The use of basilic vein and brachial artery as an A-V fistula for long term hemodialysis
Abstract
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1. A new access for long-term hemodialysis has been developed by creating a fistula in the upper arm between the end of the basilic vein and the side of the brachial artery.
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2. The operative procedure is simple to carry out, providing a straight, long, easily accessible fistula with high flow.
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3. The use of Bovine, saphenous, or prosthetic grafts is avoided, and anatomic continuity at the venous end of the fistula is maintained.
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4. The initial experience suggests that the trouble-free patency rate is high.
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5. The procedure is indicated when suitable vessels are not available at the wrist or forearm.
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Cited by (138)
Early Experience with Sine Wave Technique for Superficialization of a difficult to cannulate Arterio Venous Fistula
2022, Annals of Vascular SurgeryTo highlight safety and efficacy of sine wave technique (SWT) in superficializing deep arterio venous fistula (AVF) and managing infiltrations and other complications.
It is a single center observational study done from Jul 2017 to July 2020. All successive cases of deep AVFs, aneurysm / pseudoaneurysms of AVFs, and AVFs requiring open venoplasty were managed with SWT. Data was collected prospectively and analyzed. SWT is based on random pattern skin flaps. Using ultrasound, a line is marked on either side of centre line (AVF) at a distance of approximately 1.5–2 cm. A sine wave is drawn starting from either of the lines to the other with multiple crests and troughs. The base of flap should be double the height of the flap, that is, about 3-4 cm. Skin is incised and flaps are raised at level of AVF. Excess fat is removed. A sliver of unhealthy skin can be sacrificed if required. Flaps are sutured back to restore sine wave continuity.
SWT was used in a total of eleven patients. Median age was 58 years (range 10–67 years). Eight were females and three males. One was radio-cephalic and rest were brachio-cephalic AVFs. Eight AVFs were deep with median depth of 10.25mm (range 8–13mm), median body mass index of 25.5 kg/m2 (range 23.9–26.5kg/m2), median vein diameter of 7 mm (range 6-8 mm), and median flow rate of 1137.5ml/min (range 650- 1380 ml/min). Out of eight, four AVFs presented with infiltration. In other three, SWT was used for exposing AVF to treat underlying pathology (one case each of aneurysm, pseudoaneurysm & stenosis). Ten cases were done under local or regional anesthesia and one under general anesthesia. There was no peri-operative mortality or loss of AVF. Transient limb oedema developed in one case. Median time to cannulate was 20 days (range 13–28 days). Median follow up was 13 months (range 6 - 31months). Cumulative patency at 18 months was 90% (95% CI 47.3%–98.53%) and 45 % (95% CI 9.9%–87.1%) at 24months and at the end of the study.
SWT is safe and effective in superficialization of deep / difficult to cannulate AVF as well a good approach to treat complications like infiltration. Post procedure cannulation time is reasonably short.
Modified Brachio-basilic/brachial Arteriovenous Fistula Creation with Short-segment Elevation Preserving the Axilla
2020, Annals of Vascular SurgeryBrachio-basilic/brachial transposition arteriovenous fistula has emerged as one of the autologous arteriovenous fistula options. However, there have not been many reports on the outcomes of basilic or brachial elevation of arteriovenous fistula compared with those of conventional transposition. We evaluated the efficacy of modified brachio-basilic and brachio-brachial arteriovenous fistula creation with short-segment elevation preserving the axillary area.
From March 2016 to August 2018, medical records of the patients who underwent short-segment elevation of brachio-basilic or brachio-brachial arteriovenous fistula in the upper arm (sBAE or sBRE) were reviewed retrospectively.
Of the 51 patients, 37 underwent sBAE and 14 underwent sBRE. Maturation failure occurred in two patients (3.92%), who underwent sBAE. Stenosis was the most common complication, which developed in 13 patients (25.5%), and there was no significant difference between the sBAE and the sBRE. In the 51 patients, cumulative primary patency rates at 6 and 12 months were 88.3% and 69.1%, respectively. Assisted primary patency rates at 6 and 12 months were 97.8% and 90.7%, respectively. Secondary patency rates at 6 and 12 months were both 100%. There were no significant differences between the sBAE and the sBRE in 1-year primary patency (79.1% vs. 46.7%; P = 0.20), assisted primary patency (91.6% vs. 88.1%; P = 0.36), and secondary patency rates (100% vs. 100%).
Brachio-basilic/brachial arteriovenous fistula with short-segment elevation preserving the axilla showed excellent 1-year patency rate, easier cannulation, and other future advantages, and therefore, is a logical modification of conventional transposition of arteriovenous fistula.
Innovations in vascular access for hemodialysis
2019, Kidney InternationalWorldwide, hemodialysis remains the prevalent dialysis modality for more than 2 million patients who require well-functioning vascular access for this procedure. Creation of an arteriovenous fistula for long-term hemodialysis was the first innovation since the Scribner shunt and was followed by the development of an arteriovenous graft and catheter. Bioengineered vessels were developed during the last century, but this field has been energized by recent technology relating to the creation of human vessels. Novel endovascular techniques for creating an arteriovenous fistula may resolve some of the logistical issues involved in obtaining a timely arteriovenous fistula. Treatment of access stenosis, infection, and thrombosis has remained suboptimal, and innovative technologies are evolving. Many new approaches are now targeting the biological and mechanical aspects of vascular access, such as creation and maturation of arterial and venous anastomoses, development of a biological conduit for outflow, and negotiating the problems of central vein stenosis. Importantly, processes of access care that have long focused on arteriovenous fistulas are now recognizing the new paradigm, providing a complementary niche to arteriovenous grafts and dialysis catheters in the algorithm for individualized access placement. Cumulatively, to the credit of the multidisciplinary team approach, the long overdue focus on the very existential issue of vascular access for hemodialysis is being approached with newfound evidence-based enthusiasm as the vexing challenges related to regulations and reimbursement in hemodialysis persist. Patient choice and experience, often missed and ignored in the challenging management of an end-stage organ failure, need to stay central as we focus on patient-centered care of vascular access.
Outcomes of basilic vein transposition versus polytetrafluoroethylene forearm loop graft as tertiary vascular access
2019, Journal of Vascular SurgeryRadial-cephalic arteriovenous fistula and brachial-cephalic arteriovenous fistula are the first and second choices for creating vascular access in dialysis patients as recommended by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Basilic vein transposition or use of a forearm (polytetrafluoroethylene [PTFE]) loop graft is recommended thereafter. The aim of this study was twofold: first, to compare the outcomes and patency rates of patients treated with a basilic vein transposition with those of patients treated with a PTFE loop; and second, to identify patient-related factors of influence on patency rates.
Data collected in our prospectively maintained database of patients with chronic renal dysfunction requiring hemodialysis were analyzed. From April 2006 to August 2017, there were 55 patients with a basilic vein transposition and 75 patients with a PTFE loop included. Primary, primary assisted, and secondary patency rates were calculated. Multivariate analysis was used to identify factors of influence on survival. Incidence rates of complications and reinterventions were calculated and compared.
Mean follow-up time was 29 months. A significantly higher 2-year primary assisted patency rate was found for the basilic vein transposition group (72.7% ± 6.5% vs 47.6% ± 6.2%; P < .01). The 2-year primary patency rates and secondary patency rates were comparable between basilic vein transposition and PTFE loop (25.1% ± 6.6% vs 13.7% ± 4.4% [P = .11] and 75.5% ± 6.5% vs 73.9% ± 5.3% [P = .17], respectively). Cox regression identified body mass index (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.05-2.98; P = .03) and age (HR, 0.54; 95% CI, 0.32-0.91; P = .02) as predictors for failure regarding primary patency in PTFE loop patients. Previous catheter use (HR, 0.29; 95% CI, 0.12-0.70; P = .006) and the presence of diabetes (HR, 3.32; 95% CI, 1.50-7.39; P = .003) were independent predictors for failure regarding primary patency in basilic vein transposition patients. The incidence rate of total complications was significantly higher in the PTFE loop group with 0.70 per patient-year (PY−1) compared with 0.28 PY−1 in the basilic vein transposition group (P = .001). In terms of intervention rate, a significantly higher percutaneous transluminal angioplasty rate and surgical revision rate were found in the PTFE loop group than in the basilic vein transposition group (1.77 PY−1 vs 1.05 PY−1 [P = .022] and 0.20 PY−1 vs 0.07 PY−1 [P = .002], respectively).
In this nonrandomized study, basilic vein transposition has better primary assisted patency, fewer complications, and fewer reinterventions compared with PTFE loop.
Comparison of one-stage and two-stage upper arm brachiobasilic arteriovenous fistula in the Vascular Quality Initiative
2019, Journal of Vascular SurgeryAn upper arm brachiobasilic arteriovenous fistula (BBAVF) is a reliable autogenous hemodialysis access created with a one-stage or two-stage technique. Although both techniques are variably used, the optimal approach is uncertain. In this study, we compared the outcomes of one-stage and two-stage BBAVF procedures.
We identified 2648 patients who had received BBAVFs within the Vascular Quality Initiative data set (2010-2016) and compared those created using the one-stage and two-stage technique. The primary outcome measures were primary and secondary patency rates at 12 months. Other outcomes assessed were wound infection, steal, and swelling at 3 months. The log-rank test was used to evaluate patency by Kaplan-Meier analysis. Cox proportional hazards models were used to examine the adjusted association between surgical technique and outcomes.
There were 1234 (47%) one-stage and 1414 (53%) two-stage BBAVFs in the study cohort, including 1848 (70%) patients who were on dialysis at the time of surgery and 1795 (68%) patients with a history of previous access. Patients who underwent a one-stage BBAVF were more likely to be male (54% vs 45%; P < .001), to be white (60% vs 41%; P < .001), and to have a history of coronary artery disease (22% vs 17%; P = .001). Patients undergoing one-stage BBAVFs have larger vein diameters (4.1 vs 3.4 mm; P < .001) and have the procedure in an inpatient setting (21% vs 13%; P < .001) compared with patients undergoing a two-stage procedure. The 12-month primary patency rate was higher for the one-stage BBAVF (49.1% vs 40.4%; P = .005), although the secondary patency rate was comparable (80.0% vs 77.9%; P = .54). Postoperative bleeding (4% vs 1.5%; P < .001), wound infection (1.01% vs 0.4%; P = .047), and arm swelling (2.1 % vs 0.8%; P = .006) were higher for one-stage BBAVFs. In multivariable analysis, although loss of primary patency at 12 months (adjusted hazard ratio [aHR], 1.12; 95% confidence interval [CI], 0.97-1.30; P = .12) and 3-month wound infection (aHR, 0.42; 95% CI, 0.14-1.25, P = .12) were similar between the two approaches, the risk of 3-month arm swelling was significantly lower for two-stage BBAVFs (aHR, 0.35; 95% CI, 0.16-0.77; P = .009).
Whereas surgeons were more likely to perform a two-stage BBAVF in patients with a history of previously failed access and smaller basilic vein, our data show no difference in primary or secondary patency of one-stage and two-stage BBAVFs at 12 months.
A systematic review and meta-analysis of one-stage versus two-stage brachiobasilic arteriovenous fistula creation
2018, Journal of Vascular SurgeryLong-term patency of arteriovenous fistulas (AVFs) is critical for hemodialysis vascular access. We compared the efficacy of a one-stage vs two-stage approach to brachiobasilic AVF creation by primarily investigating primary and secondary patency rates. We hypothesize that the two-stage is superior to the one-stage procedure in terms of efficacy and safety.
This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database. Risk of bias and quality assessment scores were both performed based on previously validated tool.
The systematic search revealed a total of 242 publications for possible inclusion. On the basis of title and abstract review, two randomized controlled trials and nine case-cohort series fit our inclusion criteria. There were no statistically significant differences in failure rates (pooled risk ratio [RR], 1.10; 95% confidence interval [CI], 0.79-1.55; P = .25), 1-year primary patency rates (RR, 1.31; 95% CI, 0.83-2.06; P = .24), 1-year secondary patency rates (RR, 0.97; 95% CI, 0.54-1.77), 2-year primary patency rates (RR, 1.68; 95% CI, 0.99-2.83; P = .05), and 2-year secondary patency rates (RR, 1.19; 95% CI, 0.54-2.63; P = .67) between both groups. However, the two-stage procedure had significantly improved 2-year primary patency rates (RR, 2.50; 95% CI, 1.66-3.74; P < .00001). There were no differences in steal syndrome, hematoma, infection, pseudoaneuryms, or stenosis, although there was a trend toward an increased incidence of postoperative thrombosis (RR, 1.81; 95% CI, 0.95-3.45; P = .07) in one-stage procedures.
With improved 2-year primary patency rates that trend toward statistical significance and the absence of significant differences in complications, this study suggests potential benefit of a two-stage over a one-stage procedure for brachiobasilic AVF creation. However, rather than being a definitive answer, our results merely highlight the continuing need for an adequately powered, well-designed, randomized controlled trial to interrogate this question further.