Brachial-Cephalic Arteriovenous Fistula Creation 
Jerry Svoboda, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Introduction:  
 
Brachial-Cephalic Arteriovenous fistula is the 
preferred option for patients who have no useable 
veins in their distal forearm, or who have failed 
fistula creation there. The cephalic or medial 
antecubital veins are reliable in this area. They must 
be evaluated for suitability though, as this is a 
favorite area for venipuncture and IV’s.  
This procedure can and should be done under 
local anesthesia, due to perioperative risks of general 
anesthesia in patients with renal disease. If the 
patient is already receiving dialysis, surgery is done 
on a non-dialysis day. 
Meticulous attention to detail is needed for 
success. As with all vascular anastomoses, poor 
attention to detail or hasty, “ham-fisted” technique 
will lead to a poor result. An acceptable failure rate 
is 10% despite the best technique. While you are 
learning this operation, take notes on each procedure 
you do and track your patency rate. This will allow 
you to refine your technique.  
Brachial-Cephalic fistula formation proceeds in 
the following steps:  
● Careful evaluation of the patient’s superficial 
venous and arterial systems and marking of the 
planned surgical site.  
● Incision, exposure, and dissection of the cephalic 
vein 
● Exposure of the brachial artery 
● Confirmation that the vein will reach the artery 
and further mobilization if necessary 
● Systemic administration of heparin and clamping 
of vessels 
● Tailoring of the artery and vein for anastomosis 
● Anastomosis 
● Confirmation of patency and closure 
 
Steps: 
1. The venous and arterial system must be evaluated 
carefully. Vein(s) and the arterial pulsation are 
marked and the planned incision is indicated. 
Local anesthetic with epinephrine is infiltrated 
intradermally only, to avoid the possibility of 
injury to the vein, which may be very superficial 
at this point.  
 
The right antecubital fossa has been examined and marked. The 
upper arm and shoulder are up in the photo. The line shown by 
the Blue arrow indicates the cephalic vein, which is visible and 
palpable after application of the phlebotomy tourniquet. This 
vein often extends laterally as it runs in a cranial direction, 
upwards and towards the left in this photo. The line shown by 
the Red arrow is the brachial artery location, as assessed by 
palpation. This is just medial to the biceps tendon, which is also 
palpable in the antecubital fossa.  The white line is the planned 
incision, extending transversely across the elbow crease and 
then superiorly up the lateral aspect of the upper arm.  
 
2. A wide and stable operating armboard is used. 
Alternatively a narrow table is brought next to the 
operating table. The regular armboards may not 
be stable enough, though using two of them 
together on the bed rail may be an option. The 
arm is prepared and draped from the axilla to the 
wrist, using betadine rather than chlorhexidine or 
alcohol-based prep, to avoid erasing the lines that 
have been drawn.  
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The arm is prepared with iodine-based prep.  
 
3. A curvilinear incision is made through the 
epidermis and dermis in a controlled fashion. In 
many cases the vein is adherent to the dermis and 
can be injured with a careless incision.  
 
Right arm incision, upper arm and shoulder are up in this 
picture. The incision is made carefully, in layers, with adequate 
retraction, through the epidermis and then through the dermis. 
The cephalic vein is just below the dermis, visible as a blue 
shadow on the left (lateral) aspect of this incision (Blue arrow.) 
Note that the arm is rotated more medially in this photo than 
the following photos.  
 
4. With the vein in sight, careful dissection 
continues through the remainder of the dermis, 
which is dissected off the vein.  
 
The vein becomes more visible during careful dissection in a 
cranial and caudal direction.  
 
5. The vein is encircled carefully with a right angle 
clamp and a vessel loop is passed around it. 
Traction on this vessel loop is then used to retract 
the vein during further dissection. There are often 
many tiny branches, which must be individually 
dissected and ligated with 4-0 silk, otherwise 
these will leak when arterial pressure is applied 
to the vein.  
 
Once dissection is sufficient, a right angle clamp is used to pass 
a vessel loop around the vein.  
 
Brachial-Cephalic Arteriovenous Fistula Creation 
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The assistant places traction on the vessel loop while the 
surgeon continues the dissection. . 
 
 
Side branches of the vein, no matter how small, must be 
dissected and ligated.  
 
6. Undiluted papaverine HCl is applied to the vein 
throughout the dissection, to help it dilate. This 
can be done by a non-sterile assistant who 
dispenses drops at a time through an intravenous 
cannula, to economize the medication.  
 
Papaverine is applied periodically by a non-sterile assistant to 
relieve spasm of the vein.  
 
7. Attention is now turned to the brachial artery. 
Two layers of fascia must be passed. The first is 
the fascial tissue that envelops the upper arm. 
This is located just underneath the subcutaneous 
fat. Divide it with scissors or electrocautery.  
 
The fascia of the upper arm is divided to reveal a small amount 
of fat covering the bicipital aponeurosis.  
 
Brachial-Cephalic Arteriovenous Fistula Creation 
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8. The brachial artery can now be more easily 
palpated through the bicipital aponeurosis. Feel 
this structure, clear any fat, and then divide the 
bicipital aponeurosis. Be careful here as the 
artery may be either medial to it or directly 
underneath. It is acceptable to make a cruciate 
incision, a notch from the medial side, or to even 
excise a “window” of the aponeurosis, as this 
structure is not essential to arm function.  
 
The artery is palpated after the superficial facia is divided, to 
help decide where to cut the bicipital aponeurosis. 
 
 
The bicipital aponeurosis may be a thick structure. The artery 
may be directly underneath so it is divided in a controlled 
fashion, first with a scalpel and then with scissors.  
 
9. Gently dissect the fat below the divided bicipital 
aponeurosis. Palpate periodically as you search 
for the brachial artery. Be careful, there are veins 
running next to the artery and bleeding can be 
difficult to control if they are cut. 
 
The deep fat of the antecubital fossa is gently dissected 
searching for the brachial artery.  
 
 
Inevitably there are one or two large veins running adjacent to 
the artery, often these are seen before the artery itself.  
 
10. Once the artery is seen, dissect it carefully and 
encircle it with a vessel loop. This allows further 
dissection of the artery. Take care not to injure 
the adjacent veins. Do not use electrocautery here 
to avoid injury to the median nerve.  
Brachial-Cephalic Arteriovenous Fistula Creation 
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The brachial artery is clearly seen in the base of the incision. 
The adjacent veins have been dissected free.  
 
 
Once the artery is encircled by a vessel loop, gentle traction on 
the loop allows further dissection and mobilization of the 
artery. A second vessel loop is placed after further dissection.  
 
11. Mobilize the cephalic vein further to be sure it 
will reach the dissected brachial artery without 
tension. Prepare the distal end of the vein for 
division. 
 
Further dissection of the proximal and distal aspect of the 
cephalic vein will allow it to reach the brachial artery. 
 
 
The cephalic vein branches distally in this case. The surgeon 
will divide both branches and use the junction point to make a 
“hood” for a wide anastomosis.  
 
12. Once it is adequately mobilized, apply a 
Diethrich (fine Bulldog) clamp to the proximal 
end of the cephalic vein. Doubly divide and ligate 
the distal end. Take care here, slippage of the 
distal tie would result in a hematoma and possible 
loss of the fistula.  
Brachial-Cephalic Arteriovenous Fistula Creation 
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After division of the cephalic vein, the distal end is first ligated 
and then suture-ligated to prevent a postoperative hematoma.  
 Back bleeding from the vessel is not usually a problem, but the 
Diethrich clamp helps preserve its orientation.  
 
13: Optional: If the distal vein is divided near a 
branch point, this area can be tailored to allow the 
surgeon to control the width of the anastomosis. An 
incision is made through the “confluence” of the 
branch point which results in a widened part of the 
vein, whose width can be controlled as needed later 
during the anastomosis.  
 
 
The confluence, the place where the vein divides, is cut.  
 
 
After the division of the vein has been cut, the two branches can 
be splayed open, resulting in a widened area that can be 
tailored as needed to the width of the anastomosis.  
 
14. Verify the patency of the vein and its capacity for 
flow by inserting the olive-tip catheter and injecting 
heparinized saline. 1cc should easily pass within 
Brachial-Cephalic Arteriovenous Fistula Creation 
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each 1-2 seconds. If there is more resistance, check 
that the vein has not become twisted. Gently pass a 
2mm dilator feeling for resistance proximal to your 
dissection. If, despite your best efforts, you cannot 
achieve smooth unrestricted flow, a fistula using this 
vein is unlikely to succeed. Search for another 
adjacent vein, consider dissecting and anastomosing 
the basilic vein, or abandon the procedure. If you use 
the basilic vein, it must be made superficial, either 
concurrently using a vein tunneler, or later on as a 
separate 
operation 
after 
the 
vein 
becomes 
arterialized. 
 
The syringe of heparinized saline is cleared of air and the olive 
tip catheter is inserted into the vein. The end of the vein is 
pinched, and the heparinized saline is injected, to assess for 
resistance to flow. This maneuver can also be done with an 18G 
or 20G IV cannula, but it is possible to injure the intima of the 
vein if this is done carelessly.  
 
15. Administer 5000U of heparin IV and wait 2 
minutes. Neglecting this step can endanger the arm! 
 
16. The two vessel loops encircling the dissected 
brachial artery will be used to control arterial flow 
during the anastomosis. Put each under tension by 
clamping them to the drapes proximally and distally.  
 
The vessel loops encircling the brachial artery are put under 
proximal and distal tension, blocking flow and raising the 
artery up in the operative site for the anastomosis. 
 
17. The anterior wall of the artery is cut with a #11 
scalpel blade, with the blade edge facing anteriorly. 
This incision is made in an area that the end of the 
cephalic vein will easily reach without tension. Be 
very careful to use only the tip of the scalpel to avoid 
injuring the back wall of the artery.  
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The anterior wall (only!) of the artery is incised with a #11 
scalpel blade with the sharp edge facing up. Insert only the tip 
of the scalpel and push the blade upwards to make an incision 
large enough to accommodate the tip of a fine scissors; no 
further incision is needed. Note also that the cut edge of the 
cephalic vein lies near the area the artery is incised and will 
easily reach here without tension.  
 
18. The incision is extended proximally and distally 
with fine Wescott or Pott’s scissors, to a total length 
of no more than 6-7mm. A longer incision may divert 
enough flow from the forearm and hand to put the 
patient at risk of steal syndrome.  
 
The incision is extended distally with fine scissors.  
 
The incision is extended proximally.  
 
19. The arteriotomy is converted from a linear one to 
an ellipse by trimming the edges. This avoids the 
need for stay sutures. Grasp a minute amount of each 
edge with the fine forceps, separately excising a tiny 
curved part of edge of the arteriotomy on each side 
with the curved scissors. 
 
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The edges of the arteriotomy are cut. Grasp and elevate a tiny 
amount of each side with the fine forceps and cut just 
underneath the forceps with fine scissors. Performed on both 
sides, this maneuver converts a linear incision to an elliptical 
one.  
 
20. Freshen the end of the cephalic vein so that the 
cut angle matches the angle at which it meets the 
artery. The width of the vein should match the length 
of the arteriotomy.  
 
The vein reaches the arteriotomy without tension. It is cut at an 
angle so that the length of the cut end matches the length of the 
arteriotomy. Care is taken to make sure that it is not twisted 
before it is cut.  
 
21. The anastomosis will now be made with 7-0 
monofilament polypropylene (Prolene©) using 
double-armed suture with tapered needles. If you are 
using a magnifying device such as optical loupes or 
a magnifying headset, put it on now. The first step 
will be to pass the suture through the heel of the vein 
and the adjacent apex of the arteriotomy. Both will 
be done from the inside of the vessel outward.  
 
The headband magnifier with 2x strength is an affordable 
alternative to operating loupes. Once the vein and artery have 
been completely prepared, the headband is placed on the 
surgeon’s and assistant’s heads. Each can then put on sterile 
gloves, adjust their headset, and discard the gloves.  
 
 
Schematic representing the artery (Red) and the vein (Blue.) 
The elliptical arteriotomy has been made in the side that is 
facing the vein. The vein has been cut transversely to match the 
angle at which it meets the artery. The length of available vein 
Brachial-Cephalic Arteriovenous Fistula Creation 
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edge is tailored for the arteriotomy site and trimmed to avoid a 
kink in the vein when complete. The parts of the vein referred 
to as the Heel and the Toe are shown in the diagram.  
 
 
Both needles of the double-armed suture are initially passed 
from inside to outside of each vessel, at the heel of the vein.  
 
 
One of the needles is passed through the vein, from inside out, 
at the heel.  
 
 
The other needle is passed through the apex of the arteriotomy, 
from inside out, on the side adjacent to the heel of the vein.  
 
22. The suture, still with a needle on each end, is 
pulled through the vessels so that one side of it is 2/3 
of the total length and the other is 1/3. The suture is 
then tied 3-4 times in this position, bringing the heel 
of the vein down to the apex of the arteriotomy.  
 
The suture is pulled through the vessels until 2/3 of its length is 
on one side and 1/3 on the other. It is then tied with 3 or 4 knots.  
 
23. The longer suture is then passed under the vein. 
It will be used to sew the vein to the artery on this 
side.  
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The suture is passed under the vein to the other side. Now, there 
is a needle on either side of the anastomosis. We will call the 
side with the 2/3 length suture the “back wall,” as it is usually 
opposite the surgeon.  
 
  
The needle, loaded in the needle holder with the tip protected, 
is passed under the vein to the back wall of the anastomosis.  
 
24. The same needle is passed through the vein wall, 
from outside in, adjacent to the heel stitch. 
 
The suture is passed through the back wall vein, from outside 
in. Now the surgeon is ready to begin suturing the back wall of 
the anastomosis.  
 
25. The back wall of the anastomosis is now sewn. 
The needle is passed inside-out on the artery and 
outside-in on the vein. Artery and vein are sutured 
separately at first, but after a few passes it may be 
possible to line them up and pass the needle through 
both at the same time. It is important that the assistant 
“follows,” maintaining traction on the suture that has 
been placed.  
 
The back wall of the anastomosis is sewn, with the needle 
passing inside-out on the artery and outside-in on the vein.  
 
Brachial-Cephalic Arteriovenous Fistula Creation 
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The first stitch on the back wall anastomosis is taken, inside-
out on the artery. The vein is not yet aligned, so the needle will 
be reloaded and then passed through the vein separately rather 
than trying to take it all in “one bite.” 
 
 
Placing the stitch on the vein of the back wall of the 
anastomosis, outside-in. 
 
26. Continue sewing the back wall of the 
anastomosis until you reach the apex of the 
arteriotomy and the toe of the vein. Continue sewing 
around the toe. As you come around this corner, 
prompt the assistant to relax the tension without 
completely letting go of the suture. This results in a 
better view and avoids taking oversized bites or 
catching the opposite intima of the artery. At this 
point the surgeon transitions from suturing the back 
wall to suturing the front wall. This is a crucial step 
that deserves special attention.  
 
The back wall suturing is complete and the toe of the vein aligns 
with the apex of the arteriotomy. The suture passes outside in 
on the toe of the vein, then inside out again at the apex of the 
artery.  
 
 
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The suture is passed inside out at the apex of the arteriotomy, 
bringing the toe of the vein down to the apex.  
 
 
The “back wall” anastomosis completed. The vein and 
arterotomy line up perfectly and the surgeon is now ready to 
suture the front wall. Both needles will be sewing towards each 
other to meet in the middle of the “front wall.”  
 
27. The surgeon continues with the same needle, 
suturing now away from the toe heading towards the 
heel, continuing inside-out on the artery and outside-
in on the vein. In this way about 1/3 of the front side 
is closed.  
 
Using the same needle, the surgeon now sews away from the 
toe, towards the heel, until 1/3 of the front wall is complete.  
 
28. The other suture is now loaded into the needle 
holder and the front wall closure is continued, 
starting from the heel. Continue outside-in on the 
vein, and inside out on the artery. The surgeon must 
take care not to catch the “back wall” with these 
sutures, as this would occlude the lumen of the 
anastomosis.  
 
Suturing the front wall anastomosis from the heel side of the 
vein. The vein stitch (outside-in) has been placed and now the 
arterial stitch (inside-out) is being placed. A small vascular 
dilator is placed in the lumen of the artery to make sure the 
Brachial-Cephalic Arteriovenous Fistula Creation 
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posterior wall of the artery is not inadvertently included in the 
suture. 
 
 
The 1/3 of the front wall anastomosis adjacent to the heel is now 
completed, leaving only a few sutures remaining to complete 
the anastomosis in the middle of the front wall.  
 
29. Remove the small clamp and flush the vein with 
heparinized saline to confirm that it still flows freely.  
 
The anastomosis is almost complete. The olive tip catheter is 
inserted into the vein, the Diethrich clamp is opened, and the 
vein is flushed to assure flow is still good.   
 
30. The vessel loops on the artery are loosened, first 
distally and then proximally, to “flush” the 
anastomosis through the remaining open ⅓, to 
remove any air, clot, or debris. Heparinized saline is 
again injected into the vein with the olive-tip catheter 
to make sure that it is still patent. If pulsatile bleeding 
or backflow does not immediately appear, careful 
insertion of the dilator a short distance into the artery 
will usually solve the problem. If this is needed, take 
care not to perforate the side of the artery with the 
dilator. The artery, when lifted by the vessel loops, 
assumes a curved configuration and can be 
perforated away from where you can see it. Once 
flow is confirmed from the artery both proximally 
and distally, the final stitches are taken.  
 
First the distal and then the proximal (shown) vessel loop is 
loosened, both to assure continued arterial bloodflow and to 
remove any clot or debris that might have accumulated while 
the artery was clamped.  
 
31. Apply gentle traction to both vessel loops again 
to control bleeding. Finish the anastomosis with 
either needle, using whichever is more comfortable 
to sew with.  
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Continued awareness of the “inside-out on the artery” rule will 
result in two sutures on the same side of the anastomosis.  
 
 
The final stitch is taken, through only the edges of the vessels, 
to complete the anastomosis. 
 
32. Tie the suture with great care, it must be tight but 
it must not break (the beginning vascular surgeon 
would be wise to practice with the same suture before 
attempting this operation.) Save the leftover sutures 
for repairing any bleeding points if needed. If the 
suture breaks, undo stitches from both ends of the 
front wall anastomosis until there is enough “stub” of 
suture to perform an instrument tie at each end. Take 
a single armed 7-0 suture, pass it through the vessels 
adjacent to this stub, tie the suture you have passed, 
then instrument tie it to the stub. Repeat with the 
other stub then resume suturing with both needles to 
meet in the middle of the anastomosis. Tie the sutures 
together again.  
 
The fine 7-0 polypropylene suture is tied with great care. The 
clamp on the vein is still in place, but it can be removed at this 
point.  
 
33. Release the clamps. If there is a diffuse ooze, 
hold gentle (non-occlusive) pressure. If there is a 
discrete bleeding point, repair it using the leftover 7-
0 suture, using a simple, figure 8, or horizontal 
mattress configuration to close the bleeding point. 
Take care not to pass the needle deep, to avoid 
catching the posterior wall of the artery or vein.  
 
34. Palpate the vein. You may feel a buzzing 
sensation (known as a “thrill”) or only a pulse. If you 
feel a pulse only, palpate the skin over the vein 
proximally and you may feel the thrill there. If you 
feel nothing, assess the anastomosis. Are all the 
clamps and vessel loops off tension or removed? 
Does the vein look full but has a pulse only and no 
thrill? Likely there is a distal occlusion or the vein is 
twisted more proximally under the skin flap where it 
cannot be seen. Does the vein look flat? Likely there 
is a technical error at the anastomosis, some of your 
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“front wall” stitches caught the “back wall” and 
closed off the anastomosis.  
 
The vein is palpated with all clamps removed. There should be 
a palpable thrill or a pulse in the vein. 
 
35. Palpate the radial pulse. It may be diminished 
compared to the preoperative state but you should be 
able to palpate either the radial or ulnar artery pulse. 
If not, reassess your anastomosis, as possibly one of 
your apex stitches caught the posterior wall of the 
artery and occluded it. At this point, returning flow 
to the arm is a higher priority than maintaining the 
fistula, though obviously if both can be preserved 
this is ideal.  
 
Palpate the radial artery. If it is diminished, assess the patient 
for steal symptoms such as hand or arm pain or tingling. If any 
of these are present, the fistula must be occluded and another 
attempt must be made at another time. Tingling in the fingers 
may be tolerated and will usually resolve. Anesthesia, pain in a 
digit, or spasm of forearm musculature will generally not 
resolve. The fistula must be carefully examined, explored if 
necessary, and possibly ligated if these danger signs do not 
resolve.  
 
36. Assure hemostasis. Close the wound in 2 layers 
with interrupted absorbable subcutaneous followed 
by nonabsorbable sutures in the skin. Check the thrill 
and the distal pulses again after wound closure. Place 
a very loose dressing: a non-elastic bandage can be 
wrapped around the arm but the tape that secures it 
should not go around the arm. Listen with a 
stethoscope and mark the area where the bruit can be 
heard. Surprisingly, this will often be quite loud even 
when the thrill is difficult to palpate.  
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Non-elastic bandage can be placed circumferentially, loosely. 
Do not wrap the bandage tightly and do not place tape 
circumferentially. The wound will swell a bit and the tape, 
which will not expand, may cause occlusion. The location 
where the bruit is best heard is marked.  
 
37. Place a posterior plaster splint (“backslab”) to 
keep the arm in extension overnight. Wrap the splint 
loosely with non-elastic bandage, as above.  
 
A posterior splint of plaster, wrapped very loosely with non-
elastic bandage, to keep the arm in extension for 12-24 hours 
after surgery.  
 
Pitfalls 
● Fistula failure, either early or late, is a constant 
risk that the patient should be advised of. As long 
as this fistula is working, they should avoid 
phlebotomy, IV placement, and blood pressure 
measurement on this arm. For the first two weeks 
they should keep it elevated as much as possible 
and use the arm only to eat and drink. 
Circumferential bandages of any type should also 
be avoided, at all times but especially in the first 
two weeks.  
● Injury to the brachial artery and arm ischemia is 
a risk, as the brachial artery is the unique blood 
supply to the forearm. The techniques above 
must be meticulously followed, especially taking 
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care to avoid catching the posterior wall of the 
artery during the anastomosis. This is most 
possible when suturing at either apex of the 
arteriotomy. A small vessel dilator can be 
inserted into the artery as this stitch is placed to 
push the posterior wall away from the needle.  
● Injury to the median nerve, which runs just 
medial to the brachial artery in the antecubital 
fossa. 
Careful 
dissection 
and 
especially 
avoidance of diathermy when dissecting the 
brachial artery will help to 
avoid this 
complication.  
● Elbow stiffness or contracture can occur if the 
patient avoids fully extending or flexing the arm 
during the postoperative period. Initially, they 
may be unable to flex completely. After the first 
overnight with the splint, they should be 
instructed to cautiously flex and extend the arm 
every day until full range of motion is achieved. 
● Operating with the elbow flexed could lead to 
excessive tension and even tearing of the 
anastomosis when the arm is straightened. Be 
sure the arm is fully extended on the armboard.  
● Failure to administer systemic heparin before 
occluding the brachial artery is a novice’s error 
and could be catastrophic. This could result in 
thrombosis of the arteries distal to the brachial 
artery, which may cause irreversible damage 
even if embolectomy is performed later.  
● Steal syndrome is avoided by making a brachial 
artery incision no bigger than 6-7mm, smaller if 
the artery is very small. The patient may 
complain of constant numbness, tingling or pain. 
Alternatively, they may only feel 
these 
symptoms when using the hand excessively, or 
during dialysis. Feel the radial pulse after 
placement of the fistula; if it is strong and 
unchanged from preoperatively, steal syndrome 
is unlikely. Treatment consists of completely 
ligating the vein of the fistula: this should be 
done even immediately after the surgery if classic 
steal symptoms appear. The use of the DRIL 
(Distal Revascularization and Interval Ligation) 
procedure for steal syndrome is beyond the scope 
of this text.  
 
 
Jerry Svoboda, MD FACS 
Rochester, New York 
USA 
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
