Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

Подождите немного. Документ загружается.

CHAPTER 89 • Mesenteric Ischemia 981

SELECTED REFERENCES

1. Foley MI, Moneta GL, Abou-Zamzam AM, et al: Revascularization of the SMA alone for treatment of

intestinal ischemia. J Vasc Surg 2000;32:37-47.

2. Morasch MD, Ebaugh JL, Chiou AG, et al: Mesenteric venous thrombosis: A changing clinical entity.

J Vasc Surg 2001;34:680-684.

3. Wylie EJ, Stoney RJ, Ehrenfeld WK: Manual of Vascular Surgery. New York, Springer Verlag, 1980.

982

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of both the arterial inﬂ ow and venous outﬂ ow of the arm

and forearm is critical to the successful placement and maintenance of hemodialysis access.

◆ Figure 90-1 demonstrates typical target sites for arterial and venous anastomoses.

◆ Figures 90-2 through 90-4 demonstrate key anatomic relationships underlying operative

planning.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Placement of new access should be initiated several months before the anticipated need for

hemodialysis to allow time for ﬁ stula maturation and troubleshooting, as well as to avoid

catheter placement and the associated risk of central vein stenosis.

◆ Physical examination for compressible veins in the forearm and arm should be performed,

as well as Allen’s test for palmar arch patency. Any history of congestive heart failure, diabe-

tes, intravenous drug use, or chemotherapy should be elicited.

◆ In most patients, preoperative vein mapping should be obtained to maximize the creation

of arteriovenous ﬁ stulae over graft placement. Target veins should have a diameter larger

than 3 mm, although smaller distendable veins may be used.

◆ Access creation should occur in the nondominant forearm ﬁ rst, starting at the most distal

site possible. Strategic placement of access is important to maximize the number of sites

available over the life of the patient.

◆ In patients with more subcutaneous fat, consider vein transposition to make the vein closer

to the skin surface and more accessible by the dialysis center.

CHAPTER

Hemodialysis Access Procedures

Kenneth J. Woodside

CHAPTER 90 • Hemodialysis Access Procedures 983

Cephalic vein

Radial artery

Possible route

of graft

Possible route

of graft

Ulnar nerve

Median nerve

Coracoid

Median nerve

Basilic vein

Incision for Cimino

arteriovenous fistula

Incision for

basilic vein

Incision for

brachial artery

anastomosis

Incision for

arteriovenous fistula

Brachial artery

Ulnar artery

Ulnar nerve

FIGURE 90 –1

Cephalic vein

Brachial vein

(deep)

Basilic vein

FIGURE 90 –2

984 Section XII • Vascular

Radial nerve

Brachioradialis

muscle

Superficial branch of

radial nerve

Biceps muscle

tendon

Pronator teres muscle

Brachialis

muscle

Ulnar nerve

Median nerve

Brachial artery

Radial artery

Median nerve

Flexor digitorum

superficialis muscle

Ulnar artery

Ulnar nerve

FIGURE 90 –3

◆ Steal syndrome, in which too much blood is shunted away from the hand, is more likely to

occur in patients with diabetes and in those with upper extremity atherosclerotic disease. In

addition, placement of the access above the elbow or use of synthetic conduit increases the

risk of steal symptoms.

◆ The axilla and shoulder must always be included in the surgical ﬁ eld. Fistulograms, shunto-

grams, and central venograms are often required, so a suitable vascular bed and arm board

should be used. Preoperative antibiotics should be given at the appropriate time. Regional

anesthesia may promote venous dilation and assist in successful ﬁ stula creation.

CHAPTER 90 • Hemodialysis Access Procedures 985

Brachial artery

Axillary artery

Median nerve

Musculocutaneous

nerve

Ulnar nerve

Biceps muscle

FIGURE 90 –4

986 Section XII • Vascular

STEP 3: OPERATIVE STEPS—RADIOCEPHALIC ARTERIOVENOUS FISTULA

1. INCISION

◆ The patient is placed supine, with the arm placed on an arm board.

◆ The radial artery and the target cephalic vein are located. Intraoperative ultrasound can help

the surgeon localize the vein and reassess patency of the vessel.

◆ A longitudinal incision is made between the target vein and the radial artery (Figure 90-5).

Radial artery

Incision for

atreriovenous

anastomosis

Cephalic vein

Ulnar artery

FIGURE 90 –5

CHAPTER 90 • Hemodialysis Access Procedures 987

Cephalic vein

Incision for

arteriotomy in

radial artery

FIGURE 90 –6

2. DISSECTION

◆ A small ﬂ ap is made to allow mobilization of the cephalic vein. The vein is mobilized for a

short distance and assessed for adequacy.

◆ The fascia over the radial artery is incised, and proximal and distal control of the vessel is

obtained (Figure 90-6).

◆ The cephalic vein is divided as distally as possible, ﬂ ushed with heparinized saline, and

dilated manually.

◆ The patient is heparinized, and proximal and distal arterial clamps are placed.

988 Section XII • Vascular

◆ An end-to-side anastomosis is performed with 6-0 Prolene suture (Figure 90-7).

◆ The clamps are removed, with the distal arterial clamp removed last. The cephalic vein is

palpated for a thrill. Revision may be necessary if a thrill is not readily palpable. If the

ﬁ stula is pulsatile without a thrill, a distal obstruction may be present. If the obstruction is

not from inadequate vein mobilization, a venogram may need to be performed.

3. CLOSURE

◆ The wound is closed in two layers with interrupted 3-0 Vicryl subcutaneous sutures and a

running 4-0 Monocryl subcuticular layer.

Cephalic vein

Arteriovenous

end-to-side

anastomosis

Radial artery

Cephalic vein

FIGURE 90 –7

CHAPTER 90 • Hemodialysis Access Procedures 989

STEP 3: OPERATIVE STEPS—ANTECUBITAL ARTERIOVENOUS FISTULA

1. INCISION

◆ The patient is placed supine, with the arm placed on an arm board.

◆ Approximately 1 cm below the antecubital crease, a horizontal incision is made, with care

taken to preserve the subcutaneous veins (Figure 90-8).

Incision for

arteriovenous

fistula

FIGURE 90 –8

990 Section XII • Vascular

2. DISSECTION

◆ A suitable antecubital vein is identiﬁ ed and mobilized. The basilic, cephalic, or antecubital

bridging veins are typically used. Strategically, ﬂ ow through the cephalic vein will be easier

to access at the dialysis center (Figure 90-9).

◆ The brachial arterial pulse is identiﬁ ed just proximal to the elbow. The bicipital aponeurosis

is divided, exposing the artery. Proximal and distal control is obtained. Communicating

veins overlaying the artery may need to be divided to allow adequate control. Care must be

taken to avoid damage to the nearby median nerve (Figure 90-10).

◆ The vein is divided as distally as possible, ﬂ ushed with heparinized saline, and dilated

manually.

◆ The patient is heparinized, and proximal and distal arterial clamps are placed.