Angeline Budiman

07120120042
ARTERIOVENOUS (AV) FISTULA / CIMINO

Introduction
A vascular access is a hemodialysis patients lifeline. The access is surgically
created vein used to remove and return blood during hemodialysis. Two types of vascular
access designed for long-term use include arteriovenous (AV) fistula and AV graft. A
third type a vascular access, the venous catheter is for short-term use.
Of these, the AV fistula is preferred for long-term hemodialysis vascular access since it
has the best long-term primary patency rate, requires the fewest interventions of any type
of access, and, most importantly, is associated with the lowest incidence of morbidity and
mortality

Definition
A fistula is any abnormal connection between one part of the body and another; in
this case the fistula is created between an artery and a vein and is therefore called an
arterio-venous fistula. Cimino was the physician who originally described this technique
in 1966. A Cimino fistula is created by joining a large vein directly to an artery, typically
in the forearm at the wrist, or higher in the arm near the elbow crease.

Indication
End-stage renal disease requiring hemodialysis

Procedure
To ensure adequate arterial supply to the limb after construction of a fistula the surgeon
must make sure that the followings are fulfilled:
- An alternative arterial supply is available, i.e. in the upper extremity the Allen test
should be negative
- The artery is not interrupted i.e. a side to side anastomosis is constructed.
- The anastomosis should be made as peripheral as possible or if a more central
location between larger vessels such as the brachial artery & cephalic vein is
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required. The anastomosis should be made small enough to avoid a steal
syndrome.

A surgeon performs AV fistula surgery in an outpatient center or a hospital. The

vascular access procedure may require an overnight stay in the hospital; however, many
patients go home afterward. A health care provider uses local anesthesia to numb the area
where the surgeon creates the AV fistula. An AV fistula frequently requires 2 to 3
months to develop, or mature, before the patient can use it for hemodialysis. If an AV
fistula fails to mature after surgery, a surgeon must repeat the procedure.

Essential Steps Radiocephalic Fistula

1. Evaluate the cephalic vein with duplex scan unless good quality and continuity to the
upper arm clearly established by physical exam.
2. Allen test
3. Regional/local anesthesia
4. Incision: The whole arm, including the axilla, is prepped and draped. As no prosthetic
device is being employed, antibiotics are not a requisite. A vertical incision is
fashioned just proximal to the flexion crease of the wrist between the radial artery and
the cephalic vein (black arrow). Some surgeons prefer to make an incision over the
anatomic snuff box more distally and use the deep branch of the radial artery to create
the fistula (grey arrow)
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5. Exposure: The incision is carried through the subcutaneous tissue, and then medial and
lateral flaps are raised. Both the cephalic vein and radial artery are very superficially
located and can readily be exposed. (Figure a)

6. Isolation of vessels: The cephalic vein is mobilized as far proximally and distally as
possible and any large branches ligated. The radial artery is also mobilized for a short
distance. Once mobilization is complete, both the cephalic vein and radial artery are
placed adjacent to each other in a side-by-side fashion. This can be accomplished by
placing a vessel loop proximally and distally, with each loop incorpo- rating the artery
and vein. By tightening up on the loop, the two vessels are brought together (Figure b).
If necessary, systemic heparin can now be administered. Control of the vessels can be
achieved by tightening up on the vessel loops or by using small vas- cular clamps
(Figure c)

7. Arteriotomy: A corresponding venotomy and arteriotomy are made in the cephalic

vein and radial artery (Figure a). The arteriotomy should be limited to 6 or 7 mm to
prevent a steal syndrome.

8. Anastomosis: A side-to-side anastomosis is then constructed using fine, nonab-

sorbable monofilament suture (Figures b and c). One technique is to sew the pos-
terior wall from within the lumen, then running the suture anteriorly to complete the
anastomosis. Prior to reperfusion, the anastomosis can be probed through an opening
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created in the distal cephalic vein (Figure d). The probe is passed sequentially up the
cephalic vein and the radial artery. The distal cephalic vein is then ligated and the arte-
rial clamps released to perfuse the fistula (Figure e).

Alternatively, an end-to-side or end-to-end anastomoses between the radial artery

and cephalic vein can be created by dividing the vein initially (Figure a) and then
anastomosing it to the artery (Figure b).

9. Evaluation: When the vascular clamps are removed the vein is checked for filling and
for a palpable thrill. Haemostasis is ascertained.
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10. Wound closure: The wound is closed with a single row of continuous vertical
mattress suture of 4/0 nylon or prolene. A loose dressing which is not circumferential
is applied to the incision. The patient is advised to make ordinary use of the extremity,
to avoid placing it in a dependent position and not to modify the dressing. In men with
large vein this sort of fistula can be used for dialysis in 1-2 weeks. In women and
children who tend to have small vessels, a period of maturation of several weeks or
months may be desirable before every use without risk of loss of the fistula. A
radiocephalic fistula usually requires 8 to 12 weeks to mature. Sometimes a second
procedure is required to ligate a side branch or angioplasty an area of proximal
stenosis.

Essential Steps Brachiocephalic Fistula

If a suitable cephalic vein at the wrist is not present, then a more proximal brachio-
cephalic fistula may be created. In some instances, the cephalic vein might be deep in the
upper arm and not clinically visible. If it is seen on ultrasound examination and has a
diameter of 3 mm or more, then it may be suitable for fistula creation. Brachiocephalic
fistulas have a primary failure rate of close to 10% and good long-term patency.

1. A preoperative evaluation is performed as described for the radiocephalic fistula. The

whole arm is prepped from the wrist to the axilla. This procedure can be performed
under local anesthetic with sedation. The elbow is examined to mark the course of the
cephalic vein (red arrow) and palpated to locate the position of the brachial artery
(broken red line), which lies adjacent to the basilic vein (yellow arrow) (Figure 2.5).
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2. Both the brachial artery and cephalic vein can be isolated througha transverse
incision either above (Figure 2.6a) or below (Figure 2.6b) the antecubital crease. The
cephalic vein may require some mobilization to reach the brachial artery and may
need to be dissected distally to the upper part of the forearm to gain adequate length
for it to reach the artery. Frequently, an antecubital or median cubital vein (blue
arrow) can be found that communicates with the cephalic vein, and this vein can be
used for the anastomosis with the distal cephalic vein being ligated (Figure 2.6b). It
usually easily reaches the brachial artery (red arrow) (Figure 2.7)

3. Once an adequate length of vein is dissected free, it is divided. An end-to-side

anastomosis is then constructed using fine, nonabsorbable monofilament suture
(Figure 2.8). If the cephalic vein is found to be unsuitable, then the basilic vein can be
used through the same approach and transposed so it runs in a more superficial course
(described next). If none of these veins is suitable, a loop forearm graft can be created
through the same incision. A primary brachiocephalic fistula matures in 8 to 12
weeks.
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4. Sometimes the cephalic vein at the level of the elbow and above is of adequate size,
but too deep to simply anastomose directly to the brachial artery. If the vein is deep, it
may be difficult to cannulate for subsequent dialysis. In this case the vein can be dis-
sected for some length above the elbow, and then brought through a tunnel created
just below the skin to transpose the vein to a more superficial location. This is done
by first isolating the vein either just above or below the antecubital fossa and then
dissecting it further proximally as much as possible through the transverse incision.
The vein is divided as far distally as possible. A longitudinal counterincision is then
made higher in the arm and the same vein is isolated and mobilized into this incision
(Figure 2.9). At this point it is helpful to gently dilate the vein (large blue arrow) with
saline solution to ensure that there is no twisting. The vein can be marked with a pen
to maintain this ori- entation. One is now ready to create the superficial tunnel for the
vein (small blue arrows).

5. A subcutaneous tunnel is created for the vein using a tunneler or other blunt instru-
ment (Figure 2.10). The tunnel should start just above the brachial artery and end at
the proximal extent of the upper arm incision.
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6. The cephalic vein is brought through the tunnel, making sure that the vein does not
twist as it is being pulled through. The end of the vein (blue arrow) is positioned just
above the brachial artery (yellow arrow), in preparation for the anastomosis (Figure
2.11).

7. An end-to-side anastomosis (yellow arrow) is created between the cephalic vein and
the brachial artery (Figure 2.12).

8. The arterialized vein is then inspected carefully through both incisions (blue and
yellow arrows) to ensure that there is no twisting of the vein and to document that
there is good flow (Figure 2.13).
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Complication
Infection
Thrombosis
Hemodynamic complication
Intimal hyperplasia
Aneurysm formation

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Bhuiyan MBG, Ahsan NAK, Shirin M. Radio-cephalic fistula for haemodialysis:

Vascular surgical consideration. The Orion Medical Journal. 2007; 26: 425-6.

Khwaja KO. Dialysis Access Procedures. Dalam: Humar A, Matas AJ, Payne WD,
penyunting. Atlas of Organ Transplantation. Ed ke-XV. London: Springer-Verlag;2009.
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Santoro D dkk. Vascular access for hemodialysis: current perspectives. International

Journal of Nephrology and Renovascular Disease. 2014; 7: 281-94.