|Year : 2018 | Volume
| Issue : 2 | Page : 87-91
Outcomes of basilic vein transposition at 1 year of follow-up
Mukesh Kumar Garg, Dhruv Agarwal, Ambarish Satwik, Ajay Yadav, Sandeep Agarwal, Varinder Singh Bedi
Departments of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India
|Date of Web Publication||3-May-2018|
Dr. Mukesh Kumar Garg
Departments of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Background: In dialysis-dependent end-stage renal disease patients, arteriovenous access (AV access) is the chief mode of hemodialysis access. Basilic vein transposition (BVT) is an alternative in patient with failed multiple AV access. The aim of the study is to assess the outcomes of BVT at 1 year of follow-up. Materials and Methods: This prospective, nonrandomized, observational study was conducted in the Department of Vascular Surgery at Sir Ganga Ram Hospital, New Delhi. Forty consenting patients with end-stage renal failure on maintenance hemodialysis having no other options utilizing superficial veins of the upper limb for AV access formation were included. All the complications, secondary interventions and patency rates were calculated at 1 year of follow-up. Statistical analysis was performed using Chi-square test, and patency rates were assessed using Kaplan–Meier survival curve. Results: Most of the patients were in the age group of 51–70 year with the mean age of 51.98 year. The mean basilic vein diameter was 2.84 mm. Fistula thrombosis was the most common complication and was seen in 17.5% cases followed by limb edema in 13% of cases. Re-interventions (fistula thrombectomy, balloon angioplasty etc.) were performed in 27.5% of the patients. The primary patency rate and secondary patency rate at 1 year of follow-up were 77.5% and 85%, respectively. Conclusions: BVT is a feasible and suitable surgical option to provide a durable and autogenous AV access to end-stage renal disease patients requiring maintenance hemodialysis.
Keywords: Arteriovenous access, basilic vein transposition, end-stage renal disease
|How to cite this article:|
Garg MK, Agarwal D, Satwik A, Yadav A, Agarwal S, Bedi VS. Outcomes of basilic vein transposition at 1 year of follow-up. Indian J Vasc Endovasc Surg 2018;5:87-91
|How to cite this URL:|
Garg MK, Agarwal D, Satwik A, Yadav A, Agarwal S, Bedi VS. Outcomes of basilic vein transposition at 1 year of follow-up. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2018 Sep 21];5:87-91. Available from: http://www.indjvascsurg.org/text.asp?2018/5/2/87/231849
| Introduction|| |
End-stage renal failure is a significant health problem. In 1944, hemodialysis was developed as a successful temporary renal replacement treatment option in patients with end stage renal disease. The improved survival of patients on maintenance hemodialysis and limited availability of renal transplant donors have led to an ever-increasing pool of patients requiring hemodialysis for a prolonged period. For this purpose, it is essential to secure and maintain an adequate vascular access, and this is a continuing challenge for both the vascular surgeons and the patients.
The Brescia–Cimino (radial artery-cephalic vein) wrist fistula and the brachiocephalic arteriovenous (AV) fistulas remain the first and second choices in the order of preference for the patient who begins hemodialysis according to the new updated dialysis outcome quality initiative (DOQI) guidelines. When the forearm or arm vessels are not suitable, the alternatives include either the brachiobasilic AV fistula (BBAVF) with basilic vein transposition (BVT) or the use of a prosthetic graft as recommended by the updated DOQI and European guidelines.,
Proponents of the BVT maintain that it is a suitable site for access because, like all autogenous fistulas, it has a low incidence of infection, keeps the body free from foreign material and has longer patency than polytetrafluoroethylene graft.
In the currently available literature, there are several contentious views regarding BBAVF and significant variation in reported outcomes. On this background, this study was contemplated to evaluate the outcomes of brachiobasilic AV access.
| Materials and Methods|| |
This was a prospective, nonrandomized, observational study conducted in the Department of Vascular and Endovascular Surgery at Sir Ganga Ram Hospital, New Delhi. The patients were drawn from a pool of patients who have undergone the operative procedure of BVT for the formation of BBAVF between April 2011 and January 2013. Forty consenting patients with end-stage renal failure on maintenance hemodialysis having no other options utilizing superficial veins of the upper limb for AV access formation were included. The patients who had basilic vein diameter of <2.5 mm as determined by preoperative USG Duplex imaging, active localized or generalized infection, peripheral ischemia of the upper extremity/poor flow in the ipsilateral radial or ulnar arteries or with ipsilateral venous outflow obstruction on the side of the planned BBAVF were excluded.
Each patient included in the study underwent clinical examination and duplex scanning of the upper limbs before surgical intervention. Demographic data with associated comorbid illness and previous history of fistula creation and/or dialysis catheter placement were recorded. The anteroposterior internal diameter of the vessels was measured using B-mode technique. Brachial artery was evaluated to exclude arterial disease. Brachial artery <2 mm (intima to intima) was deemed unsuitable for creating an arteriovenous access. The central venous system was also assessed indirectly by assessing the phasic flows in the subclavian vein.
BVT was performed as a single-stage procedure under regional anesthesia (in form of brachial plexus block) or local anesthesia. The basilic vein and brachial artery were marked at the lower 1/3rd of the arm at the cubital fossa using USG duplex imaging. The basilic vein was mobilized from the cubital fossa to axillary vein with careful preservation of medial cutaneous nerve of forearm. Brachial artery was also dissected at cubital fossa. The basilic vein was then divided as distal as possible [Figure 1]. Hydrostatic dilatation was performed, and dilated vein was tunneled subdermally using a long-curved artery forceps. Balloon dilatation was kept. The AV fistula was created with end to side anastomosis using running polypropylene 7-0 double-armed sutures [Figure 2]. Thrill was confirmed clinically, and wound was closed over a drain after securing adequate hemostasis [Figure 3].
|Figure 1: Brachial artery dissected and controlled between loops along with the prepared basilic vein ready for tunneling|
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|Figure 3: Immediate postoperative appearance with the vein seen in subcutaneous plane|
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All patients were followed up for 12 months after the formation of AV fistula. The follow-up was done during visits of the patient to the hospital for dialysis and by means of telephonic conversation. As a standard protocol, all patients received 75 mg of oral Aspirin (acetylsalicylic acid) daily for 1 month following the operative procedure.
All BVTs were allowed to mature for a minimum of 4 weeks before being used for hemodialysis. Follow-up visits were scheduled (day 0, day 15, day 30, and day 60) with the surgeon. At each follow-up, the patency of the AV access was evaluated clinically and by ultrasound evaluation. Any complications were also recorded. All patients with suboptimal fistula function or nonfunctional fistulas were evaluated, and intervention for salvage of the fistula was offered if considered feasible. After 2 months, no routine surveillance was performed, and the patients were followed up telephonically or during dialysis visit at 6 and 12 months postoperative period, respectively. Patients and the treating nephrologists were advised to report any complications as and when detected. Dialysis technicians were also instructed to report the patient if flow rate in the fistula was <600 ml/min or time to achieve hemostasis had increased more than the usual time for the patient from the access site after the dialysis along with limb edema.
Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as absolute numbers and percentage. Nominal categorical data between the groups were compared using Chi-squared test or Fisher's exact test as appropriate. P <0.05 was considered statistically significant. Kaplan–Meier survival curves were used to determine primary, assisted, and secondary patency rates over 12 months.
| Observations and Results|| |
Out of forty patients, 55% of the patients were male and 45% were female. Most of the patients were in the age group of 51–70 year with the mean age of 51.98 year. Distribution of comorbid conditions is shown in [Table 1]. About 75% of the patients had diabetes.
Nearly 90% of the patients had a history of failed AV access. About 85% of the patients had a history of dialysis catheter insertion on the same side on which BVT was contemplated. The mean basilic vein diameter was 2.84 mm in the study. All the patients had triphasic flows in the brachial artery. No patients had any direct or indirect evidence of central venous stenosis or occlusions.
No complication was reported in 50% of the cases. Fistula thrombosis was the most common complication and was seen in 17.5% cases followed by limb edema in 13% of cases. Rests of the complications are shown in [Table 2].
Re-interventions were performed in 27.5% of the patients for the complication mentioned in [Table 2]. All the re-interventions are mentioned in [Table 3].
Nine cases had developed fistula thrombosis. Out of which, 66.7% had a history of dialysis catheter insertion. On statistical analysis, there was no significant correlation (P value– 0.115) between the history of dialysis catheter insertion and fistula thrombosis.
Nearly 77% of the patient had basilic vein diameter in the range of 2.5–3.0 mm. On statistical analysis, there was no significant correlation (P = 1.000) between basilic vein diameter and fistula thrombosis.
Patency rates were calculated using Kaplan–Meier life table analysis. The primary patency rate at 12 months of follow-up was 77.5% while the primary-assisted and secondary patency rates were similar at 85% each since the fistulas which underwent successful intervention for suboptimal function maintained their patency at 12 months.
| Discussion|| |
BVT was usually a secondary access procedure in most participants as most had the history of previous procedures for AV access (90%), only in 10% cases, it was offered as the primary procedure with no history of any previous AV access creation. Casey et al. concluded that an upper extremity BVT may be a good first access procedure, particularly if the forearm veins are small.
BVT is considered to be a durable access. Primary fistula failure is associated with various kinds of risk factors (history of dialysis catheter insertion, suboptimal diameter of basilic vein, end-stage renal disease in itself, etc.).
The preoperative history of ipsilateral central venous dialysis catheter insertion and/or an in situ dialysis catheter on the side of BVT is probably related to catheter induced central venous outflow obliteration. Wolford et al. concluded that the presence of an ipsilateral hemodialysis catheter had no significant impact on rate of maturation or long-term patency of the fistulas. However, some other studies suggest that the previous subclavian venous catheter insertion is a risk factor associated with poor patency., In the present study, there was increased risk of fistula thrombosis, but this correlation was not statistically significant. Hence, this is suggested that an ipsilateral dialysis catheter must be removed/relocated to other side before creation of an AV access on that side.
Multiple studies have also stated that preoperative vein diameter does not affect fistula patency.,, We did have a cutoff diameter of 2.5 mm as our size of the vein for making a suitable fistula as smaller veins, especially those <2 mm, tend to be technically difficult to handle and this also causes increased technical failures in creation of the fistula. The preoperative size of the basilic vein and its relation to fistula thrombosis was analyzed but did not find any statistically significant correlation. Although this is suggested that preoperative vein mapping and vein marking on the skin surface as it allows assessing the quality and patency of the vein which is of the utmost importance for successful creation of a fistula. Vein marking also enables precise incision placement and decreases surgical trauma which leads to lesser postoperative complications.
In the present study, complications were recorded in 50% of cases over 12 months of follow-up. Many of these were conservatively managed while other required interventions. Other studies have also reported high complication rates.,, Technical failure of the fistula was observed in two cases on day 0 due to deficiencies in surgical technique. Both these cases underwent surgical revision on the same day, following which fistula patency was achieved. In both of these cases, the transposed vein was found to be kinked/twisted in the subcutaneous tunnel. Both of these cases were not included in calculation of patency rates. Primary fistula failure occurred in 1 (2.5%) case where the fistula although patent failed to mature even after 2 months of follow-up and underwent percutaneous balloon angioplasty following which it matured and was used for dialysis. A review of the studies of BBAVF has stated that the primary failure rates range from 5% to as high as 40%.
Hossny  Taghizadeh et al. and Murphy et al. reported high rates of thrombosis of 16.7%, 33%, and 22%, respectively. Thrombosis of fistula was the most common complication in the present study. Three patients underwent fistula thrombectomy with success rate of only 33%. One patient underwent a successful percutaneous balloon angioplasty for stenosis which was causing suboptimal fistula function. Another underwent a successful percutaneous balloon angioplasty for a primary fistula failure. Dix et al. stated that transient edema of the hand and forearm is common but underreported and in most cases resolves with arm elevation. All cases of limb edema except one were managed conservatively. One patient underwent central venous stenting for persistent limb edema.
Dix et al. have concluded that the overall mean primary patency rate of the BBAVF at 12-month follow-up is 72% (35%–92%), whereas the mean secondary patency rate is 67.5% (52%–86%). Keuter et al. reported a 1-year primary and assisted primary patency rate of 46% ± 7.4% and 87% ± 5%, respectively, whereas the secondary patency rate at 1 year was 89% ± 4.6% for the BBAVF cohort. The present study has a high primary patency rate of 77.5% [Figure 4] and a secondary patency rate of 85% [Figure 5] after a follow-up of 12 months.
With these results, it can be proposed that BVT may be added to the armamentarium of the vascular surgeon in the quest for providing an AV access for continuing hemodialysis.
| Conclusions|| |
BVT is a feasible and suitable surgical option to provide a durable and autogenous AV access to end-stage renal disease patients requiring maintenance hemodialysis if other superficial veins of the upper limb are not available or suitable for AV access creation. This procedure has a good primary patency rate after 1 year of follow-up and patency may be extended by suitable interventions. A large number of complications, especially those comprising of hematoma formation, limb edema, and wound infections may be managed conservatively without affecting the patency of the fistula. Intervention is required in cases of thrombosed fistulas or fistulas with suboptimal function.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]