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Hi, I'm Chris Stever, Julio

and I am one of the vascular surgery

faculty and the chair

of the Department of Surgery at

Harvard UCLA Medical Center.

So today we're going to be

performing an arterial venous

fistula for dialysis access

in this young gentleman.

We're going to do it in his right

arm.

And we're going to start by

exploring down at the wrist

with the plan of connecting his

real artery and systolic

vein together the so-called radius

of fallick fistula.

However, we have some concerns

about the vein down at the wrist

in that there may be some narrowing

in the vein at the wrist.

So what we will do is we'll start

by exploring the vein first

dividing it, and then see

if a dilator will pass into the

vein. If a dilator passes

easily, we will proceed with

connecting the psephology vein

to the radial artery.

However, if, on the other hand, we

find that the dilator will

not pass into the vein, we

will then proceed to the elbow

and expo's at the elbow,

the brachial artery and the anti

cubical vein, which will then

lead to this fallick creating

what we call a brachial

fallick arterial venous fistula.

So the plan today is to perform a

radius of fallick you fistula.

We're going to dissect out the radio

artery here.

This patient's cifelli

vein is a little bit more

lateral than or dorsal

the normal.

And so for

that reason, we're going to make two

separate incisions begin

to dissect up the vein first,

distend it up and make sure that

it's of adequate caliber and that

we can pass the dilator down once

we're able to confirm that.

Then we'll dissect out the artery.

So scalpel.

I'll start with the

shorter incision.

Mosquito, please.

Let them extend that with the

cutting.

Yeah, 20, 20.

He's cutting again.

Yes, both pick up.

You get your mess,

hold it right there.

There's so Fallick been.

So when you look at the rain at the

moment, the vein looks pretty small.

Ideally, our veins should be a

minimum of two

and a half millimeters.

And right now it looks like it might

be only to

cover.

You've got to realize that

we have to distend the vein and see

what its real diameter is.

I hope that gentle.

Just grab the.

And get the right angle there.

And then all the way at the base,

then what we do is we mark the top

of the vein so that we don't lose

the orientation

to a tie.

And then give us the Hepp sailing

plea.

So now we have the vein dissected

out and divided.

Our next step now is to try to

gently distend the vein with a

little help. Nice sailing.

Grab the edge.

I will hold there and inject

you can see how nicely that being

the stands. Now, can we get

a measuring tape.

Of the press here?

Inject Elermore.

And so when you see the vein

distending that nicely, it usually

predicts that when you create the

fistula, it will also

distend mature.

And as you can see from the

measurement, what would you measure

this as now?

I'd say it's about four millimeters,

four and a half.

So.

All right. So go and take that out.

And so now we take the

two and a half dilator and

we use the two and a half because

that's the minimum diameter that we

feel is suitable for

fistula creation.

And we pass it up once for

two purposes.

One is to confirm that

the diameter is, in fact at least

two and a half.

And this one single pass all the way

up.

And the second is to make sure that

there are no stenosis

any.

And so here it seems like it's

getting caught in something

so good.

Put the Hepp sailing in again,

Jack.

See how it distending when I

inject

ejecta and see how it's distending

without me holding up.

So what does that mean?

Yeah, I think there's a synopsis

here and

I can't pass the diet, the two and a

half dilator.

So unfortunately, I'm will try

more time. But I think there's a

problem in the

vein here.

So we're left

with taking sort of a strategic

pause to kind of think this

over.

What options do we have?

Extend the incision

and explore the areas.

Right.

But then assume this synopsis is

here

and then you you then have to be

able to move the vein

to here.

Right.

So then we'd need at least

the length the here

and and then move it

to here.

So that's one option.

The other.

It's just simply

to go up here

and do a break.

It's a fallick or the third option

would be to just

try. Right.

And just try and connect it.

My concern is that when

I inject, then it stands.

It tells me there's a synopsis

there.

And typically then when you connect

it, you will end up being pulsatile.

And this to Gnosis is likely from a

prior I.V..

So

my tendency would be to just go up

here.

We're going to inject a little more

local.

Mosquito,

come on.

So the plan now is that we're going

to explore the median

anti Kubota vein with

the idea that that will lead

to the phallic vein here

and hopefully then be able to

perform a brachial support like

this Chilean stem.

There's a vein there.

Get your Metsu.

Keep going, I get through all that.

Push harder.

Spread their.

We can divide this

thing here.

Three oh, yeah.

Another one.

It can relax on that and

it will get the artery out.

Now we're going to get the brachial

artery out here.

And as we head down here,

we will encounter an apple

neurosis.

Nice. And a white down there.

That right there. And by Sippel, up

in an hour or so to get

to the artery, we actually have to

divide the.

And you can put your logo and you

can put your finger there and see

if you can feel the pulse.

Right angle. You can see there's a

little branch

or tributary of a vein right there.

The three

three oh.

Another one,

another three oh times

two.

There's another one right there.

Now, one.

Sometimes I'll use my right angle

here. Let go first.

I to kind of push to

make sure that there's enough space

between us and we don't

necessarily have to divide every

branch of the artery.

But this is a small one, and it'll

help us to kind of mobilize the

artery a little bit.

So there's a big branch who would

have left it alone.

So I would have a.

We freed up.

Now we need to do is does

it always want to feel it like you

do to make sure it's soft?

And I actually like to compress

it where I'm planning to clamp

to make sure there's not a big

plaque there.

And now we have to make sure that

are. Let's free the vein up a little

more.

Proximally.

Now,

I think we're ready to divide the

vein.

But before we divide, I want to make

sure. Is it going to reach over?

And I think.

What do you think?

Writing, I think.

Yes. Right.

They're marking pen.

All that and cut to a tie

and a passer.

Check.

Put it in further.

To dilator.

That goes a

long.

Sharp.

We're going to put it about right

there. So

make it about right there, little

more towards you while you

go in. Push forward,

then lift.

Good. That's it.

Parts.

Define.

Kind of, if I'm right there

at all, a little shorter than

Darian.

Like I we're going to put

it right there.

So then open it.

On the back, Wall Street.

All right there.

Notice how this vein looks a little

thick and

it didn't distend as well.

So I'm a little worried about this

vein that it may

have been a little scarred from.

Are here.

Yeah. He'll heal and then

toe.

Toe.

All right.

You're gonna start on

the vein. That's partly gonna be

easier for you to go inside out.

But then what do you need to do?

Yeah. So you have to switch needles

inside out.

And then switch to the other Nito,

and then you're going to go inside

out with the other needle right in

the middle of the back wall.

Good.

OK, so now both

futures are on this side.

So we need to move one of them over

to the other side.

So she's going to get the right

angle.

So here this are Despain

isn't that big.

So we have to take really tiny

bites,

which I'm doing here,

and I'm going to flip it.

You are back.

I keep my hands down there

and take that by going to pull

it and turn it

to a for him.

Let go.

Don't let down. Let go of the vein,

though.

The same thing here.

Little by

forehand, pull

it. Turn it.

Turn back and

then turn my hand.

Backhand.

And I pull it and pivot it

for him.

Forehand.

I never grabbed the tip of the

needle, but close the tip and then I

turn it slowly.

I'm back to.

A bad can grab it near the

tip, not at the tip, then pivot it

and turn it.

Go a little.

I'll do it in fast motion.

Boom,

boom, boom.

That grab

turn.

You know, it's going to be a for

him. Suction, please.

Contempt on their arteries.

See, it just sits there and I

can just tease, tease

and then flip it.

So I'm going to go out and start on

your side. Now, I'm going

to put this in here to protect.

So you don't backwell a little bite

on the vein and I'm gonna grab

it with your pickup

and then

turn it to a forehand and pull it

out.

Load it down there.

Pull up.

Little more by.

Could turn into a back, very nice

and pull up a switch

my hand over here.

I would have put my pick up in

there, pull back on that and put

my pick up in there.

Just the edge.

Not to be good by. A little less by.

Try to just get that with him

pulling the edge point

I.

Home right away.

And again, you just want to get just

that little edge of being, so I'm

pulling all that adventitious off,

just cutting the edge.

Good.

And taurel that to your

good forehand.

Pull up.

Good. Good.

Turn up

now.

Hold this right here

and aim it towards

the artery.

Good. Just do it in two and the

corner is always on the corners.

You want to do it in two?

Probably a forehand again.

You think or. No.

But you get it back.

OK. I think it'll work.

Sometimes when it's sitting on the

artery like that, you just keep it

back in.

Can kind of pull on that

like this, and that exposes it for

an they can do it in one.

Pointing down a little more to make

sure you get the artery and

leave your pickup, do it in one year

and then leave your pickup where it

is.

Don't move your pickup and then just

tease it out, release and then

tease it.

Make sure.

There you go.

And as you pull it out, make sure

you follow the curve of that.

Expose it for you.

So as you tease it, make sure your

tip turns up.

Go ahead.

Keep going.

And don't forget that we have two

good.

So when they clash, we'll just put

a finger here, quick squirt.

I did pull

up two more bites.

Maybe one more thing,

give you your pick up there

on the main.

That's all you need. Good.

One more by.

Not too big on the artery.

Perfect.

Tease it out.

So grab it low,

cut, high,

and then I release this as you try

to help it stand a little and not

prevent it from per stream.

But I'm in jail phone.