A thorough patient history is taken documenting patient’s dominant extremity, recent history of peripheral intravenous lines, site of indwelling or previous central venous lines including pacemakers and defibrillators, all previous access procedures, any history of trauma or previous nonaccess surgery to the extremity, and all comorbid conditions. On physical examination, the brachial, radial, and ulnar arteries are evaluated for compressibility and equality; an Allen’s test is performed to evaluate for palmar arch patency. With a venous tourniquet in place, the cephalic and basilic veins are evaluated for diameter, distensibility, and continuity; the arm is examined for any signs of central venous stenosis including prominent venous collaterals, edema, or a differential in extremity diameter.

If any abnormality is noted on clinical arterial examination, the patient is further evaluated with segmental pressures and duplex ultrasound. Any abnormalities noted on noninvasive testing, including pressure gradients between the bilateral upper extremities, arterial diameters less than 2.0 mm, and nonpatent palmar arches, are further evaluated with an arteriogram. Any inflow stenosis is treated first with endovascular techniques such as angioplasty and/or stenting, and if not amenable or unsuccessful, open surgical techniques such as patch angioplasty or bypass.

If superficial veins cannot be visualized or any abnormality is noted on the superficial venous examination, the patient is further evaluated with superficial venous duplex; using duplex the superficial veins are examined for diameter, distensibility, and continuity. We only use superficial veins for autogenous access that are greater than 2.5 mm in diameter.

If any central venous stenosis is suspected by history or any abnormality is noted on physical examination, the patient is further evaluated with deep venous duplex; if the deep venous duplex is nondiagnostic or any central venous stenosis is noted, the patient is further evaluated with a venogram. Any central venous stenosis is treated first with endovascular techniques such as angioplasty and/or stenting, and if not amenable or unsuccessful, open surgical techniques such as internal jugular to axillary venous bypass or subclavian vein turndown.

In patients nearing dialysis, the risk of contrast arteriogram or venogram is weighed against the need for an access to mature before beginning dialysis; in this population, we use renal protective agents prearteriogram, including intravenous fluids, N-acetylcysteine, and sodium bicarbonate.

In the upper extremity, the cephalic and basilic veins are both options for autogenous AV access; however, when unavailable, we perform a prosthetic upper extremity access, beginning in the forearm. Sources of arterial inflow include the distal or proximal radial and brachial arteries; we
use the most distal artery in the arm felt to be adequate by preoperative evaluation for inflow to preserve more proximal arteries for future accesses. Sources of venous outflow include the antecubital vein or the brachial vein; we use the superficial system if felt to be adequate on exploration to help with venous dilation of the upper arm superficial veins for future accesses. Therefore, when the distal radial artery is adequate, we perform a prosthetic radial–antecubital (or brachial) forearm straight access (Fig. 1). If the distal radial artery is inadequate but the brachial or proximal radial artery is adequate, we perform a prosthetic brachial (or proximal radial)–antecubital (or brachial) forearm looped access (Fig. 2).

One of the interesting debates in this area is whether, after exhausting the forearm autogenous options, the surgeon should recommend a forearm prosthetic access before proceeding to an upper arm autogenous access. We handle this decision by having a discussion with the patient about this alternative option and its advantages and disadvantages, and allow the patient to make an informed decision. If a prosthetic forearm access is chosen, we explain to the patient that this access is used as a “bridge” to an autogenous upper arm access; we minimize attempts to salvage this access to avoid damaging the venous outflow so it can still be used for an autogenous upper arm access.

When use of the forearm has been exhausted, efforts are directed to the upper arm. Like the forearm, the cephalic and basilic veins are both options for autogenous access; however, when unavailable, we perform a prosthetic upper arm access. Sources of arterial inflow include the proximal radial and brachial arteries; we use the most distal artery in the arm felt to be adequate by preoperative evaluation for inflow to preserve more proximal arteries for future access. Sources of venous outflow include the proximal brachial and axillary vein. Therefore, in patients with no adequate vein, a prosthetic brachial (or proximal radial)–axillary (or brachial) upper arm straight access (Fig. 3) is performed.