**8. Conclusions**

This chapter has reviewed important aspects of AVF access for patient with ESRD on hemodialysis. The current enigma is that with increased need for placement the failure rate is high. Multiple factors cause fistula failure including: underlying demographic variables, stress of the dialysis treatment itself, along with flow changes and characteristics as illustrated in Fig. 6. Careful research to identify a comprehensive understanding of these factors will enhance fistula maturation thereby improving the outcomes for patients with ESRD on hemodialysis.

The AVF is by far the best access with the least risk of complications for patients with ESRD. If a patient starts hemodialysis with a mature fistula, their transition to renal replacement therapy occurs with less risk of morbidity and mortality. As more fistulas are being placed, there is an increased awareness of complications including venous stenosis. We need to review and improve the surgical techniques of fistula placement and maintenance while optimizing novel therapies that promote fistula maturation. The etiology of venous stenosis in an AVF is the subject of future investigation with treatment trials to follow.

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**3** 

*Romania* 

**The Brachio-Brachial Arteriovenous Fistula** 

The autogenous arteriovenous fistula (AVF) is the preferred access for chronic hemodialysis in patients with end-stage kidney disease. Careful examination of the upper extremity is essential for the creation of a successful fistula. The quality of the arterial and venous circulation should be well established prior to surgery. However, there are cases when the superficial venous system of the upper extremity is unsuitable for the creation of an autogenous AVF. This problem has two solutions: the use of a prosthetic graft or the creation of a brachio-brachial AVF. Prosthetic grafts have a 1-year patency rate of 65- 75%(Haimov, 1978), mostly due to the frequent and varying complications that they may sustain, especially ischemia, thrombosis, infection, and aneurysms. The brachio-brachial AVF, a relatively new type of angioaccess, is shown to have similar patency rates to the prosthetic grafts, but without their number of complications and is a very good alternative for patients with an unsatisfactory superficial venous system (Dorobanţu et al., 2006, 2010).

**2. Anatomy of the brachial artery and the venous system of the upper arm** 

The brachial artery is the continuation of the axillary artery beyond the inferior margin of the teres major muscle. It continues down the anterior aspect of the arm to the cubital fossa, being accompanied by two venae comitantes and the brachial nerve. Proximally, the nerve is lateral to the artery but it crosses the medial side of the artery distally, lying anterior to the elbow joint. The brachial artery divides into its terminal branches, the radial and the ulnar, 2

The venous system of the upper extremity comprises the superficial and the deep veins. Both groups have valves. The superficial veins (figure 1) are the the cephalic, the basilic and the median vein of the forearm; they are subcutaneous in the superficial fascia. The cephalic vein forms over the "anatomical snuffbox" and ascends along the forearm's radial side and then in front of the elbow, in a groove between the brachioradialis and the biceps. It then crosses anteriorly the lateral cutaneous nerve and continues along the lateral border of the biceps, up to the delto-pectoral groove. It pierces the clavipectoral fascia and joins the

The basilic vein begins medially in the hand's dorsal venous network and continues on the medial side of the forearm and then anterior to the elbow. Just distally to the elbow, it is joined by the median vein of the forearm. It ascends superficially between the biceps and the pronator teres, between filaments of the medial cutaneous nerve. It perforates the deep

**1. Introduction** 

cm below the elbow bend (Gabella, 1995).

axillary vein below the clavicular level.

Lucian Florin Dorobanţu, Ovidiu Ştiru, Cristian Bulescu,

Şerban Bubenek and Vlad Anton Iliescu

*UMF "Carol Davila" Bucureşti* 

