This transposed basilic fistula was created in one stage from a 5mm basilic vein. Although there is disagreement amongst vascular access surgeons about whether basilic transpositions should be done in one or two stages (the moving and tunneling of a vein to a new position under the skin is traumatic, and the veins do better after the move if they are larger and tougher after a preliminary fistulization), we are worried about taking the extra time for two surgeries, and will do a one-stage procedure if the vein is 5mm or larger.
In this case, the vein was large, the patient was healthy and slender, and the fistula was released for use in four weeks.
A few important points:
In this slender patient with very little subcutaneous tissue to protect the fistula, the fistula is right under the skin. We ordinarily consider these fistulas not suitable for buttonholes due to the risk of local skin erosion and bleeding (see our previous post on buttonholes).
Also, the fistula is long, running from just above the elbow to the axilla, and placed anteriorly on the arm to be easily accessible for cannulation. It is sizable, gently curved and uniform, so there are many appropriate sites for cannulation. To protect the fistula from wear, the cannulation sites can and should be spread widely.
And third, in a slender patient with a shallow fistula and excellent flow, smaller needles and lower pump flows should be considered as long as good clearances are maintained.
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