Perioperative management - Dialysis access surgery: Brescia-Cimino (radiocephalic) fistula – Vascular surgery

• Decompensated renal failure

• Heart failure NYHA III to IV with massively impaired cardiac ejection fraction
• Infections in the immediate vicinity of the surgical site
• Poorly developed/interrupted arm veins, e.g., following multiple punctures
• Small caliber (<2 mm) cephalic vein (in Cimino fistula) or basilic vein (in basilic fistula) in the distal forearm, occlusion of the cephalic or basilic vein further centrad
• Small caliber radial artery, possibly ulnar artery, marked arteriosclerosis of the radial or ulnar artery, positive Allen test (see preop. diagnostic work-up)

Medical history

• Prior central venous line? -> central veins patent? possibly duplex ultrasound/phlebography
• Prior cardiac pacemaker? -> which vessel was used? occluded cephalic or subclavian vein?
• Prior vascular surgery or arm injury?
• Diabetes?-> if necessary, fashion AV fistula on the upper arm
• Indications of CHD and possibly PAOD in the upper limb? -> possible contraindication for AV fistula there
• Anticoagulants? Continue perioperatively?
• Prior dialysis access surgery? -> spontaneously occluded? recurrent fistula thrombosis?

Inspection

• Edematous swelling of the arm? -> central problems?
• Venous collaterals in the shoulder region? -> indicative of occluded subclavian vein
• Inflammatory changes, eczema, cutaneous mycosis? -> local contraindication
• Acral skin color

Clinical examination

• Palpation of the brachial, radial, and ulnar arteries: Palpable pulses?
• Allen test (see below): Function testing of the blood supply to the hand via the radial and ulnar arteries 
• Vein quality assessment by mild compression with a BP cuff

Technical examination

• Arterial and venous duplex ultrasonography (“fistula mapping”)
  • Search for deep-lying veins in obese patients
  • Evaluation of venous diameters
  • Evaluation of arterial vessel walls (arteriosclerosis?) 

Allen test

Technique

First, the examiner manually compresses both the radial and ulnar arteries. The patient then makes a fist several times to pump out the venous blood until the palm of the hand turns white.

Selective opening of the manually compressed radial or ulnar artery is used to determine whether the collateral blood supply to the hand provides adequate perfusion. Due of the collateral blood supply of the hand, one of these two arteries normally suffices to supply the entire hand with arterial blood. 

Evaluation

If the hand rapidly (approx. 5–7 sec.) turns pink after releasing the compression, the Allen test is normal. If rapid reperfusion is missing or if this time is significantly prolonged, the test is pathologic and indicates vascular anomalies, occlusion, or arteriosclerotic vascular changes in the artery in question. 

• Plan AV fistula surgery on day without dialysis!
• If necessary, trim the hair around the surgical site 
• Mark the side where the AV fistula will be fashioned

General risks

• Secondary bleeding, hematoma, possibly reoperation
• Allogeneic blood transfusion, risk of infection (hepatitis, HIV)
• Wound infections, pharmacological or surgical measures
• Allergy/intolerance (latex, medications, contrast agents)
• Thromboembolism
• Skin, tissue, nerve damage
• Keloid

Specific risks

• Infection, thrombophlebitis, possible surgical revision
• Nerve lesion (especially with corrective/repeat procedures)
• Poor limb perfusion -> possible fistula exposure or termination, or fashioning of a new AV fistula
• Steal phenomenon
• Chronic arm edema due to central venous run-off obstruction, possible balloon dilation or stenting
• Heart failure due to fistula-related increase in cardiac output
• X-ray contrast agents → compromised renal function
• Aneurysm, stenosis → surgical revision

• Usually local anesthesia
• Plexus block possible
• General anesthesia uncommon

Supine, affected arm abducted on arm table

Surgeon sits facing the arm table, scrub nurse next to him/her, assistant across

• Vascular instrument tray with soft vascular clamps (e.g., cardiac bulldog clamps), retractors, Pott scissors
• monofilament sutures 5/0 and 6/0
• Vessel loops

Postoperative analgesia:

Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current German guideline Behandlung akuter perioperativer and posttraumatischer Schmerzen [Treatment of acute perioperative and posttraumatic pain].

Postoperative care

• In the first few days elevation of the hand, e.g., on a pillow
• Early movement of the fingers
• Monitoring of the AV fistula, which must exhibit a thrill during the immediate postoperative course and afterward
• AV fistula auscultation → rumbling/swooshing noise
• Periodic sterile dressing changes
• No circular dressings!
• No blood pressure measurement on arm with AV fistula!
• Leave skin sutures in place at least for 2 weeks, unless they are absorbable
• Fistula can be accessed usually after 6 to 8 weeks
• In dialysis patients, no additional anticoagulation is required; otherwise antiplatelet agents, e.g., ASA 100 mg QD 

Deep venous thrombosis prophylaxis

• None

Ambulation

• 2 hrs. postoperatively in case of local anesthesia
• 3–4 hrs. Postoperatively in case of general anesthesia

Physical therapy

• None

Diet

• Immediately in case of local anesthesia

Bowel movement

• Unnecessary

Work disability

• Case-by-case basis, depending on disease severity