1. Comparison between several groups of patients with brachio-brachial fistulas

There were two cases of technical difficulties in mobilization of the brachial vein that had not been reported before: in one case we managed to maintain the native AVF (due to successful reconstruction of the arterialized vein in front of the median nerve) (figures 5 & 6), while in the other case where the arterialized vein remained too small, we were forced to make a prosthetic fistula. That was a rare event and we believe that it does not diminish the

No operative deaths occurred, but three patients died (after 2, 8 and 10 months) due to non-

We consider that pre-operative ultrasound deep vein evaluation for the first step of the procedure is useless because the brachial vein is always a good native conduit with a variable diameter which does not influence the future of the AVF. Although there are authors that used only brachial veins with a diameter superior to 3 mm, they did not resolve

When compared to the more traditional brachio-cephalic and brachio-basilic AVF, the brachio-brachial fistula shows similar patency and complications rates. A study published by Woo et al. in 2007, analyzing 190 patients with brachio-cephalic and brachio-basilic AVFs shows a patency rate of 56% for the brachio-cephalic and 71% for the brachio-basilic at 1 year. At 5 years, the patency rate was 40% for the brachio-cephalic and 56% for the brachio-

Fig. 4. Mobilization of the brachial vein
