Program Book - Keck School of Medicine of USC - University of ...

found that failure to mature occurred in 35% of radiocephalic procedures versus only5% of brachiocephalic and the mean time to successful hemodialysis was 13 weeks forthe radiocephalic compared to only 6 weeks for the brachiocephalic (J Vasc Access2007; 8:275-280). The only caveat to this approach is that the patient with thebrachiocephalic fistula may develop a late symptomatic steal as the venous outflowcontinues to develop. Accordingly, in patients for whom you cannot predict at least 75%successful functional patency for the radiocephalic fistula I suggest turning first to thebrachiocephalic construction.Second, an AV graft may be placed in the forearm which will allow dialysis with carefulpuncture within 48 hours. This approach is preferable to the uncertain function of an AVfistula and avoids the complications associated with prolonged central venouscatheterization (central venous occlusion and catheter infection). The radial artery toantecubital vein graft, useful in the absence of a satisfactory distal cephalic vein, hasthe added advantage of dilating both the upper arm basilic and cephalic outflow veins,allowing for an autogenous brachiocephalic AVF when the graft becomesunsalvageable.Third, in the patient over 65 years of age the secondary patency of a PTFE graft in thebrachioaxillary position is equal to that of a successful basilic vein transposition.Functional patency of the brachiobasilic transposed vein occurs in only 75% patients atmost and requires approximately 3 to 5 months until it is first used. During this intervalthe patient is often maintained with a central venous catheter. Further, the primarypatency of the transposed brachiobasilic AV fistula at one year will vary between 35 and50%. Basilic vein transposition is optimal when the patient has approximately 3 months63