The radial artery and the cephalic vein may be exposed through a single incision placed 1 cm lateral to the longitudinal axis of the radial artery. The nondominant upper extremity is preferred for dialysis access, presuming the vessels are of good quality because this allows freedom of movement for the dominant hand during the considerable hours spent undergoing hemodialysis. The nondominant upper extremity should be used only if both arms have equal access opportunities; otherwise the side with the better veins will take precedence. In diabetic patients with calcified radial arteries at the wrist that are seen to be inadequate on preoperative Doppler study, it may be prudent to consider more proximal access sites in the arm.

Establish the position of the wrist joint crease by inspecting the skin folds of the flexed wrist. If needed, place a tourniquet above the elbow to facilitate inspection of the distended veins of the forearm. Phlebitic, occluded, or stenotic veins, whether at the forearm, brachial, or axillosubclavian level, will mandate selection of an alternate site. Large side branch tributaries of the cephalic vein may be identified on ultrasound; these should be ligated to promote fistula maturation. A straight vein that is confined to the anterior surface of the arm and has few tributaries is ideal for the creation of a fistula.

Place the incision proximal to the mobile areas of the wrist to prevent normal joint motion from affecting the anastomosis. A longitudinal incision, placed parallel to the vessels, allows the vein to be dissected far enough distally to reach the artery easily. Sharp dissection will minimize adventitial loss and destruction of the vasa vasorum when dissecting the vein. Bathing the vein in papaverine minimizes vasospasm and allows more accurate assessment of conduit quality and size.

The goal of this procedure is to anastomose the cephalic vein, located in the superficial fascia lateral (or dorsal) to the brachioradialis tendon, to the radial artery, located deep to the deep fascia and medial to the brachioradialis tendon. An incision 1 cm lateral to the axis of the radial artery, or directly over the brachioradialis tendon, generally provides access to both of the radial artery and the cephalic vein. A longitudinal incision carries less risk of dividing the sensory nerves in this area, which are branches of the superficial branch of the radial nerve. These branches frequently communicate with branches of the lateral antebrachial cutaneous nerve, a sensory branch of the musculocutaneous nerve. This incision can also easily be extended. The cephalic vein begins on the dorsum of the hand over the anatomic snuffbox, draining the lateral aspect of the dorsal venous arch. At approximately the junction of the distal and medial thirds of the forearm, it courses from the lateral aspect of the forearm to lie on its anterolateral surface. Distal to the cubital fossa, it has a wide communication with the median cubital vein, which is an oblique communication with the basilic vein. In the cubital region, there is typically
a large communication between the superficial cephalic or median cubital vein and the deep venous drainage in the cubital fossa. The cephalic vein usually is accompanied by branches of the superficial radial nerve.