Brescia-Cimino method (part 5)

Drukwerk

 

Operative procedure:

  • Incision

A transverse incision is made,  proximal and distal skin flaps are developed to allow exposure of adequate lengths of the vessels

  • Exposure

To expose the artery  the deep fascia is incised longitudinally along the palpable radial pulse. Branches are tied with silk or cauterised and divided so that artery can be lifted from its bed

  • Isolation of vessels

The vein is tied distally. Controlled proximally with a vascular clamp and divided just proximal to the ligature. The isolated segment is dilated gently with a clamp and irrigated with heparinised saline

  • Arteriotomy

The artery is controlled with vascular clamps applied perpendicularlyand is rotated medially to present the lateral aspect of the vessel for anastomosis. A longitudinal arteriotomy 2-3 times width of the lumen is made and flushed free of blood or clot with heparinised saline

  • Anastomosis

The cephalic vein end is spatulated to fit the arteriotomy. The anastomosis is constructed with two running 6/0 or 7/0 monofilament polypropylene (prolene)  sutures inserted at the proximal and distal vertices with the help of lateral and medial stay suture. Posterior anastomosis is constructed through the open anastomosis with the knots tied outside the vein should describe a gentle curve as it passess from the anastomosis to its native bed and should not be kinked or twisted

  • Evaluation

When the vascular clamps are removed  the vein is checked for filling and for a palpable thrill. Haemostasis is ascertained

  • Wound closure

The wound is closed with a single row of continous vertical mattress suture of 4/0 nylon or prolene. A loose dressing which is not circumferential is applied to the incision. The patient is advised to make ordinary use of the extremity, to avoid placing it in a dependent position and not to modify the dressing. In men with large vein this sort of fistula can be used for dialysis in 1-2 weeks. In women and children who tend to have small vessels, a period of maturation of several weeks or months may be desirable before every use without risk of loss of the fistula

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