Chapters Transcript Video EndoAVF Anatomy 1 - EndoAVF Anatomy Review Didactic discussion reviewing basics of endoAVF anatomy, including arterial system, deep and superficial venous system and perforating veins Hello, I'm Stephen Holman vascular Surgeon from Dallas Texas. Welcome, Stephen. I'm Nga Mala, an interventional nephrologist, also from Dallas Texas. Uh Let's go through the anatomy kind of the highlights here and what to look for and pay attention to. Yeah. So the first thing on the end, oav fistula anatomy review I'd like to cover is the radial tuberosity. Now, you may think, hey, we're here for endo A V fistula. Why are we starting off with the bony structure? Well, for me, the radio tuberosity is really home base. It's how I really um line up my C arm. It's a location where the perforator usually joins a deep system and it's where the vast majority of your anastomosis are going to be created. So whenever you're trying to figure out exactly where to go start off with the radial tuberosity, um that's a great landmark to begin with. The next thing we're going to jump right into is the arterial system and the arterial system. Normally everybody thinks, well, we know the arterial system, the upper extremity, not a lot to think about. But there are really two things I always like to point off one as the brachial artery comes down, it then gives off the radial artery. Um The question is, what do we call this segment? And kind of the two most common ones would be either the common ulnar artery or the ulnar osseous trunk before it gives off both the inner osseous and the proper ulmer. One of the things you really notice here is this vessel is much larger than the ulnar here. So the reason why this is important is this where the vast majority of our endo ay fistulas are going to be created. I think the only other thing to mention and pay attention to are the recurrent vessels. You've got a recurrent radial artery coming off that may impact your lateral radial anastomosis. You've got a recurrent ulnar coming off the medial side. So just be mindful of that when you're creating an ulnar medial vein anastomosis. Absolutely. Yeah, that's a great point. The other thing I would like to once again restress as this brachial artery comes down, it really becomes this common ulnar and this is a very large artery, a vast majority of the time we do arteriograms. If you actually kind of covered up the radial artery, it can be difficult to tell exactly where this transition is prior to the takeoff of the inner osteo and ulnar. So this is a very big artery and this is with either this location here or location here would be the kind of the two most common spots uh for the end of a fish to the creation site, let's bring in the vein. So we've got the medial brachial vein that you can see that very uniformly comes down and becomes the medial ulnar vein. And then from that, you'll become medial proper and usually we will communicate over to the inos vein as well. But that medial ulnar vein is really kind of a very consistent and reliable vessel to make your anastomosis to. Now you can do it on the lateral side as well. But I think a lot of the early cases were done on the medial side. The medial brachial vein is usually large and easier to access and tracks down very nicely to the medial ulnar. Yeah, those are great points. Also, it tends to be a little bit farther away from the median nerve. So for access purposes, it's nice to stay away from that. But I would say the medial brachial vein that becomes the medial ulnar vein um stays very nicely in parallel in order to allow activation. Now we're gonna bring in the lateral veins, Doctor Mala. So if you look at the lateral brachial vein, typically this is a little bit smaller in my experience and sometimes a little bit harder to cannulate and get into but becomes your lateral ulnar vein as well and then feeds your lateral inner inner osseous vein as well. So you can see between the two ulnar veins. There's usually good communication and kind of bridging collaterals between the medial and the lateral side. So it doesn't matter necessarily which side you make your anastomosis on. Because you've got good communication. If you are on the medial side, you'll still fill to the lateral and up to the perforating vein. Yeah, absolutely. So, the ulnar vessels here, this would be, of course, the lateral ulnar vein um on the thumb side and then of course, then the media ulnar vein on the pinky side, there's a very good communication between those vessels. The radial veins, not as much as I say, I think they stay pretty independent. So if you're on lateral, you stay lateral, if you're on medial, you kind of stay medial. Yep. All right. Now, this is my favorite slide of the whole deck. I would say, I think this really shows it all. So um this is one I really want to spend a little bit of time on and really focus. So when we're creating endo a av fistulas, how, how is it actually working? So we're creating a connection between the deep arterial system, deep Venus system and we're wanting it to fill out the superficial. So this perforator is key. So I really want everyone to focus in on this perforating vein. So this comes from the cephalic, the median cubital joints here and then it comes down classically, you'll see this perforator come down join most of the time the lateral radial vein and almost exclusively the lateral ulnar vein. I think that's really key. Yes, I think so too. So as you can see here, it joins the lateral ulnar vein and it may sound redundant. Why does he keep saying that? Well, this is something that definitely if I had to think back to training something I really wish I would have focused a little bit more on is this picture here? Because when you're first doing your venogram, it's really important to see how this connection is made. So, of course, is with the anastomosis, either here or here, the flow would then come from the artery to the vein up and out the perforator and then fill the superficial system. And, and this is really, I think the crutch slide, if you can understand the basic concept of what the deep veins are supposed to look like based off of this slide, then as you start doing your angiograms, things will start to make a little bit more sense. You think about the variations that you may see always come back to OK. We've got paired radial veins, paed ulnar veins, the perforator communicates to the lateral radial vein, the lateral ulnar vein. And then of course, you've got your superficial veins, your cephalic outflow or your basilic outflow via the median cubital vein. And you're going to look at whether your perforator communicates to both of them or it may communicate cephalic only or medium cubital only as well. Yeah. And in certain ways though, you know, I don't worry too much that we're kind of giving here the media lateral because a lot of times all of this is interconnected and we're just kind of dividing it up in order to make sense of it and be able to interpret venogram in arteriograms. Here's a great example as far as coming down to place the devices, um you kind of access the brachial artery and then of course, the lateral brachial vein, um they're coming into position here. Um So lateral ulnar vein and um ulnar artery, common ulnar artery in osseous trunk. And then you can see here um the catheter coming into position, um you have the arterial catheter and then the venus catheter and then activation, you can see the blood coming down through here and then flowing up and out the perre or up to the superficial system and, and it's a very nice flow and even if it, this was the medial side, you get good communication to the lateral and then out the perf absolutely. Then here kind of diagrammatic view once again, coming down the brachial artery flowing up and out across the lateral vein and then filling out the superficial system. Similarly with the radial endovascular A V fistula, seeing the same sort of thing, blood coming down filling across um and then up and out the perforator, same sort of thing like you said, paired veins, um filling up to the perforator, which once again, the perforator is communication between the deep and then the superficial system. So we see that nice and diagrammatic form also. Um then here it kind of zoomed in this would be, I would say another one of the really um important pictures in this deck. Can you take us to this one doctor? M sure. So start with your, so this is after you've got your anastomosis, let's start with the brachial artery, follow the arrows and the flow down and then there's your endo anastomosis right there to the lateral ulnar vein. And you can see you've got primarily your flow up the perforating vein into your cephalic and your median cubital. But remember this is an a side to side anastomosis. So you will also have some deep flow into the brachial vein system, either via lateral ulnar vein or uh medial ulnar vein. And so that's the idea behind coiling this to help redirect the flow into the superficial. Yeah. So we'd be looking at putting a coil in just one of the brachial veins and usually the one that you've access to actually do the procedure when you're coming from above. Um some more approximately in this area. And on the latter one, approximately this area on the media, one in order to drive more of that flow superficially, um of course up and out the perforator. Um And this is a nice kind of diagrammatic flow also. Um as far as as you see the flow come down, the veins medial to the artery can tend to stay medial and those that are lateral, tend to stay lateral. Although you see some variation, you see a little variation. And that's why I think if you understand the basics and kind of what you're supposed to see that it makes it easier to identify the variations. Absolutely. Um And then also there's this nice bridging veins that Doctor Mala mentioned earlier, particularly on the ulnar side. And that's why if you do create your nastasia from the common ulnar artery to the medial ulnar vein, you still get nice filling across to the lateral and then up and out the perforator and they tend to be a little bit more robust, I think on the ulnar side than they do on the radial side, you will see them in the brachial veins as well. Absolutely. And then, as you mentioned before, you ha you do have the recurrent vessels, the recurrent radial artery, the recurrent um uh ulnar artery. Um and then the perforator, like we said, joining both with the radial vein and then the ulnar vein most classically the lateral side. Um And as we mentioned there, you can see that nice filling up and out the perforator with for a successful endo a fistula. You wanna take us through this one doctor. So same thing, let's start at the brachial artery OK. And we'll come down. And so this is the same diagram we're looking at. So it's a lateral osteosis into the lateral ulnar vein and then we're going up and out the PF. So here you can see is mark the cephalic and then this kind of match it up with the um arteriogram on the other side. So here's the cephalic vein. Well, that's a really good looking cephalic vein, isn't it? Very nice clic vein that looks great. Um Then of course, in the perforating vein that we discussed, and that's right here. And I think, you know, the first couple of times you look at these arteriograms, particularly when it's a still shot. It can be a little confusing I would say and that's why I think it's really important like we mentioned before about having that really kind of in your mind of the way that it should look. Um And you can see the ulnar vein here and of course, the medial ulnar vein as well. Um And this anastomosis, everyone can look at home. I want you to think about where that anastomosis is created over here. Um You can see that kind of we like to call that the jelly bean. Um It's a nice description of the anastomosis and you can see the brachial fills down and then across and this is to the lateral ulnar vein, but you see everything lights up, you see the medial side lights up with a lateral anastomosis and vice versa. If you have a medial anastomosis, the lateral side will light up as well. All right, Doctor MLA, here, we can see the arteriogram. Let's take a look. I'm injecting down the brachial artery. Here's the radial artery coming off and you can see that very large vessel there, that common er ulnar in her osseous trunk. And I think this one fits where the fact, right. So if you put your hand over that radial artery, you almost can't tell a difference that radial artery wasn't there. That common ulnar and the brachial artery would be the same vessel itself. Absolutely. And then here's it nicely labeled. Um You can see the brachial artery here um coming off to the uh radial artery. Um and then um ulnar artery as well as in os and take a look at the recurrent art vessels lining up, lighting up very nicely on the radial side. And you see two recurrent ulnar arteries there. Yeah, that is very nice coming off here inferiorly and another one inferiorly as well. And here's the venogram and this one looks like they're injecting from the wrist. So that's one of the things with the forefront system. It gives you that kind of opportunity either come from above um from the brachial artery above or from the wrist below. So here you can see it injecting. Um It looks like they've actually crossed over, it looks like maybe they were in the media one originally and now they're in the lateral one nicely up that perforator you can see. So how we go ahead and go to the still one of that um kind of orienting kind of from top to bottom. So here's the uh cephalic vein coming down median cubital vein. And then as far as that perforator and the perforator joining the lateral ulnar vein like we mentioned earlier. So we touched on that before. This definitely highlights that. And of course, then there's a wire in the artery boy, this would be a really great spot would be look at the communications between the medial and the lateral side again, makes it really nice to do either side for the anastomosis here. And it's almost like they hurt us because that's exactly where they created it. So you can see the brachial artery coming down here and then filling across the anastomosis helping out the lateral. And I think this is one of those ones the first time you see this sort of one, it's a little confusing and that's why we like to break it down because everything lights up right once you're done and you're successful and you see everything light up great. Then it's a matter of, you know, figuring out what everything is, but you know, you've done it absolutely. And of course, these injections are done through the brachial artery. So injecting the artery coming down, filling across the anastomosis, then over to the lateral ulnar vein and then up and out the perforator. Um Here we are kind of with them all labeled. Once again, brachial artery coming down and the A B fisa, the little jelly bean connection there, filling up the lateral ulnar vein, up and out the perforator, out the cephalic and then median cubital, which of course goes and joins the basilic as well. Now, this is a great picture here. Let me walk us through it as a nephrology surgeon. Let me OK, I'll allow you go ahead, doctor me, get me oriented. Please. Sure. The c the labels, the labels help. But if you look at the cephalic vein there and again, follow that perforating vein down and this was from a cat dissection. You did a great job here, but look at that perforator go behind the radial artery. You can see just above the R A where it communicates to the lateral radial vein right there and then it dives down and communicates to the lateral ulnar vein, right. And so there is your anastomosis between the ulnar artery and the lateral ulnar vein. But you can see the medial ulnar vein. Look at the track of that very parallel and very consistent with the ulnar artery up to the brachial level as well. So that's why if it's a medial side and it's a medial anastomosis, it lines up well, a lot of times easy to do and they do just as well. Absolutely. Um Then of course, this kind of proceeding on. Um this is where the end of a V fish would be created, kind of lights up there nicely for us. And then here's the actual anastomosis itself. So it's one millimeter wide by five millimeters long. Here, we are kind of having opened it up. Of course, this has been separated in order to show that. And you know, as far as dissection wise, as a surgeon, when you go to get that vein off the artery, there definitely is a very kind of strong adhesion in that area that you actually have to physically dissect off. And so that's what allows us to function is the hole in the artery and the vein and then that flow differential, pressure wise um to allow it to flow through. So once again, it creates a one millimeter by five millimeter cut. Um the vessels are not welded directly or connected. It's that pressure differential um that allows it to happen. That's what makes it fascinating, right? I love this. I I really do, you know, and dissecting it out really shows you, of course, this is a CIC model. We're opening it up in order to demonstrate more of this rather than it doesn't actually look like that. It's for demonstration purposes. So I think in summary, the end of a VF anatomy is like a fingerprint on the basic components are the same. Um The things I would like to highlight is it's really the perforator is the key to the procedure and the perforator comes um from the cephalic and median cubital. Of course, there's variations where it can just come from the clic or just in the median cubital goes down and joins the radio vein, usually the lateral side and then almost exclusively the lateral ulnar vein. But I think if you study your venogram, that's where all your information is gonna be. The art, the arterial system is usually pretty reliable and consistent. It's that venogram where you get your fingerprint and your, and once you've got a baseline down, then I think you'll be able to identify everything. Excellent. Thank you for your attention. Thank you. Published September 5, 2024 Created by Related Presenters Stephen E. Hohmann, MD, FACS Vascular Surgery View full profile Neghae Mawla, MD, FASDIN Interventional Nephrology View full profile
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