Vascular Access – Brescia-Cimino - Sarkar

Preop: find good cephalic by exam, no need for vein mapping by US. Otherwise do vein mapping for targets. Document patient has no paresthesias, no weakness, and normal sat in planned side. Preferred order of access:

1. non-dominant hand cimino

2. non-dom basilic vein transposition OR loop forearm bridge graft

3. non-dom brach->axilla bridge grft

Key Instruments and Equipment

1.  ¼% marcaine

2.  blue vessel loops

3.  3-0 silk ties, 3-0 vicryl, 4-0 monocryl, 6-0 prolene double armed.

4.  2.0, 2.5, and 3.0 coronary vein dilators

5.  4.0mm angioplasty balloon

6.  11 blade

7.  Castros

8.  fine gerald forceps, fine metz scissors.

9.  vascular doppler and sterile lube.

Setup:

MAC + local, arm out on double armboard, duraprep to axilla, kefzol, no foley, stockingette (cut hole at wrist), no tourniquet.

Operation:

1.  place temporary tourniquet and mark vein's path on skin as far up as it will go with pen.

2.  ¼% marcaine, longitudinal incision halfway between radial artery and cephalic vein, cheat slightly towards artery

3.  dissect vein first, tie off all visible branch veins with 3-0 silk, watch for superficial radial nerve, control vein with blue vessel loops.

4.  mark vein with pen along long axis to ensure no twisting

5.  dissect artery 3cm length. tie or bovie side vessels and separate artery from the little veins that run alongside. vessel loop either side.

6.  divide vein distal, tie off end with 3-0 silk

7.  dilate cut end of vein with kelley, then dilate with coronary dilators to 3mm.

8.  dilate vein to 4mm with 4cm angioplasty balloon, as far as catheter will go.

9.  swing vein to artery and cut to length, cutting at angle

10.  wet paper fenestrated drape.

11.  make longitudinal arteriotomy with 11 blade, slightly spiraling. extend with Potts.

12.  flush 20cc heparinzed saline (100U/cc) proximally and 20cc distally. pull tension on loops and snap to drape. No systemic heparin.

13.  6-0 prolene to crotch. make anastomosis. vent.

14.  doppler

15.  close in 2 layers: 3-0 dexon, 4-0 monocryl.

16.  telfa / tegaderm or dermabond to wound

Postop:

neuro exam after regional anesthesis has worn off, finger sat, distal radial pulse exam, thrill.

All 4 need to be ok. home same day.

use:

cimino--min 8 weeks maturation

AV bridge graft--min 4 weeks.