A brachiocephalic arteriovenous fistula (AVF) is a great fistula for renal patients. It’s simple to create, the involved vessels are usually of acceptable caliber and in the long-run it is autologous. However, occasionally the cephalic vein may end to be perpendicular to the brachial artery which may compromise AVF’s long-term patency. So what is the best geometry of the fistula?

I will give my point of view: try to keep the cephalic vein on an oblique configuration to the brachial artery. How are you doing this? It is quite simple.

Make a slightly curved skin incision with the top end on the lateral area of the elbow continuing on an oblique way to the medial area of the elbow toward the brachial pulses. The cephalic vein is dissected first, down to its bifurcation or occasionally trifurcation. There the vein is divided, the end is spatulated and the vein is flushed.

Then the brachial artery is dissected at a length of about 1 cm to accommodate the anastomosis. Here is the crucial point. Dissect the artery at a distal level as compared to the cephalic vein. This way the anastomosis will have an oblique orientation as compared to the artery. Now, make the anastomosis. I prefer the parachute technique with a 6/0 or a 7/0 polypropylene stitch. Just keep your eye not to twist the vein. And that’s it. You have a nice AVF with a good geometry.

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