Editing Haemodialysis access surgery (section)

== Brachiocephalic ==

* Three possible incisions - transverse across ACF, sigmoid coursing medially in upper arm across ACF and into lateral forearm, and separate incisions over the brachial artery and cephalic vein in upper arm
* Palpate and mark brachial artery and cephalic vein
* Dissect free cephalic vein 4cm
** Potentially you can just take the median antecubital vein and plug it into the brachial artery without interrupting the cephalic vein, as above picture
** Suture-ligate the median antecubital vein with silk if not using it
** Mark the top side of it to ensure no twisting
* Expose 2-3cm of brachial artery - need to incise bicipital aponeurosis and maybe the flexor retinaculum of the brachioradialis muscle. If it's easy to expose the bifurcation, you can loop both radial and ulnar branches.
* Distend vein with saline (check to ensure low resistance), spatulate, repair defects. May need to use Bakes dilators to rupture valves in the distal cephalic vein, which increases the length of vein available for dialysis (start with 3, then 3.5, then 4).
* Give 5000 units heparin IV
* Occlude brachial artery proximally and distally. 6mm arteriotomy. Anastomosis with 6-0 Prolene.
* Check thrill, distal pulse, hand perfusion