Vascular

Arteriovenous Fistula Formation

OPERATION: Arteriovenous Fistula (AVF) Formation — [Radiocephalic (Brescia-Cimino) / Brachiocephalic / Brachiobasilic — First/Second Stage] — [Right / Left] Arm
ANAESTHETIC: Regional anaesthesia [brachial plexus block / wrist block] / General anaesthesia / Local infiltration
POSITION: Supine. Ipsilateral arm extended on arm board, supinated.

INDICATION:
End-stage renal failure requiring haemodialysis access. [Preoperative vascular mapping: USS / venography — [cephalic / basilic / brachial] vein diameter [measurement], [radial / brachial] artery diameter [measurement], suitable for [configuration]]. [Previous access sites / fistula failures noted].

PROCEDURE:
WHO Checklist performed. Arm prepared and draped from fingers to above elbow.

INCISION AND VESSEL EXPOSURE:

RADIOCEPHALIC FISTULA (wrist):
Transverse or oblique incision at the wrist over the anatomical snuffbox / at the volar wrist crease. Cephalic vein identified and mobilised over a suitable length. Radial artery identified and isolated between slings. Systemic heparin administered [2500–5000 IU IV]. Radial artery clamped proximally and distally. Cephalic vein divided at its distal end, spatulated, and flushed with heparinised saline. Vein brought adjacent to the artery without kinking or tension. Arteriotomy created with No.11 blade and Potts scissors — [length]. End-of-vein to side-of-artery anastomosis fashioned with continuous 7-0 Prolene. Clamps released — thrill palpated / audible bruit confirmed on Doppler.

BRACHIOCEPHALIC FISTULA (elbow):
Transverse incision in the antecubital fossa. Cephalic vein identified and mobilised from the antecubital fossa. Brachial artery and its bifurcation identified. Vein mobilised to gain adequate length without tension. Systemic heparin administered. Arteriotomy created. End-of-vein to side-of-artery anastomosis with continuous 6-0 Prolene. Flow and thrill confirmed.

BRACHIOBASILIC FISTULA — FIRST STAGE:
Longitudinal incision along the medial aspect of the arm. Basilic vein identified in the subcutaneous plane above the deep fascia. Vein mobilised from cubital fossa to axilla, dividing tributaries between clips. Brachial artery identified and isolated at the cubital fossa. Heparin administered. End-of-vein to side-of-artery anastomosis with continuous 6-0 Prolene. Thrill confirmed. Vein left in situ to mature — second stage transposition planned at 6–8 weeks.

BRACHIOBASILIC FISTULA — SECOND STAGE (Transposition):
Matured basilic vein confirmed on USS. [Single long incision / tunnel technique]. Basilic vein dissected from its bed throughout its length, dividing all tributaries. Vein tunnelled subcutaneously to a more superficial and lateral position suitable for needle cannulation. Proximal and distal ends secured. Thrill confirmed.

HAEMOSTASIS AND CLOSURE:
Wound irrigated. Haemostasis confirmed. Wound closed in layers — subcutaneous absorbable sutures, skin subcuticular absorbable suture / interrupted monofilament.

Dressing applied — non-constrictive.

FINDINGS:
Arterial and venous anatomy suitable for anastomosis. Anastomosis patent — palpable thrill and audible bruit confirmed immediately post-anastomosis. [Vein diameter at anastomosis: [measurement]].

EBL: Minimal. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Avoid BP cuff, cannulae, and venepuncture in the fistula arm permanently. Limb elevation for 24 hours. Assess thrill daily. Opiates avoided where possible — may cause venospasm. Haematology and renal team review. AVF assessed by renal access nurse at 6 weeks — maturation USS at 6–8 weeks before first cannulation attempt. [If no thrill post-operatively — return to theatre for revision / Doppler assessment urgently].