The patient was seen in the holding area and brought to the OR where after the timeout procedure he underwent general anesthesia with no complications. The left arm, shoulder and axilla were prepped and draped in a sterile fashion. I proceeded to do a longitudinal skin incision over the cephalic vein fistula on the lateral aspect of the upper arm, and after cutting the skin with a knife dissection of subcutaneous tissues continue with electrocautery until the cephalic vein is identified. I proceeded to dissect it all around and isolated with a vessel loop. Now I proceeded to dissect the cephalic vein proximally and distally to have adequate length for the placement of vascular clamps. So I proceeded to clamp the cephalic vein proximally and distally with atraumatic vascular clamps, and a partial transverse venotomy is done with an 11 blade. The cephalic vein is clamped proximally with a DeBakey clamp and the proximal vascular clamp is removed. The DeBakey clamp is open to allow some backflow, that he is weak, and consists in dark red blood. A #4 Fogarty catheter was passed proximally and no clots were coming out but I was feeling a resistance on the passing of the catheter after 20 cm of the catheter introduced in the vein. I proceeded to flush the proximal cephalic vein with heparinized saline and the vascular clamp is placed. Now the distal cephalic vein is clamped with a DeBakey clamp and the vascular clamp is removed. After a partial release of the DeBakey clamp I had an excellent arterial flow. The Fogarty catheter #4 is passed distally once, and I was able to pass the arterial anastomosis with no clots removed. The distal cephalic vein is flushed with heparinized saline and clamped with the vascular clamp. I proceeded to close the partial venotomy with a running suture of a 6-0 Prolene. After the closure is completed the fistula is cannulated on the distal arm with a #18 Angiocath, next to the arteriovenous anastomosis, and I proceeded to do the fistulogram. The fistulogram was showing a patent left brachiocephalic fistula with the cephalic and axillary veins having no gross abnormalities, but the axillary vein was joining the subclavian vein inside the chest forming a 90° angle, that even though looked stenotic, there was an excellent flow of contrast flow into the subclavian vein. The subclavian vein also had no gross abnormalities and it was patent. Considering the right angle of the axillary vein joining the subclavian vein I decided not to attempt any possible angioplasty or stent placement. The left upper arm wound is clean and I proceeded to close it approximating the subcutaneous tissue with a running suture of 3-0 Vicryl and the skin is closed with Monocryl 4-0 subcutaneously. The wound is covered with a dressing and the procedure was terminated. Patient tolerated procedure well there were no incidents or complications. He goes to recovery room.