Outcomes of prosthetic upper arm arteriovenous graft vs brachiobasilic fistula for hemodialysis access.

OBJECTIVE: Primary arteriovenous access such as radiocephalic and brachiocephalic fistulas are initial choices for creating vascular access in dialysis patients. When neither of these choices is an option, upper arm arteriovenous graft or brachiobasilic transposition is recommended. Although primary fistula is better than prosthetic graft for suitable patients, there is little data to guide the best treatment strategy in the absence of suitable vein for primary access creation. This study identifies factors that influence patency rates and compares outcomes of patients treated with brachiobasilic fistula vs upper arm graft in patients who have failed forearm access or are not candidates for primary access. METHODS: A prospectively maintained database of patients with dialysis-dependent renal failure from 2010 to 2022 was analyzed. Primary, primary assisted, and secondary patency rates were calculated. Incidence rates of complications and reinterventions were compared. RESULTS: There were 148 patients with brachiobasilic fistulas and 157 patients with upper arm grafts. The graft group was older (70.1 ± 14.7 vs 62.5 ± 14.6 years; P = .003) and had a higher incidence of pacemakers (11.9% vs 4.1%; P = .005). Brachiobasilic fistulas had higher 6-month (77.0% vs 64.3%; P = .02) and 1-year (68.2% vs 55.4%; P = .03) primary-assisted patency. Secondary patency rates were better for upper arm grafts at 1-year (82.2% vs 72.3%; P = .05). Access complications of non-maturation and aneurysm were higher in basilic vein transposition (21.6% vs 1.3%; P < .0001; 15.5% vs 6.4%; P = .017). Grafts had higher rates of occlusion (58.0% vs 25.7%; P < .0001). In terms of interventions, upper arm grafts had higher rates of thrombectomy (50.3% vs 18.9%; P < .0001), but there was no difference seen in angioplasty, stent, surgical revision, or steal procedures. Basilic vein transpositions had longer time to cannulation (104.6 ± 81.1 vs 32.5 ± 22.4 days; P < .0001), longer total catheter days (251.1 ± 181.7 vs 72.9 ± 56.3 days; P < .0001), and higher number of procedures to aid maturity (0.7 ± 0.7 vs 0.1 ± 0.3; P < .0001). CONCLUSIONS: In this retrospective analysis, when forearm access or primary arteriovenous access is not an option, basilic vein transposition and upper arm grafts have fairly equivalent primary patency. Primary assisted patency is slightly better in basilic vein fistulas, but secondary patency is better in upper arm grafts at 1 year. Basilic fistulas also had longer time to cannulation, longer total catheter days, and more procedures to aid maturity.

Single-stage basilic vein transposition-An effective and viable autogenous access for dialysis.

INTRODUCTION: The National Kidney Foundation's/Kidney Disease Outcomes Quality Initiative recommends autogenous arteriovenous fistulas as the preferred method for long-term hemodialysis access. Basilic vein transposition is not only an alternative in patients with failed arteriovenous access but also can be the first option for arteriovenous access in patients with inadequate cephalic vein. Several studies have shown better patency rates, cost-effectiveness, and fewer complications of autogenous access over prosthetic arteriovenous grafts. AIMS AND OBJECTIVES: To analyze patency, complication rates, and outcomes of single-stage basilic vein transposition. MATERIALS AND METHODS: A single-center retrospective non-randomized study conducted at Ramaiah Medical College and Hospitals, Bangalore from July 2015 to June 2018. A total of 94 consented patients who underwent single-stage basilic vein transposition were included in the study. All the surgeries were done in a single stage under regional anesthesia. All the complications and patency rates were calculated at the end of one year. Statistical analysis was performed using the Chi-square test, and patency rates were assessed using the Kaplan-Meir survival curve. RESULTS: A total of 94 single-stage basilic vein transposition was performed. Fifty-four patients had a previous failed autogenous access and 40 had either absent or thrombosed cephalic vein. The mean age was 56.6 years with 59.57% males. The mean basilic vein and brachial artery diameter was 3.6 and 3.8 mm, respectively. The primary patency rate at one year was 84%. Edema and thrombosis were the most common complication in our study. CONCLUSION: Single-stage basilic vein transposition is a feasible surgical option in end-stage renal disease patients and provides durable autogenous access with very reasonable outcomes in terms of complication rates and patency rates.

A Comparison of Two Surgical Techniques for the Second Stage of Brachiobasilic Arteriovenous Fistula Creation.

Two-stage transposed brachiobasilic arteriovenous fistula is a common procedure after brachiobasilic fistula (BBF) creation. Different techniques can be used for basilic vein transposition but few comparative literature reports are available. The aim of our study was to compare two different techniques for basilic vein transposition. The first maintains the BBF anastomosis and the basilic vein is placed in a subcutaneous pocket (BBAVF). The second transects the basilic vein at the BBF anastomosis and tunnels it superficially, with a new BBF in the brachial artery (BBAVFTn). From 2009 to 2014, all patients who underwent basilic vein superficialization were treated by one of the two techniques, recorded in a dedicated database and retrospectively reviewed. The surgeon chose the technique on the basis of personal preference. The two techniques were compared in terms of perioperative complications, length of hospital stay, time of cannulation, ease of cannulation, and long-term patency. Eighty patients were included in the study: 40 (50%) BBAVF and 40 (50%) BBAVFTn. Length of hospital stay was similar in the two groups (median [interquartile range-IQR] 3(2) [BBAVF] vs. 2(1) [BBAVFTn], P = 0.52, respectively). BBAVFTn was associated with a lower hematoma incidence (1/40 [2.5%] vs. 15/40 [37.5%], P = 0.01), shorter first cannulation time (median IQR: 11(10) vs. 23(8) days, P = 0.01) and easier cannulation compared with BBAVF (32/40 [80%] vs. 15/40 [37.5%], P < 0.001). Median (IQR) follow-up was 16(7) months. No statistical differences in terms of primary and assisted primary patency were found in BBAVFTn vs. BBAVF (at 24 months 91(5) vs. 71(7), P = 0.21 and 93(6) vs. 78(8), P = 0.33, respectively). Patients who underwent BBAVFTn surgery showed fewer surgical complications, better dialytic performance, and easier cannulation compared with those submitted to BBAVF.

Single stage versus two stage basilic vein transposition for hemodialysis access: A retrospective observational study.

BACKGROUND: The basilic vein transposition is a brachio basilic arteriovenous fistula (AVF) made after the mobilization and transferring of basilic vein to the ventral aspect of arm inside a subcutaneous pocket by direct dissection. The procedure can be performed either in single stage or two stages. This study compares the clinical efficacy and long term utility of single-stage and two-stage basilic vein transposition among patients of renal failure and to evaluate failure rate, primary patency rates, and postoperative complications. METHOD: Patients who underwent basilic vein transposition at Sindh Institute of Urology and Transplantation, Karachi from January 2021 to December 2021 were retrospectively reviewed. Patients were divided into two groups according to single stage or two-stage procedure. After the surgical procedure, assessment of fistula maturation and surveillance were undertaken using ultrasound and physical examination. Patients were requested to visit the out-patient clinic for assessment of fistula patency and post-operative complications at regular intervals of 3, 6, and 12 months respectively. RESULT: During the 12 months' interval, 82 (39.04%) basilic vein transpositions were performed in single-stage and 128 (60.95%) were two-staged transposition. In our analysis we have found that as compared to single stage, two-stage basilic vein transpositions showed significantly better primary patency rates (76.82% vs 96%; p-value 0.000) and required less interventions for maintaining fistula patency. More post-operative sequelae were noted in the single stage version of the procedure as compared to the two stage procedure. CONCLUSION: Two stage procedure of basilic vein transposition is found to have better patency rate and lesser post-surgical complications. However, a matched cohort prospective study is still needed to further strengthen the conclusion.

Forearm Basilic Vein Transposition: A Single-Centre Experience.

INTRODUCTION: Forearm basilic vein transposition (FBVT) is a viable alternative for arteriovenous grafts (AVGs) and can be used as secondary vascular access as well, as it allows for the use of veins that are remote from the arterial source of inflow. FBVT involves two main steps: first, the basilic vein is dissected from its original location; and second, the basilic vein is transposed to a subcutaneous tunnel on the volar aspect of the forearm and anastomosed to a suitable artery, usually the radial or ulnar artery. OBJECTIVE: This paper aims to present a series of FBVT cases performed at our hospital and present it as a viable option for secondary vascular access. We also aim to review the available literature relating to FBVT fistula in terms of surgical technique, patency rates, maturation time, and one-year outcome, and to establish a comparison with our clinical experience. MATERIALS AND METHODS: This is a retrospective descriptive case series. The data were collected from online medical records, and patients were contacted by telephone to make a follow-up visit. For a review of the literature, a search was done on PubMed for articles containing the following keywords in either the title or the abstract: basilic, transposition, fistula, and forearm. Similarly, a search was done on Google Scholar for articles with the following words in the title: basilic, transposition, and forearm. The data are expressed as mean and standard deviation. Statistical analysis was done using SPSS 26.0 software (IBM Corp., Armonk, NY). CONCLUSION: The primary patency rate of FBVT in our study makes it a suitable solution to opt for before moving to AVGs. FBVT should be considered before moving more proximally in patients with inadequate forearm cephalic veins.

Clinical outcomes of transposed brachial-basilic vein fistula: Tunneling versus elevation.

BACKGROUND: The Kidney Disease Outcome Quality Initiative (KDOQI) suggests a transposed brachial basilic vein fistula (TBBVF) in the patients who have good likelihood of long-term survival. To superficialize the basilic vein, a disconnected basilic vein is anterolaterally transposed inside a subcutaneous tunnel. A simple elevation in situ is an alternative technique. The aim of this study was to compare clinical outcomes of TBBVF according to the type of superficialization. METHODS: A total of 42 patients (mean age of 66 years, male: 45%) who underwent a TBBVF from April 2014 to March 2019 at our hospital were retrospectively reviewed. The method of superficialization (tunneling (n = 18) vs elevation (n = 24)) was determined by the surgeon's preference. It was done as a one-stage surgery. There was not any statistically significant difference in demographic or clinical characteristics of patients between the two groups. As early outcomes, postoperative mortality and morbidity were investigated. For clinical outcomes, primary patency, primary-assisted patency, and secondary patency were analyzed for both groups. RESULTS: There was a case of a 30-day mortality in the elevation group. Regarding morbidities, there was a postoperative bleeding in the tunneling group and a steal syndrome in the elevation group. The mean follow-up was 28 months (range, 0-63 months). There was no significant difference in primary patency (64.8% vs 77.5% in 1 year and 54.0% vs 54.1% at 3 year; p = 0.816), primary-assisted patency (88.9% vs 86.5% in 1 year and 88.9 vs 81.4 at 3 year; p = 0.624), or secondary patency (100% vs 86.5% in 1 year and 100% vs 86.5% at 3 year; p = 0.126) between the two groups. CONCLUSIONS: Clinical outcomes of TBBVF showed no significant difference between tunneling and elevation groups. Thus, TBBVF can be done with either method.

Stretching the boundaries: suitability of an arteriovenous fistula in elderly patients on hemodialysis-a northern India experience.

PURPOSE: Considering various factors, such as multiple co-morbidities, unsuitable vessels for access creation, non-maturation, vascular calcifications, the outcome of arteriovenous fistula (AVF) in the elderly population, may not be similar to the younger people. Our study aims to analyze the outcomes of AVF in elderly patients (> 65 year). METHODS: It was a prospective observational study. Patients of more than 65 years of age in whom AVF was created from January 2012 to December 2015 were included in the study. These patients were followed up for 4 years. The primary endpoint of our study was to assess primary and secondary patency rates. RESULTS: A total of 450 AVFs were included in the study. The mean age was 68.5 years. The most common site of AVF was radiocephalic (RCAVF) in 70% (n = 315), brachiocephalic (BCAVF) in 24% (n = 108) and basilic vein transposition (BVT) in 6% (n = 27). At 48 months, the primary patency rate of RCAVF, BCAVF, and BVT was 55%, 61.6%, and 60.4%, respectively. The commonest cause of access failure was thrombosis followed by non-maturation. CONCLUSION: AVF remains the preferred vascular access for hemodialysis even in the elderly population. Failure to mature and thrombosis continue to be a concern with AVF. Location of the AV access does not seem to impact the long-term patency.

Results of first stage brachiobasilic and brachiobrachial fistula creation: Implications for staged versus single procedure decision making.

INTRODUCTION: Transposed brachiobasilic AV fistulas (BVT) have increasingly been performed in two stages. Published reports give conflicting results, perhaps in part as many reports of staged procedures eliminate those patients who "fail" the first stage (i.e. are lost to follow-up in addition to anatomic failure). METHODS: A prospectively maintained database was reviewed to identify all patients at two institutions who underwent the first stage of planned two-stage BVT by the senior author. Success in this context was defined as patients who eventually underwent second stage fistula creation, leaving the operating room after the second stage with a patent, transposed fistula. RESULTS: From October 2012 to June 2020, 218 patients underwent first-stage procedures. At the first visit, 185 (85%) of fistulas were patent, 23 (11%) were occluded, 8 (4%) of patients were lost to follow-up, and 2 (1%) died. In the interval before the second operation, another eight (4%) patients were lost to follow-up, two were cancelled for medical reasons, and two declined surgery, leaving a total of 173 patients who made it to the second stage (80%). At operation, four patients were found to have unusable veins, leaving a total of 169 patients who completed both stages. If all patients who underwent first stage are included, 77% of patients entering this pathway left the OR after their second stage with patent access. If those lost to follow-up are excluded, this number increases to 84%, while if all those lost to follow-up are assumed to mature, success increases to 85%. CONCLUSIONS: Depending on results in patients lost to follow-up, between 77% and 85% of patients undergoing first stage brachiobasilic fistulae undergo successful second stage transposition. These numbers are equivalent or slightly lower than published maturation rates for single-stage BVT, so there is little margin for failure at the second stage.

The role of surgery for assisted maturation after endovascular and percutaneous arteriovenous fistula creation.

Even in the best of circumstances, a significant number of patients will require adjunctive endovascular and/or surgical revision prior to achieving functional patency after endovascular or percutaneous AVF creation, at least within the United States. This rate appears to be higher after percutaneous AVF than after endovascular AVF, although because published reports of the former are mostly derived from American experience and those of the latter derived from experience outside the United States, it is unclear whether these differences are due to the technique itself or cultural and/or anatomic differences in dialysis access practices and patient populations. If arterial inflow is poor, this should be corrected first. When flow is adequate (perhaps 900 cc/min) but no single vein is cannulatable, a dominant suitable vein can be superficialized or transposed. If no suitable vein is dominant (most accurately assessed by using an intraoperative flowmeter), the best vein can be used, with or without occlusion of the other veins or reimplantation into the brachial artery. Finally, if the original anastomosis remains the sole supply to the cannulated vein, the original fistula has achieved assisted primary maturation (and assisted primary patency continues), while if a new arteriovenous anastomosis has been constructed, the original fistula has failed. We point out that for this reason as well as to best utilize the upper arm for later access, endovascular and percutaneous AVFs should be constructed and maintained within an atmosphere where both surgeons and non-surgeons work together on the overall access plan.

Proximal Arteriovenous Fistulas in Hemodialysis Patients: Advantages and Disadvantages.

INTRODUCTION: The main objective of the present study is to investigate the advantages and disadvantages of proximal arteriovenous native fistulas. Hemodialysis is indispensable for patients with end-stage renal disease. For this purpose, arteriovenous fistulas (AVFs) are used. Among the native fistulas, distal radiocephalic AVF is the most preferred. However, brachiocephalic AVF (BCAVF) and brachiobasilic AVF with basilic vein transposition (basilic vein transposition arteriovenous fistula [BVTAVF]) can be used for a long time in dialysis patients whose distal vascular bed is depleted. METHODS: This is a retrospective study of 117 AVFs (BCAVF and BVTAVF), in patients with end-stage chronic renal disease, that were opened with a surgical technique (2012-2018). The postoperative two-year patency rates, AVF locations, complications, and the advantages and disadvantages of these fistulas are reviewed and recorded in the light of the literature. RESULTS: The mean age of the patients (52 men and 65 women) was 60.6 ± 13.6 years. The percentages of primary patency rates at 3, 6, 9, 12, and 24 months were 96.6%, 93.1%, 92%, 87.4%, and 82.8% in BCAVF patients, and 96.7%, 93.3%, 90%, 86.7%, and 80% in BVTAVF patients, respectively. The percentages of secondary patency rates at 6, 12, and 24 months were 100%, 93.3%, and 86.7% in BCAVF patients, and 100%, 100% and 87.7% in BVTAVF patients, respectively. Fistula thrombosis was seen as the most common complication. The early complication was bleeding/hematoma. As late complications, we encountered steal syndrome, ischemic pain in the relevant extremity, pseudoaneurysm, and high-output heart failure. CONCLUSION: Proximal AVFs are preferable fistulas with early maturation and high primary patency rates. We believe that relatively high complications can be avoided by opening fistulas with an appropriate surgical technique.

Brachial Vein Transposition with Consecutive Skin Incisions in a Hemodialysis Patient with Absence of Adequate Superficial Veins: A Case Report.

The creation of an arteriovenous fistula instead of a synthetic vascular graft is a smart decision in hemodialysis patients who do not have a suitable superficial vein. Basilic vein transposition (BVT) is a viable option in most cases, except in patients who do not have a proper basilic vein. In patients with inadequate superficial veins, another source of the autogenous vein is the brachial vein, a deep vein of the upper arm. Most surgeons choose a full medial arm incision to perform brachial vein exploration. We describe a patient in whom BVT was not possible and so brachial vein transposition using skip incisions was performed, with good results.

Two-Stage Basilic Vein Transposition: Second Stage Results.

The increasing survival of hemodialysis patients results in the depletion of superficial venous capital justifying the use of the basilic vein. Many groups still prefer an arteriovenous graft due to transposition complexity and the time needed to achieve maturation. In this work we review the results of our series of basilic vein transpositions (BVT). BVTs were performed in two stages: first, creation of the fistula; second, transposition of the vein using three small incisions in the arm. All patients had to have direct arterialization of the basilic vein, therefore, patients with previous ipsilateral wrist fistulas also followed a two-stage protocol. Data were retrospectively revised from all transposition procedures made between September 2005 and November 2012. Patency and complication rates were the primary outcomes evaluated. A total of 276 basilic veins were transposed. Usage rate was 82.2%. 8% (N = 22) of the fistulas were never used due to thrombosis. Secondary patency rates at 1 and 2 years were, respectively, 84% and 66.3%. Complications occurred in 61.6% (N = 170) of fistulas and 65.9% (N = 112) of which had to undergo surgical or endovascular revision. The most frequent complication was vein stenosis (39.7% of late complications, N = 92). Albeit its greater technical complexity, the transposed basilic vein represents a hemodialysis access with good patency rates. Complication rates, although high, are less than those of CVC or prosthetic grafts. These results support the use of the transposed basilic vein as hemodialysis access after the brachiocephalic fistula.

Basilic vein transposition for unsuitable upper arm hemodialysis needle access segment may attenuate concurrent hand ischemia.

INTRODUCTION: Some hemodialysis patients with a brachial arteriovenous fistula (AVF) have an unsuitable upper arm needle access segment (NAS) necessitating basilic vein transposition (BVT). It was frequently observed that a portion of these patients spontaneously experienced a warmer and less painful dialysis hand after BVT. Aim of this study was to determine whether BVT for an inadequate NAS attenuated hemodialysis access-induced distal ischemia in patients with a brachial AVF. METHODS: Patients with a brachial AVF and an unsuitable NAS also reporting hand ischemia and scheduled to undergo BVT between 2005 and 2016 in a single facility were studied. Hand ischemia was graded as proposed in a 2016 consensus meeting. Hand ischemic questionnaire (HIQ-) scores (0 points, no ischemia-500 points, maximal ischemia), digital brachial index (DBI, ischemia <0.6) and access flow (mL/min) before and after BVT were compared. The cephalic vein and all side branches of the basilic vein were ligated during the BVT. FINDINGS: Ten patients were studied (8 males, 61 [54-75] years). BVT was performed 8 [4-10] months following the initial AVF construction. HIQ-scores dropped from 220 [71-285] to 9 [0-78] (P = 0.043) postoperatively, whereas DBI increased from 0.51 [0.39-0.67] to 0.85 [0.68-0.97] (P = 0.012). DBI and HIQ-scores were inversely correlated (R2 =71%, P = 0.001). Access flows dropped significantly (Flowpre 1120 mL/min [1100-2300] vs. Flowpost 700 mL/min [600-1760]; P = 0.018). Surgery-associated complications were absent and dialysis continued uninterruptedly. Eight patients reported total recovery from hand ischemia six weeks postoperatively. DISCUSSION: Basilic vein transposition for an unsuitable upper arm needle access segment may attenuate hand ischemia in patients with a brachial AVF previously reporting hemodialysis access-induced distal ischemia.

Minimally invasive basilic vein transposition in the arm or forearm for autogenous haemodialysis access: A less morbid alternative to the conventional technique.

OBJECTIVE: To devise a minimally invasive, less morbid yet effective alternative technique for basilic vein transposition (BVT) in the arm/forearm and to compare perioperative outcomes with the conventional technique. PATIENTS AND METHODS: Patients undergoing BVT in the last two years (June 2013 to June 2015) were included in the study and the results were analysed. All patients were preoperatively evaluated using colour Doppler ultrasonography performed by the operating surgeon himself. For minimally invasive BVT, two or three small 1-2 cm incisions were made to completely mobilise the basilic vein, transposed in an anterolateral arm/forearm tunnel, and then anastomosed to the brachial or radial artery in the forearm and arm, respectively. The incision in the conventional technique was along the full length of the basilic vein, with the rest of the procedure remaining the same. Complications, pain, analgesic use, maturation and primary patency rates were compared between the techniques. RESULTS: In all, 30 patients underwent minimally invasive BVT and 34 patients underwent conventional BVT, with mean age of 52 and 55 years, respectively. The complications of wound haematoma (one vs four) and wound infection/dehiscence (two vs six) were less common in the minimally invasive BVT group compared to the conventional group. The analgesic requirement and visual analogue scale pain score was significantly less in the minimally invasive BVT group. All other variables assessed, such as maturation and primary patency rate at 1 year, were not significantly different between the groups. CONCLUSION: Minimally invasive dissection of the basilic vein for vascular access transposition is a safe, reliable procedure with patency and functional outcomes comparable with those of conventional BVT.