If a suitable cephalic vein at the wrist is not present, then a more proximal brachiocephalic fistula may be created. In some instances, the cephalic vein may 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.

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 and palpated to locate the position of the brachial artery, which lies adjacent to the basilic vein (Fig. 3.5).

Both the brachial artery and cephalic vein can be isolated through a transverse incision either above or below the antecubital crease (Fig. 3.6). The cephalic vein may require some mobilization to reach the brachial artery, and it 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 can be found that communicates with the cephalic vein (Fig. 3.7) and easily reaches the brachial artery. This vein can be used for the anastomosis with the distal cephalic vein being ligated.

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 (Fig. 3.8). 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 are suitable, a loop forearm graft can be created through the same incision. A primary brachiocephalic fistula matures in 8–12 weeks.

Sometimes the cephalic vein at the level of the elbow and above is of adequate size, but it is 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 dissected 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 (Fig. 3.9). At this point it is helpful to gently dilate the vein with saline solution to ensure that there is no twisting. The vein can be marked with a pen to maintain this orientation. One is now ready to create the superficial tunnel for the vein.

A subcutaneous tunnel is created for the vein using a tunneler or other blunt instrument (Fig. 3.10). The tunnel should start just above the brachial artery and end at the proximal extent of the upper arm incision.

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 is positioned just above the brachial artery, in preparation for the anastomosis (Fig. 3.11).

An end-to-side anastomosis is created between the cephalic vein and the brachial artery (Fig. 3.12).

The arterialized vein is then inspected carefully through both incisions to ensure that there is no twisting of the vein and to document that there is good flow (Fig. 3.13).

As the basilic vein in the upper arm runs deep to the fascia, it is protected from trauma related to venipuncture. It may be transposed to a more superficial location for dialysis access. This is a suitable option when the cephalic vein is inadequate for fistula creation. The primary patency for this fistula is about 60–70 % and the long-term patency is similar to that of a graft.

The procedure can be performed with a general anesthetic or local anesthetic with sedation, though the former is preferred due to the extensive dissection involved. The whole arm is prepped, including the axilla. The incision is begun at the antecubital crease in a vertical fashion just medial to the brachial artery pulse (Fig. 3.14a). Another option rather than one long incision is to create several smaller incisions along the course of the basilic vein and use them to dissect out the entire vein. The incision is carried through the subcutaneous tissue; the fascia is incised and the brachial artery exposed. The median nerve lies medial to the brachial artery at this location and should be identified and preserved (Fig. 3.14b). Proceeding slightly more medial and still deep to the fascia, the basilic vein is visualized and traced proximally, all the way to its junction with the axillary vein (Fig. 3.15). At some point, usually in the proximal third of the arm, the medial cutaneous nerve is encountered. This nerve usually crosses superficial to the basilic vein and, if injured, can result in numbness over the medial aspect of the arm.

Once the basilic vein is fully mobilized and all its branches ligated, it is divided as far distal in the arm as possible and brought superficial to the medial cutaneous nerve (Fig. 3.16a). If there is adequate length, the vein can be tunneled in a more lateral, subcutaneous location (Fig. 3.16b). Alternatively, a lateral flap can be created subcutaneously as a “pocket” for the vein.

Proximal and distal control of the brachial artery is obtained and the patient is given heparin. An arteriotomy 6–7 mm long is then made and an end-to-side anastomosis between the basilic vein and the brachial artery is constructed using fine, nonabsorbable monofilament suture (Fig. 3.17a). Clamps are then released and flow established in the arterialized basilic vein (Fig. 3.18). The deep fascia is then closed with interrupted, absorbable sutures, keeping the basilic vein superficial to the fascia (Figs. 3.17b and 3.19). The basilic vein is positioned in the subcutaneous pocket, thereby relocating it in a more lateral and more superficial position (Fig. 3.17c).

It generally takes about 12 weeks before the arterialized basilic vein is ready for cannulation. Most surgeons prefer a two-stage procedure for basilic vein transposition. At the first stage, the distal vein is anastomosed to the brachial artery without mobilization. The vein is then brought to a more superficial position several weeks later. The proponents of this approach feel that delayed mobilization results in less damage to the vessel wall and a better chance of maturation.

Arteriovenous (AV) grafts are reserved for patients who do not have a suitable vein for primary fistula creation. Most commonly employed grafts are made out of polytetrafluoroethylene (PTFE). The preoperative assessment is essentially the same as for fistulas. The primary patency of PTFE grafts is in the 70–80 % range.