**7. Conclusions**

The brachio-brachial arteriovenous fistula is a viable solution for patients with an unsuitable superficial venous system. It can also be used in patients who already have malfunctioning arteriovenous fistulas using the superficial veins of the upper extremity. Studies have shown that it has good patency and low complication rates, therefore its construction can postpone the use of a prosthetic bridge graft or a long-life hemodialysis catheter by several years. The surgical technique includes the same principles of other venous transpositions, so it should be incorporated into the arsenal of techniques that are routinely used by vascular access surgeons.

### **8. References**

42 Technical Problems in Patients on Hemodialysis

basilic. Complications rates were low, including 6 cases of steal syndrome (3.15%), 7 cases of bleeding (3.68%), 3 cases of infection (1.57%) and 1 case of early thrombosis (0.52%), but

greater than in the brachio-brachial AVF.

anastomosis

**7. Conclusions** 

Fig. 5. The arterialized brachial vein runs under the median nerve

Fig. 6. Final result, after the vein has been divided and reconnected using an end-to-end

The brachio-brachial arteriovenous fistula is a viable solution for patients with an unsuitable superficial venous system. It can also be used in patients who already have malfunctioning arteriovenous fistulas using the superficial veins of the upper extremity. Studies have


**4** 

*Greece* 

*University of Athens* 

**Vascular Access for Hemodialysis** 

A progressive rise in the number of patients accepted for renal replacement therapy has been reported world wide [1]. Permanent vascular access (VA) is the life-line for the majority of these patients, when hemodialysis is the treatment of choice. Thus, the successful creation of permanent vascular access and the appropriate management to decrease the complications is mandatory. A well functional access is also vital in order to deliver adequate hemodialysis therapy in end-stage renal disease (ESRD) patients. Unfortunately, despite the advances in hemodialysis technology, the introduction of the polytetrafluoroethylene (PTFE) graft and the cuffed double lumen silicone catheter were the only changes in the field of vascular access in the last years. However the cost of vascular access related care was found to be more than fivefold higher for patients with arteriovenous graft (AVG) compared with patients with a functional arteriovenous fistula (AVF) [2]. It seems that the native arteriovenous fistula that Brescia and Cimino described in 1966, still remains the first choice VA [3]. Thereafter, vascular access still remains the "Achilles' heel" of the procedure [4] and hemodialysis vascular access dysfunction is one of the most important causes of morbidity in this population [5]. It has been estimated that vascular access dysfunction is responsible for 20% of all hospitalizations; the annual cost of placing and looking after dialysis vascular access in the United States exceeds 1 billion dollars per year [6, 7]. Nowadays, three types of permanent vascular access are used: arteriovenous fistula (AVF), arteriovenous grafts (AVG) and cuffed central venous catheters. They all have to be able to provide enough blood flow in order to deliver adequate hemodialysis, have a long use-life and low rate of complications. The native forearm arteriovenous fistulas (AVF) have the longest survival and require the fewest interventions. For this reason the forearm AV is the first choice, followed by the upper-arm AVF, the arteriovenous graft (AVG) and the cuffed central venous catheter as a final step [8-10].

Vascular access for hemodialysis is closely associated with the history of dialysis. Glass needles were employed as vascular access when hemodialysis came into view in 1924. The first haemodialysis treatment in humans was carried out by Haas G. who used glass cannulae to acquire blood from the radial artery and reverting it to the cubital vein [11]. Venipuncture needles were used as means for blood acquisition from the femoral artery and its reinfusion to the patient by vein puncture, in 1943 by Kolff W. [12, 13]. Regular hemodialysis treatments were possible in 1950s through the use of a medical apparatus (Kolff 's twin-coil kidney [14] ), thus projecting the problem of a reliable, capable of repeated

**1. Introduction** 

**2. History of vascular access** 

Konstantinos Pantelias and Eirini Grapsa

