Brachiocephalic fistula: a useful alternative for vascular access in chronic hemodialysis.

Construction of a Cimino-Brescia radiocephalic fistula is the current method of choice for vascular access in most patients on chronic hemodialysis. However, previous vascular access procedures, cephalic vein thrombosis or intrinsic arterial disease may render this procedure impracticable. The brachiocephalic fistula, which provides many advantages over the use of saphenous vein or prosthetic grafts for fistula access, is frequently overlooked as a surgical alternative in patients on chronic hemodialysis. Brachiocephalic fistula constructed directly between the brachial artery and cephalic vein at the level of the cubital fossa is associated with a 4.5-year patency rate of 80%. The incidence of complications is relatively low compared with that when interposition graft materials are used. However, two patients developed severe swelling of the upper extremity secondary to unrecognized preoperative subclavian vein thrombosis. The possibility of this complication should be suspected in any patient who has undergone previous percutaneous subclavian access.