Chapters Transcript Video EndoAVF Anatomy 3 - Anatomic Variations Didactic discussion describing different anatomic variations of the arterial and venous anatomy relevant to endoAVF creation. Hello, I'm Steven Homan, a vascular surgeon from Dallas Texas, and I'm Nga Mullen, an interventional nephrologist out of Dallas Texas. And you know, we, we've talked in other segments about normal anatomy. Let's talk about some of the variants that we see that you're gonna come across during your wavelength cases. And you know, II, I must say, as we're getting started here, this is one of the things I really enjoy the most about this procedure is really, the anatomy is fascinating and then of course, the anatomy, it inevitably involves variations as well. Um There's some consistent things so we're gonna hit on those, but there are a couple of variations. So please, Doctor Mala, take us away with typical. All right. So typically you've got your paired ulnar veins, your lateral and your medial, that will go into your brachial veins. And usually that's your lateral and your medial as well, your medial brachial vein, it becomes more consistently, your medial ulnar vein, the lateral vein is usually where you see a little bit more on the variant side. You can one of the consistent things with the lateral ulnar vein is that's where the perforator joins. So, perforator comes down from the cephalic and the median cubital, of course, median cubital becomes the basilic as well, but comes down the perforator then usually goes through the lateral radial vein, um and then almost exclusively the lateral ulnar vein. So that's one of the classic things you'll see. Although, you know, one of the things we talk about is do you have to make the anastomosis on the medial or lateral side? And I would say on the er vessel, it really doesn't matter too much because there are these large bridging collateral veins. Um but I would say the consistency of the lateral ulnar vein joining the perforator is extremely common. Occasionally the perforator won't join the owner. But I would say that that's, that's very uncommonly seen. What about this one, Doctor Mala? All right. So here's we kind of see the parallel ulnar veins becoming parallel brachial veins and this is what I would consider is quite normal in the course, right? You can track the lateral. And if you bring in the next slide, you can see the where the arterial course is gonna be. So there you can see where your radial artery will would go and where your ulnar artery is between the ulnar veins becomes your paired brachial veins. The only variation here that I, that I would want to point out if you look at the medial ulnar vein, it tends to kind of arc away from the ulnar artery. And so that may be a little bit of a challenge sometimes trying to create an anastomosis and getting the catheters to coapt in a line. Uh So, but here the lateral one looks a little bit straighter. I would probably shoot for a lateral one based off of this and somewhere about in that region. And you can see this and we're gonna show this a little bit later, almost a tenting of, of the ulnar vein. It could be the lateral one as well. Um So either side, the more parallel they are and the closer they are together as far as the vein and the artery, the better for the anastomotic creation side. Definitely. And so here's the lateral ulnar vein, then you can see they brought their catheters into position, um venous catheter and then there's the arterial backstop. So we're on the lateral ulnar vein, which is the one that joins directly with the perforator. And then here's a nice kind of catic dissection showing that connection over to the lateral ulnar vein and then up and out the perforator. All right. What about this one, Doctor Mala? All right. So again, left arm here. So on the bottom, we're seeing the medial ulnar vein right there. And then we're seeing the lateral ulnar vein and it seems to go straight up to the perforating vein and out the cephalic right there. And I think we're seeing a little blush into a radial vein right there where that perforator communicates to the radial level. But what we're not seeing is a lateral ulnar vein communicating to the brachial veins itself. All of it seems to go straight up into that perforating vein, which is great because the flow will feed up there. You just have to be a little mindful of where you're going to wire and how you're going to to get them to co opt. Yeah, this is where kind of when you're first looking at your venogram, it is very helpful to orient yourself. Um is defining that per and knowing that it leads into that lateral ulnar vein, the vast majority of the time. And this one, you can almost say it becomes the the lateral ulnar vein. Um And definitely we wanna create our anastomosis here, which actually this would make me very happy. Um You know, as far as you get an asthma, the only thing you have to consider is would you get too much splaying here? And that's kind of some of the consideration um that you have to take into mind here, we are with the radial artery come in as doctor Malo mentioned, then of course, the ulnar artery being between um the two veins and this is what I was talking about that splaying. So here we've got the catheter coming in the venous side being on the lateral ulnar vein. Um and then the uh ceramic backstop of the artery being in the ulnar artery and then get a nice creation site. Once again, a nice CIC model showing this from the ulnar artery to the lateral ulnar vein and then up and out the door freighter. All right. What about this one? So this one is very similar. Again, the lateral ulnar vein feeds very heavily into your perforating vein and your outflow. But you do see a little blush of a, of a vessel, you know, in a small lateral ulnar vein that becomes the lateral brachial vein. And so here, I think if you're able to wire into that vessel, you can get things to co opt and line up and stay a little bit more parallel that will probably bring your anastomosis a little bit closer to that perry. Yes. So what you're saying is if you could have your wire come from here and then traverse this vessel, you'd stay in much better kind of parallel versus going up and out the per freighter, which would kind of be like our last slide where it pushed you away a little bit. Definitely something to keep in mind. So we wanna stay parallel and we wanna stay close if possible. I think those are two things that definitely help along the way. And this is outlining that vein that you were just mentioning earlier. Get that nice description there, ok. Now this is back to our, if this looks familiar to you, this is our right arm with the multiple perforators. Um I think the point that they're trying to make here is that the brachial vein immediately is really a dominant vein, almost, don't see a lateral brachial vein. Um And you see it kind of splitting off here. You know, the, the Venus anatomy is really almost like a finger print. It's very unique throughout these. And I think this one not only has multiple perforators really has a dominant brachial vein. But if you're coming from above this kind of gives you the option to go into either side of this and create your anastomosis. And so the only thing to be mindful of if you're anastomosis is on the lateral side here with that artery sitting in between, you are going to have a little bit of wire cross. So the challenge is, is, are you going to, you know, or the decision is not necessarily the challenge maybe, but the decision is, are you gonna cross and make your anastomosis or are you gonna stay on the medial side where everything is parallel? And I think there's no wrong answer here clearly, you know, they, they were more on the challenging side and, and kudos to them because uh you got a very nice fish out of that. Yeah. And that's one thing I would like to say, these are not always kind of right and wrong sort of things there, there's definitely kind of some decisions to be made. I certainly think you can make a strong argument for making this one on the medial side, meaning ulnar artery to medial ulnar vein instead of lateral ulnar vein. I think either would be acceptable in this situation. Um Now, what about this? What about the prominent recurrent ulnar vein? Well, that's a mouthful, isn't it? It is, it's like prominent recurrent ulnar vein. Um When do you see this and where do you tend to see it coming from? So a lot of, you know, you've got the, the recurrent ulnar artery and there's, you know, a vein that goes with it. And so it usually stems off the medial ulnar vein and it ultimately feeds back into the basilic vein. And so I think a lot of times if you're having a lot of deep flow that you cannot get superficial, this vein will actually pick up and become almost dominant and good steel from you. So it's not something I've encountered very often, but it is something to be mindful of the question I always pose to myself is that I'm seeing a lot of increased deep flow through new vessels and multiple vessels. The question is why is it not getting superficial? Do I need to interrogate something at the superficial system or at the perforating level to make sure there's not a problem there that's keeping all the flow deep? Yeah. So this is saying when someone comes back and you're interrogating the fist and you see uh your volume flow coming in what comes in must go out. And if you're not seeing where it's going out, this is definitely something to consider. Um as far as for clarification, as far as stealing, meaning that it's taking the flow from your superficial vessels, not necessarily from the material system to the hand. Here, you can see that recurrent ulmar vein um and of course to um kind of prevent flow in it imation, I think would be um optimal. What about a high radial artery takeoff? Doctor Mala, can you do an an osteosis with a high radial artery takeoff? Absolutely. You can. The only thing that I I have noticed in my experience, the perforating vein usually communicates either to the radial side or the ulnar side versus a normal kind of take off at the level of the cubital fossil. You'll get communication through both levels here. I'm seeing either a radial option or an ulnar option. Very rarely do I see both? Yeah. And I think one of the things is that we still want to meet the three key criteria which is a superficial vessels need to be 2.5 millimeters or greater per freter needs to be two millimeters or greater and the ve the vein and the artery at the creation site need to be two millimeters or greater. So the the criteria is still the same. Um but it just be a little different. The one thing I would say you tend to see. Um and a lot of this is based on observational um kind of uh you know, cases over the years is that they tend to be very parallel the vessels in this situation. So, which makes it nicer um like I said, you want parallel vessels and as close as possible and they tend to be a little bit larger, I think on the radial side as well. Absolutely. So you can see they've created their end to a V fist successfully and you're getting nice flow up and out the perforator to that cephalic vein. What about this one? This one's kind of interesting. So it looks like we've got a high radial artery takeoff and so we've got a left arm. So we're coming down the arm screen, right. You can see the ulnar arm, ulnar artery very nicely. You can see the radial artery going along the top, but there's this kind of communication between the two. Also. This, this one's strange. I, I haven't seen this one before. Yeah, I have not as well, but I think really what this speaks to is that you can really almost see anything. But as long as you know, the basics of what you're trying to do, you can then you can then place it together. Um So here they're creating the endo a fisa with the ulnar artery, the ulnar vein filling up and out the uh perforator um to the um cephalic vein and then the basil vein. So left arm um access coming up and you can actually, it's filling retrograde and then up and out. So that's, that, that's, that's a unique one I would say. But once again, the same sort of thing, it's joining the lateral ulnar vein, it's going up, perforator is going cephalic. If you know your basics, then you can, then you can understand almost any variation. So definitely variability in the end of A B Fischer Anatomy. But the basic components are the same. That's how I always like to orient myself. So no matter what you're looking at as you do more of these, you're gonna see some of these variations and um we appreciate your attention. Thank you. 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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