Brachiocephalic Fistulas for Vascular Access

Jose R. Polo, Servicio de Cirugia III, Hospital General ‘Gregorio Marañon’, C. Dr Esquerdo 46, E-28007 Madrid (Spain) Dear Sir, Radiocephalic fistula [1] is the vascular access less prone to complications and having the best long-term results. When this fistula cannot be made or salvage is impossible after thrombosis [2], antecubital veins at the elbow crease may be used before bridged graft A-V fistulas are considered. Because of the deep and medial location of the basilic vein, a superficializing and transposition procedure [3] or, alternatively, the creation of a reverse flow fistula [4] are necessary if this vein is to be used as a vascular access. If a cephalic vein is used for end-to-side anastomosis [5], the possibility of using distal segments of this vein is lost as a result. We report the technical aspects and long-term results of brachiocephalic fistulas created using a modified technique which consists of inserting a short PTFE (Goretex) bridge graft (6 mm diameter) between the brachial artery and the cephalic vein, forming an H-shaped A-V fistula at the distal portion of the arm (fig. 1). The procedures were made under local anesthesia. The anastomoses were done using 6/0 polipropylene suture using magnification with a 2.5 × optical lens. Thirty-four fistulas were made in 33 patients. In 22 patients this procedure was chosen after recurrent and nonrecoverable occlusion of a previous radiocephalic fistula; in 11 patients the brachiocephalic fistula was constructed because no adequate veins were found in the forearm. All the fistulas functioned satisfactorily, and puncture for hemodialysis was initiated 1–2 weeks after the surgical procedure. The proximal cephalic vein was adequate for puncture in all cases. The distal cephalic vein and other veins in the elbow crease were used in 82% of the patients. No associated aneurysms, high-output cardiac failure or significant distal venous hypertension were