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INTRODUCTION

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Transformation of superficial veins to thick-walled vein segments carrying high blood flow supplied by arterial blood is the basic idea behind creation of an arteriovenous fistula (AVF) for hemodialysis.1 The vein should be easy to access and allow dual puncture with some intervening distance to avoid recirculation during hemodialysis. Shunt volume should be sufficient to allow dialysis flows with at least 250 mL/min. This requires shunt flows through the AVF of at least 300 mL/min. There are several considerations regarding vein selection when planning the surgery, during the procedure, and after surgery for long-term maintenance of the hemodialysis access.

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ANATOMIC CONSIDERATIONS IN THE UPPER EXTREMITY

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In the upper extremity, the cephalic vein extending from the wrist to the deltoideo-pectoral fossa or the basilic vein from the wrist to the axillary fossa with its interconnecting vein at the midcubital region, as well as the deep brachial vein can be used as an access for hemodialysis.2 Although the cephalic and midcubital veins are easily accessible for puncture, the forearm basilic vein is found on the dorsal aspect of the forearm, making puncture difficult and dialysis uncomfortable for the patient (Figure 36-1). In their anatomical positions, the upper arm basilic vein and the brachial vein are usually inaccessible to puncture without surgical adjuncts.3 Regarding anatomical considerations, the cephalic and midcubital veins should be used as first access option, and all other veins of the upper extremity should be used thereafter.2,3

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FIGURE 36-1.

Preparation of the forearm basilic vein shows excellent potential for arteriovenous fistula creation but in an anatomically unfavorable position on the dorsal aspect of the arm. Puncture in its anatomic bed is therefore difficult; transposition of the vein is necessary in most cases.

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ANATOMIC CONSIDERATIONS IN THE LOWER EXTREMITY

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Both the greater saphenous vein and the superficial femoral vein may be used for creation of an AVF for hemodialysis.3,4 The latter should be used only in redo procedures or in desperate redo situations. The saphenous vein may be used either as a transposed straight graft with a single anastomosis to the popliteal artery or as a subcutaneous loop graft anastomosed to the femoral artery. The superficial femoral vein may be used either as a free graft or as a straight graft transposed into the subcutaneous position.4

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PREOPERATIVE VEIN EVALUATION

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Clinical inspection with the use of a tourniquet allows adequate judgement of vein size, patency, and postphlebitic scarring in about 50% of cases. However, in some patients, the superficial veins are difficult to judge, such as because of their anatomic position, in obese subjects, in children, in the lower extremity, and in redo surgery. Preoperative vein mapping is helpful under these circumstances.5 When deep ...

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