Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique

Creating radio-cephalic arteriovenous fistula in the forearm with a modified no-touch technique. A four centimeter skin incision was created where the radical artery was close to the cephalic vein in the forearm. After the superficial fascia is exposed, the cephalic vein under the suprafascial could be seen.

A layer by layer incision was made at the position where radical artery pulse is touched. The arterial sheath was exposed. The vascular clamp was used to block the blood flow.

A vein-to-artery anastomosis side-to-side was created with a 7.0 nonabsorbable monofilament continuous suture. Finally, the distal cephalic vein was ligated to form a functional end-to-side anastomosis. In the video, we presented a modified no-touch technique in which we preserve the perivenous vascular tissue intact.

During the procedure, the fat and the connective tissue around the veins were preserved in their integrity and the injury to the cephalic vein was avoided completely. From January 2021, we enrolled 10 consecutive patients to construct AVF by modifying the no-touch technique. The eight to 20 week follow-up has now been completed.

Check the medical history. Perform physical examination results. Ensure symmetrical blood pressure in both upper limbs, good arterial pulse, strong pulsation, negative Allen test, continuous cephalic veins in the forearm and upper arm, good venous distensibility after binding the tourniquet, no edema or varicose veins in the upper limb, and no previous central or peripheral venous scars.

Perform comprehensive assessment of the forearm vasculature of the patient's operative limb by color Doppler ultrasound. Place the patient in a supine position with external rotation and abduction of the operative upper limb before routine item for disinfection draping and local infiltration anesthesia with 1%lidocaine. Make a four centimeter skin incision longitudinal incision at a distance of less than two centimeter between the radical artery and the cephalic vein of the forearm.

The subcutaneous adipose tissue was separated using curved hemostatic forceps to expose the superficial fascia. The cephalic vein and its surrounding tissues below the superficial fascia could be seen. The superficial fascia should not be open in this step, and the electric knife should not be used to stop bleeding.

Make two tunnels along the direction perpendicular to the cephalic vein. And the tunnel openings should be located more than one centimeter from both sides of the cephalic vein. Cut the tissue layer by layer, to expose the radical artery pedicle including the radical artery and it's accompanying veins on both sides in the positing area of the radical artery that can be reached with the index finger.

Ligate the small artery branches and pick out the radical artery pedicle with the hemostatic forceps the radical artery pedicle was dissected for about 40 to 50 millimeter. Pass the two red vessel loops through each end of the radical artery pedicle. The radical artery could be pulled to be closer to the cephalic vein to facilitate the surgical suture.

Place a vascular clamp at each end of the pedicle to block arterial blood flow. Although vascular clamps were used to block blood flow the intact tissue is preserved around the cephalic vein which plays a better protective role for the vessels. Lift the superficial fascia at the cephalic vein gently with mic pro forceps and cut the superficial fascia and the wall of the cephalic vein with a micro scissor or sharp knife.

The incision length should be about eight to 10 millimeter open the arterial sheath and the wall of the radical artery successively to make an eight to 10 millimeter long incision with a sharp knife and a microscopic scissor, taking care not to twist the vessel. Using the 7.0 non-absorbable single strength suture to establish vein arterial anastomosis side-to-side with the coolings technique suture the posterior wall of the vessel first and then suture a anterior wall of the vessel. The vessels should be pulled close to each other to reduce vascular tension.

Open the blood flow and like it a distal cephalic vein to form a functional Endocyte anastomosis and use a mattress suture for surgical incision. Physical examination of the cephalic vein at weeks four and eight showed significant dilation, fistula can be palpable tremor with loud murmur. Doppler ultrasonography showed up the acetylation of the cephalic vein and radical artery.

The blood flow spectrum of the cephalic vein 1.5 centimeters away from the anastomosis show spar laminar flow. This table showed that the blood flow of the cephalic vein at five centimeters from anastomosis was more than 500 millimeters per minute. And that of the brachial artery was more than 600 millimeter per minute.

Four hours of hemodialysis was successfully completed. None of the patients had any current vascular access related complications. The modified no-touch technique and functional end-to-side anastomosis for RC-AVF construction were feasible, and the short-term results were encouraging but a large number patients is needed to thoroughly evaluate this technique.