Assignment task:
Indications: This is a 48-year-old man who has end-stage renal disease and is on hemodialysis. He has fair-sized cephalic vein clinically. I discussed with him the primary AV (arteriovenous) fistula between the radial artery and cephalic vein. I had previously discussed this procedure with him. Sometimes, though, veins do not dilate nicely, depending on how many times they have been "poked" for IV (intravenous) access and blood draws. He has been in the hospital a number of times, and so they have had some access to this, but overall clinically it looks pretty good.
Procedure: The patient was brought to the operating theater and placed in a supine position on the operating room table. After receiving some IV sedation, he was prepped and draped in a sterile fashion. His cephalic vein was marked out, as was his radial artery. An incision line was marked out halfway between these two. This was longitudinal. It was infiltrated with 0.5% Marcaine with epinephrine. This was left to sit for a couple of minutes. An incision was then made. We dissected out the cephalic vein first. This was done sharply. We were able to get around the circumferential. A couple of small side branches were ligated with 4-0 silks and transected. We were able to dissect up a good segment of the cephalic vein. We then dissected out the radial artery. This was also done sharply. We were able to dissect down to it and dissect it sharply in a circumferential manner. This had a fair amount of calcifications within it. Two very small side branches were taken down with 4-0 silks and transected. We then put a right-angle clamp on the distal aspect of the cephalic vein. It was transected. We ligated this with 2-0 Vicryl. We attached a Titus needle onto the end of the cephalic vein. This dilated up nicely and flushed out quite easily. We then occluded the radial artery proximally and distally with mini vessel loops in a Potts loop fashion. Arteriotomy was made. There was still bleeding coming distally. This was controlled with a small profunda clamp. This worked well. We then irrigated it out with a heparinized saline both proximally and distally for heparinization. We spatulated the end of the vein and cut it to a length. We then performed an end-to-side anastomosis using Gore-Tex CV-7 suture. Prior to placing the last couple of bites, we back-bled and forward-bled and flushed everything out with heparinized saline. We placed the last couple of suture bites and secured our suture line. We opened up the vein and then the proximal radial artery. We let the flow initially go through this and into the vein. We then opened up the distal radial artery. A light thrill was present. With the Doppler, pulses were heard of the radial artery on the wrist distally to our anastomosis as well as on the ulnar artery. The palmar arch also had good flow both proximal and distal. There was distal artery flow and good capsular refill in all fingers. There was good, long diastolic flow through the cephalic vein up the forearm. There was a light thrill present over the area. A good bruit was also audible with a sterile stethoscope. Hemostasis was present. We closed the subcutaneous tissue with 3-0 Vicryl in interrupted fashion. The skin was closed with 4-0 Vicryl in a running subcuticular fashion. Sterile dressings of Telfa and Tegaderm were applied. The patient tolerated the procedure well and went to the recovery room in stable condition.