Superficialization of the Basilic Vein Technique in Brachiobasilic Arteriovenous Fistula: Surgical Experience of 350 Cases During 4 Years Period
Article Outline
Background
The primary use of autogenous arteriovenous fistula for chronic hemodialysis patients is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative practice guidelines (Am J Kidney Dis 2001;37(1 Suppl. 1):S7–S64; Am J Kidney Dis 1997;30(4 Suppl. 3):S150–S191). Brachiobasilic arteriovenous fistula offers excellent access in difficult cases. Many surgical techniques have been described to create brachiobasilic fistula. The purpose of this study was to present and discuss the technique of superficialization of the basilic vein in brachiobasilic arteriovenous fistula with long-term results of 350 cases.
Methods
A total of 375 brachiobasilic arteriovenous fistulas were constructed with superficialization of the basilic vein technique. Of these, 350 fistulas were used in hemodialysis (93.3%). One hundred fifty-five (44%) patients were male, 195 (56%) were female. Mean age was 57.8 (range, 18–88) years. A 2-cm longitudinal incision was made in antecubital fossa to expose brachial artery and basilic vein under local anesthesia. A separate second skin incision (4–6 cm) was done to explore proximal part of the basilic vein. Side branches of the basilic vein were isolated and ligated carefully using this second skin incision. The basilic vein was divided in antecubital fossa and brought over the fascia through the subcutaneous tunnel at the same anatomical position. Anastomosis was performed with end-to-side technique.
Results
Mean follow-up was 48 months (range, 2–84). The mean time to first puncture and use of the fistula time was 52 days (range, 25–75). Bleeding required surgical exploration which occurred in 3 (0.9%) patients. Primary patency of basilic vein superficialization fistulas was 92%, 78%, 64%, and 54% at 1, 2, 3, and 4 years, respectively. Secondary patency was 93%, 81%, 66%, and 56% at 1, 2, 3, and 4 years, respectively.
Conclusion
Superficialization of the basilic vein technique is a logical alternative method of the basilic vein transposition. Superficialization requires less extensive skin incision and surgical dissection. Long-term patency was good.
Introduction
Since the development of hemodialysis in 1944, there has been a dramatic increase in both the availability of hemodialysis and long-term survival of patients with chronic renal failure.1 Because of the expanded life expectancy, patients often require multiple operations, and options for secondary or tertiary access procedures become increasingly limited.2
Since 1976, basilic vein transposition has been a well-known technique to create brachiobasilic arteriovenous fistula.3
In this study, we evaluated and discussed the technique of superficialization of the basilic vein in brachiobasilic arteriovenous fistula. We present early- and long-term results of 350 cases.
Patients and Methods
Between 2004 and 2008, 375 brachiobasilic arteriovenous fistulas were performed using basilic vein superficialization technique. Of 375 fistulas, 25 (6.7%) failed in maturation and 350 (93.3%) arteriovenous fistulas with superficialized basilic vein were used in hemodialysis. One hundred fifty-five (44%) patients were men, and 195 (56%) were women (Table I). Mean age was 57.8 (range, 18-88) years. Left arm was preferred in 231 (68%) patients. The most associated diseases were hypertension in 185 (53%) and diabetes in 178 (51%) patients. Furthermore, peripheral vascular disease was in 105 (30%) and coronary artery disease in 52 (15%) patients. Eighty-seven (25%) patients were former smokers and 70 (20%) still smokers. Mean number of previous arterio-venous fistula was 2.5 (range, 0-5). Mean maturation time or the average time to first puncture and the use of fistula was 52 days (range, 35-75).
Table I. Demographic data of the patients, maturation time, and duration of the operation are shown
| Patients | ||
|---|---|---|
| N | % | |
| Sex | ||
 Male | 155 | 44 |
| Female | 195 | 56 |
| Age (yr) | ||
| Mean | 57.8 | |
| Range | 18-88 | |
| Site of operation | ||
| Left arm | 231 | 68 |
| Right arm | 119 | 34 |
| Associated disease | ||
| Hypertension | 185 | 53 |
| Diabetes | 178 | 51 |
| PVD | 105 | 30 |
| CAD | 52 | 15 |
| Smoking status | ||
| Never | 192 | 55 |
| Former | 87 | 25 |
| Current | 70 | 20 |
| Number of previous AVF | ||
| Mean | 2.5 | |
| Range | 0-5 | |
| Maturation time (d) | ||
| Mean | 52 | |
| Range | 25-75 | |
| Operation time (min) | ||
| Mean | 56 | |
| Range | 47-75 | |
Preoperative vein mapping is done in patients with no obviously useful superficial veins or in patients who have previously undergone upper-arm fistula creation. Vein mapping was performed using General Electric Logic 3 Expert duplex scanners (General Electric, Turkey). The evaluation was performed and reviewed by radiologist and surgeon together. Superficial veins, such as cephalic and basilic veins, were evaluated from the distal forearm to the axilla region. Subclavian and jugular veins were also evaluated. Venography and multislice spiral computed tomography angiography were rarely required to demonstrate vena cava superior, innominate and subclavian vein stenosis, or occlusion.
Hemodialysis nurses detected the thrill and found the superficialized basilic vein easily.
Surgical Technique
Superficialization of the basilic vein operations was performed under local anesthesia using 20-40 mL (prilokain 2%). A 2 cm incision was made in antecubital fossa. Brachial artery and basilic vein were identified and exposed through this incision. A separate second skin incision (4-6 cm) was done to explore proximal part of the basilic vein. Side branches of the basilic vein were carefully isolated and ligated. Median antebrachial cutaneous nerve and brachial plexus require considerable care during dissection. Side branches of the vein were marked by a marker before distal division to prevent torsion. The basilic vein divided distally at the level of the antecubital fossa was brought over the deep fascia under the skin. The vein is well mobilized and elongated, which provides anastomosis of the proximal side with a diameter larger than 3 mm. The vein was filled and dilated with heparinized saline. This maneuver provides enlargement of the vein. Anastomosis performed end-to-side with 7-0 suture (Fig. 1). A minivac drainage system was inserted through the subcutaneous tunnel. Deep fascia was reapproximated with separated sutures beneath the vein. The skin was then closed. The patients were hospitalized for 2-12 hours (mean, 3.5 hours) after operation.
Fig. 1
Operation technique of the brachio-basilic arterio-venous fistula and superficialization of the basilic vein are seen.
Definition of Success, Primary and Secondary Patency
Technical success was defined as the presence of a thrill on palpation or a bruit on auscultation until the use of the fistula for hemodialysis. Primary patency refers to fistulas functioning for dialysis up to the time of first failure or intervention performed to maintain patency. Secondary patency is the interval from the time of access placement until access abandonment, regardless of the number of interventions required to maintain patency.4
Statistics
Data were entered into a Microsoft Excel (Microsoft Corp, Istanbul, Turkey) spreadsheet for analysis. Statistical analysis was performed using SPSS 10.0 system (SPSS Inc., Chicago, IL). Kaplan–Meier analysis was used to determine primary and secondary patency rates.4
Results
The 350 superficialized brachial artery-basilic vein fistulas were successfully used for dialysis. Operation time was 56 minutes (range, 47-75). Maturation time was mean 52 days (range, 25-75) after operation. There was no kinking or torsion of the basilic vein during operation. Nurses found and cannulated superficialized basilic vein easily, as the vein was under the skin incision.
Massive bleeding required surgical exploration, which occurred in 3 (0.9%) patients (Table II). A 51-year-old woman with a bad quality of the basilic vein, because of previous needle punctures, underwent surgical revision after 6 hours of operation. The basilic vein itself was the cause of hematoma. Hematoma was removed, and surgical absorbable hemostat was used over the basilic vein. There was no further complication. The other patient was a 70-year-old woman with hypertension and diabetes mellitus. Hematoma was removed after 4 hours in this patient. The cause of bleeding was arterial side of the anastomosis. Anastomosis and brachial artery were repaired. The third case was a 65-year-old woman in whom massive bleeding occurred after 13 days of the operation. Bleeding at the anastomosis side required re-anastomosis at the proximal side of the brachial artery. Fistulas were patent in all cases after surgical revisions.
Table II. Postoperative early and late complications following superficialization of the basilic vein fistula are shown
| Total (%) | |
|---|---|
| Early complication | |
| Bleeding | 17 (4.9) |
| Minimal | 14 |
| Massive | 3 |
| Wound infection | 20 (5.7) |
| Late complication | |
| Thrombosis | 186 (53) |
| Ischemic steel | 25 (7.1) |
| Mild | 19 |
| Severe | 6 |
| Poor flow rates | 21 (6) |
| Venous hypertension and edema | 16 (4.6) |
| Transient | 13 |
| Massive edema with venous ulcus | 3 |
| Aneurysm | 32 (9.1) |
There was minimal hematoma in 14 (4.0%) patients without a need for a surgical exploration.
Wound infection in the early postoperative period was seen in 20 (5.7%) patients, 17 (85%) of whom were diabetic. Fourteen of them were successfully treated with antibiotics alone. Surgical revision of the skin incision was necessary in remaining six patients.
In follow-up period, thrombosis within the body of the basilic vein was the most common cause of primary failure. Basilic vein thrombosis was seen in 186 patients. Thrombectomy or segmental access replacement was performed successfully in 36 (23%) patients. In the remaining 150 patients, revision of the basilic vein was not possible. In these patients, intimal hyperplasia and stenosis were determined in complete basilic vein with duplex scanner. Another arteriovenous fistula was done in these patients.
Arterial steal syndrome occurred in 25 (7.1%) cases. Narrowing of the fistula with re-anastomosis was done in 14 (4%) patients. Ligation of the fistula because of severe ischemic steel syndrome was necessary in six patients (1.7%).
Flow rates decreased in 21 (6%) patients in follow-up period. Inflow was insufficient in these patients. Systolic and diastolic blood pressure was below 90 and 40 mm Hg, respectively. Duplex scanner evaluated blood flow rate of less than 300 mL/min. Permanent hemodialysis catheter was necessary in these patients.
Venous hypertension and arm edema occurred in 16 (4.6%) cases. Transient edema was in 13 (3.7%) patients. Ligation of the fistula was performed in 3 (0.9%) patients with massive arm edema.
Aneurysm was seen in 32 (9.1%) patients. Fistula was ligated in 12 patients with huge aneurysm.
Patency
Primary patency of the basilic vein superficialization fistulas was 92%, 78%, 64%, and 54% at 1, 2, 3, and 4 years, respectively. Secondary patency was 93%, 81%, 66%, and 56% at 1, 2, 3, and 4 years, respectively (Table III). Primary and secondary patency rates following brachiobasilic arteriovenous fistula are shown on Figure 2.
Table III. Primary and secondary patency rates of brachiobasilic arteriovenous fistula using basilic vein superficialization technique are seen
| P.P. | S.P. | |||
|---|---|---|---|---|
| Time (mon) | Patient | P.P (%) | Patient | S.P. (%) |
| 0 | 350 | 100 | 350 | 100 |
| 12 | 322 | 92 | 326 | 93 |
| 24 | 273 | 78 | 283 | 81 |
| 36 | 224 | 64 | 231 | 66 |
| 48 | 189 | 54 | 196 | 56 |
Fig. 2
Primary and secondary patency rates after brachio-basilic arterio-venous fistula.
Discussion
A radiocephalic fistula in the nondominant arm is the first choice for vascular access.5 When the vein is poor in the forearm, antecubital brachiocephalic arteriovenous fistula is a good alternative.6 When the antecubital cephalic vein diameter is less than 3 mm or the cephalic vein is thrombosed, brachiocephalic fistulas were not possible.7
In these patients, the choice of vascular access is between brachio-basilic native arteriovenous fistula and prosthetic graft.2, 8 Well described advantages of using autogenous arteriovenous fistula include low incidence of infection, keeps the body free from foreign material, and longer patency rates than prosthetic grafts.6, 9 In case of native fistula failure, subsequent use of prosthetic conduit at the same side is not precluded, whereas it is unlikely that the converse would be successful.9
We performed brachio-basilic arteriovenous fistula when a distal native forearm fistula could not be created and cephalic vein system was poor in the upper arm. Prosthetic graft is our next choice after native brachio-basilic fistula.
In 1976, Dagher et al. first described transposition of the basilic vein.10 This type of fistula is created by a long skin incision, wide-dissection, well-mobilization, and transposition of the basilic vein by rotating it anterolaterally through a subcutaneous tunnel in the arm.10 The operation is time consuming, technically challenging, and it has increased perioperative morbidity compared with creation of brachiocephalic arteriovenous fistula (AVF).6, 11 The well-known major disadvantages of basilic vein transposition are the potential for vein injury during the required mobilization and wound complications associated with the extensive dissection, such as hematoma or injury to the median or cutaneous nerves.6, 11 In 1979, Barnett et al. described a single-stage procedure that elevated the basilic vein by reapproximating the deep fascia and subcutaneous tissue of the arm beneath the vein instead of routing it through a subcutaneous tunnel.12 In 1986, Davis et al. first reported the outcomes of the basilic vein elevation technique in a series of 66 patients.13 Bronder et al. planned elevation technique as a single-stage or a two-stage procedure.14 We performed anastomosis and elevation in single stage. Elevation provides a longer and straighter length of fistula, which is particularly beneficial in patients in whom the basilic vein caliber is marginally near the antecubital fossa because of branching or where the vein is short because of its low insertion into the brachial vein.14 However, in basilic vein transposition, diameter of the basilic vein should be at least 3 mm in antecubital region.15
Hossny compared outcomes of brachio-basilic AVF patients transposed through a separate tunnel with those in whom elevation technique as a single- or two-stage procedure was performed.16 He reported that 20 patients underwent one- and two-stage elevation technique as compared with 30 patients who underwent basilic vein transposition technique. He concluded that the extravasation and hematoma formation were significantly higher in the elevated vein group because of difficult cannulation of the basilic vein in the inner aspect of the upper arm. Bronder et al. reported fistula elevation procedure including 295 cases.14 They did not note a difference in complications, such as needle-side bleeding, hematoma, or arm edema in elevated fistulas, compared with fistulas transposed through a separate tunnel.14
We performed elevation with two small separated skin incisions instead of a long skin incision, which requires less dissection than basilic vein transposition. After dissection of the deep fascia, elevation of the basilic vein was performed at the same anatomic place. Position of the ligated side branches is helpful against torsion. Furthermore, filling of the vein with saline confirms the position of the basilic vein. Transposition of the basilic vein technique requires dissection of the deep fascia, and additionally transposes the vein anterolaterally in the arm.
Some investigators have shown that preoperative duplex ultrasound assessment might improve fistula outcome, particularly in terms of technical success.3, 17 In our study, preoperative vein mapping is done whenever clinically indicated, such as in patients with no obviously useful superficial veins or patients who have previously undergone upper-arm fistula creation. Duplex assessment of the radial, ulnar, brachial arteries, subclavian, basilica, and cephalic veins was determined to plan the best surgical option, which is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines.7, 18 Venography and multislice spiral computed tomography angiography were rarely required to determine vena cava superior, innominate, and subclavian veins.
In conclusion, superficialization technique of the basilic vein is a logical alternative in patients with a poor cephalic vein in forearm and upper arm. This technique provides appropriate length for fistula cannulation if the superficialized vein is long. Postoperative complications are reasonable. Long-term primary and secondary patency rates are good. Superficialization of the basilic vein results in a fistula that lies on the inner aspect of the upper arm. This disadvantage is offset by the fact that the overlying cicatrix guides the nurses to precisely locate the fistula. If the scar tissue caused difficult cannulation, the procedure could easily be done near the scar tissue.
References
- Geographic and demographic variations in vascular access. In: Henry ML, Ferguson RM editor. Vascular Access for Hemodialysis. 5th ed. Chicago, IL: WL Gore and Precept Press; 1997;p. 23–31
- Arteriovenous fistula using transposed basilic vein. Br J Surg. 1998;85:653–654
- Elbow fistulas using autogenous vein: patency rates and results of revision. Postgrad Med J. 2002;78:483–486
- Recommended standards for reports arteriovenous hemodialysis accesses. J Vasc Surg. 2002;35:603–610
- Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med. 1996;275:1089–1092
- Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas. Kidney Int. 2001;60:1532–1539
- . NKF-DOQI clinical practice guidelines for vascular access. Am J Kidney Dis. 1997;30(4 Suppl. 3):S150–S191
- Long-term results of arteriovenous fistulas using transposed autologous basilic vein. Br J Surg. 2000;87:819–823
- Transposed basilic vein versus polytetraflourethylene for brachialaxillary arteriovenous fistulas. Am J Surg. 1998;176:219–221
- The use of basilic vein and brachial artery as an AV fistula for long-term hemodialysis. J Surg Res. 1976;20:373–376
- Basilic vein transposition fistula: a good option for maintaining hemodialysis access site options?. J Vasc Surg. 2004;39:1043–1047
- The basilic vein fistula for vascular access. Trans Am Soc Artif Intern Organs. 1979;25:344–346
- . Hemodialysis access: elevated basilic vein arteriovenous fistula. J Pediatr Surg. 1986;21:1182–1183
- Fistula elevation procedure: experience with 295 consecutive cases during a 7-year period. J Am Coll Surg. 2008;206:1069–1075
- . Is basilic vein transposition a real alternative to an arteriovenous bypass graft? A prospective study. Semin Dial. 2008;21:352–356
- . Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysis-related complication. J Vasc Surg. 2003;37:821–826
- Evaluation of the efficacy of the transposed upper arm arteriovenous fistula: a single institutional review of 190 basilic and cephalic vein transposition procedures. J Vasc Surg. 2007;46:94–99
- . NKF-K/DOQI clinical practice guidelines for hemodialysis adequacy: update 2000. Am J Kidney Dis. 2001;37(1 Suppl. 1):S7–S64
PII: S0890-5096(10)00082-8
doi:10.1016/j.avsg.2010.02.013
© 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc All rights reserved.
