Indian Journal of Urology
POINT OF TECHNIQUE
Year
: 2000  |  Volume : 17  |  Issue : 1  |  Page : 66--68

Fascial flap for brachio-cephalic arteriovenous fistula


Bhuvnesh Kumar Aggarwal, Sevagur Ganesh Kamath 
 Department of Cardiovascular & Thoracic Surgery, Kasturba Medical College & Hospital, Manipal, India

Correspondence Address:
Bhuvnesh Kumar Aggarwal
Department of Cardiovascular & Thoracic Surgery, Kasturba Medical College & Hospital. Manipal - 576 119
India

Abstract

In uraemic patients with low body proteins, healing of the suture line is always a problem with risk of early fail­ure of the arteriovenous fistula (AVF). To tackle this prob­lem, in brachio-cephalic AVF, a fascial flap was interposed between the newly constructed fistula and the cutaneous suture line, at the time of primary surgery. Such a fascial flap will provide a thick covering over the AVF in the event of non-healing of the suture line and thus, avoid any complication resulting from secondary infection due to exposure of the fistula. In addition, the thick viable tissue overlying the fistula will be a good base for taking a split skin graft.



How to cite this article:
Aggarwal BK, Kamath SG. Fascial flap for brachio-cephalic arteriovenous fistula.Indian J Urol 2000;17:66-68


How to cite this URL:
Aggarwal BK, Kamath SG. Fascial flap for brachio-cephalic arteriovenous fistula. Indian J Urol [serial online] 2000 [cited 2023 Feb 4 ];17:66-68
Available from: https://www.indianjurol.com/text.asp?2000/17/1/66/41027


Full Text

 Introduction



In patients with end-stage renal failure, who are depen­dent on chronic haemodialysis and have failed radio-ce­phalic fistula at wrists, brachio-cephalic arteriovenous fistula (AVF) in the arm is an alternative for vascular ac­cess. [1] As most of these uraemic patients are also low in body proteins and have problems of wound healing, in some patients AVF gets exposed once the suture line fails to heal, in the absence of any tissue between the two. This increases the risk of early failure of the AVF. After expe­riencing this problem in two of our patients recently, we developed a fascial flap raised from the investing fascia of the underlying biceps muscle, to cover the newly con­structed AVF at the time of primary surgery.

 Surgical Techique



After dissecting and looping the brachial artery and the cephalic vein at distal arm, a rectangular flap, based distally, is raised from the investing fascia of the biceps muscle [Figure 1]a. Side-to-side brachio-cephalic AVF is con­structed [Figure 1]b. The fascial flap is stitched back with few interrupted sutures, after taking it over the newly constructed AVF [Figure 2], providing a complete cover to it. Following this, the skin incision is sutured in two layers.

 Results



The fascial flap covering of the fistula was used in eleven patients, who had brachio-cephalic AVF over the last 1 year. None of the patients had any suture line problem and all of them presently have functioning AVF.

 Comments



Surgically created arteriovenous fistula at the wrist or the arm lie directly under the skin-suture line. Non-heal­ing of the suture line in uraemic patients, who are also low in body proteins, results in exposure of the newly con­structed AVF. The exposed AVF is always at risk of fail­ure from thrombosis or developing pseudoaneurysm or secondary haemorrhage, if infection sets in. [1] Early cover­age of the AVF by means of a sliding skin flap may be warranted in such patients for prevention of aforesaid com­plications, as secondary suturing or using a split skin graft directly on the functioning AVF are likely to fail.

Interposing a viable tissue flap between the AVF and the skin will ensure coverage of the AVF in the event of skin sutures giving way, safeguarding the fistula. Presence of vascularised tissue over the AVF will also help in early take-up of a split skin graft.

In addition, we feel that the intervening thick tissue flap between the functioning AVF and the suture line dampens the pulsatile force away from the suture line, hastening the healing in the first place, and thus will avoid non-heal­ing of the skin suture line.

We propose. that such a fascial flap, developed from the available local tissue, should be considered whenever a brachio-cephalic fistula is constructed. It is easy to con­struct and does not need any extra time. It will provide thick tissue coverage of the AVF in the event of non-healing of the suture line, and thus, will safeguard the fistula from the complications resulting from secondary infec­tion. In addition, it will allow early take-up of a split skin graft.

References

1Cony RJ, Patel NP, West JC. Surgical management of complica­tions of vascular access for haemodialysis. Surg Gynaecol Obstet 1980: 151: 49-54.