Clampless Technique for Aneurysmorrhaphy for Arteriovenous Fistula with a Tourniquet for Dialysis Patients
Ali Irshad, MD, Alan B. Lumsden, MD, Maham Rahimi, MD.
Houston Methodist Hospital, Houston, TX, USA.
OBJECTIVES: Aneurysm formation is a common sequelae for arteriovenous fistula, often requiring surgical intervention to repair. The tissue and vessel wall of the aneurysmal veins are tenuous and the circumferential dissection of the fistula without proximal and distal control can be challenging with risk of getting into the fistula causing bleeding. Here we describe a clampless technique for this procedure.
METHODS: The patient was brought to the operating room, given general anesthesia, and prepped and draped from the neck to the arm. We placed a tourniquet on the upper arm proximal to the brachiocephalic fistula. After making a longitudinal incision on the fistula, heparin bolus was administered and the tourniquet was turned on with a pressure of 250 mmHG, effectively occluding the outflow venous system and the brachial artery. The fistula was entered with scissors and the walls were excised to an appropriate length and the anterior wall was closed using a 5-0 prolene suture in continuous fashion. The tourniquet was released and the skin was closed in layers.
RESULTS: The aneurysmal fistula was repaired with minimal blood loss. The tourniquet was up for 5 minutes total and the patient had a palpable thrill of the fistula and palpable radial pulse at the end of the case.
CONCLUSIONS:
The clampless technique using a tourniquet is a promising and resourceful method of revising an aneurysmal fistula. It limits blood loss and expedite the procedure time as complete and circumferential dissection of the fistula is not necessary. We find that the shorter anesthesia time is especially of import in patients with end stage renal disease who are at higher risk for morbidity related to anesthesia. It is also safe and effective in that the arm ischemia time is minimal, and minimizes need for tunneled dialysis catheter during recovery. We posit this technique will be of value in the realm of open access revision in vascular surgery. 
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