|Year : 2019 | Volume
| Issue : 2 | Page : 79-81
Ulnar basilic arterio venous fistula: An useful alternative access for hemodialysis
Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||6-Jun-2019|
Dr. Sekar Natarajan
Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Objective: Native arteriovenous fistula done at the distal most site has been promoted as the vascular access of choice. Radiocephalic fistula at wrist or snuffbox is widely used but ulnar basilic fistula is seldom performed. The aim of this study is to analyse the usefulness of ulnar basilic fistula as a hemodialysis access. Method: Retrospective analysis of 52 ulnar basilic fistula done in 51 patients over 20 years (2007-2017) with a follow up of one year was done. Results: Fifty two ulnar basilic fistulae were established in 51 patients. Three patients developed early thrombosis and in one of them another ulnar fistula could be established in the same limb. Three others thrombosed within the next 4 months. Six fistulas failed to mature and could not be used for dialysis. Fortyone out of 52 remained patent at the end of one year (78.8 %).There was no distal ischaemia in any of them. Majority of the failures occurred in women. Conclusion: Ulnar basilic fistula is an useful alternative when radiocephalic fistula is not possible or has already failed. It has high long term patency, has minimal complications and has the advantage of retaining the proximal sites for fistula in case of failure.
Keywords: Arteriovenous fistula, hemodialysis, ulnar-basilic arteriovenous fistula
|How to cite this article:|
Natarajan S. Ulnar basilic arterio venous fistula: An useful alternative access for hemodialysis. Indian J Vasc Endovasc Surg 2019;6:79-81
| Introduction|| |
Radiocephalic arteriovenous (AV) fistula for hemodialysis was first described by Brescia– Cimino  in 1966, and it remains to be the best available form of vascular access till today. In those patients, where the radiocephalic fistula is either not possible or has failed, ulnar-basilic fistula can be used as an alternative. Although this fistula was reported as early as 1967 by Hanson et al., it has not become popular, and the literature has very few reports.,,,,, Experience with 52 ulnar-basilic fistulas is described here.
| Materials and Methods|| |
A retrospective analysis of 52 AV created between the ulnar artery and basilic vein at the distal forearm in the past 20 years with a clinical follow -up of 1 year was done. The age group varied between 20 and 65 years. There were 38 males and the rest were female. The ulnar fistula was considered only when radial or brachial artery fistula had failed or was not possible. In 36 patients, the radial artery was patent and in the rest, it was occluded.
The procedure was done under local anesthesia, and a transverse incision was made in the distal forearm to expose both the ulnar artery and basilic vein. The ulnar artery is at a deeper plane and is partially overlapped by the flexor carpi ulnaris tendon. The basilic vein is also away from the artery and has to go over the tendon to reach the ulnar artery. Hence, both the artery and the vein should be dissected more extensively to avoid kinking and thrombosis. Moreover, the basilic vein is thin walled as compared to the cephalic vein and is more prone to spasm. Gentle dilatation of the vein and magnification are helpful during anastomosis. End-to-side anastomosis was done in all the patients using 7–0 polypropylene sutures [Figure 1].
|Figure 1: Completed ulnar-basilic end-to-side anastomosis. The vein overrides the flexor carpi ulnaris tendon (arrow)|
Click here to view
| Results|| |
In three patients the fistula thrombosed in the early postoperative period. In one of them, another ulnar fistula could be successfully created just proximal to the previous one and that remained patent. There were two late thromboses which occurred within 4 months. In six patients, although the fistula was patent, the basilic vein was too thin and it could not be used for dialysis because the flow was inadequate. Five of these patients were women. In all other patients, the vein arterialized and could be used for dialysis by 8 weeks [Figure 2]. Forty-one out of 52 fistulae were patent at the end of 1 year (78.8%). No patient suffered from ischemia of the hand.
| Discussion|| |
Establishment of an AV that remains patent for long -term hemodialysis is the first prerequisite for successful rehabilitation of a chronic renal failure patient. Despite many innovations and surgical techniques, radiocephalic fistula first described by Brescia–Cimino in 1966 remains to be the most commonly performed vascular access. However, there are many patients in whom a radiocephalic fistula is not possible because of the nonavailability of cephalic vein or radial artery. In these patients, either a brachiocephalic fistula or a prosthetic graft has been used as the other alternative. Brachiocephalic fistula is inferior to a distal fistula and has a higher percentage of complications. Prosthetic grafts also suffer from the same disadvantages. In most series, patency of polytetrafluoroethylene loop fistulae has been reported to be about 50%–60%. The grafts are expensive and infection is a major complication. A recent prospective study pointed out that 28% of the elbow accesses developed symptoms of distal ischemia due to steal, whereas 11% needed intervention for severe symptoms within 1 year after access placement. Ulnar artery is usually the dominant artery and has greater flow than the radial artery. Moreover, the basilic vein is usually never used for routine intravenous infusion and is free from phlebitis and hence, available for fistula in almost all patients. Since the flexor carpi ulnaris tendon partially overlaps the ulnar artery, care must be taken to mobilise both the artery and the vein more extensively so that the basilic vein overrides the tendon to reach the artery for a tension-free anastomosis. Division of the tendon to avoid compression has also been reported, but was never done in our patients. Basilic vein is very thin walled as compared to the cephalic vein and may take a longer time to arterialize, but once that occurs, the flow rate in an ulnar basilic fistula is equal to or sometimes more than the radio cephalic fistula. Failure to mature was seen in six patients in which five of them were women. Hence, a good preoperative assessment with Doppler to make sure that the basilic vein diameter is at least 2 mm and it distends well with proximal compression should be done. There is a theoretical possibility of ischemia of the hand due to steal phenomenon more so when the radial artery is blocked. However, this complication was never noticed in any of the patients including those six with radial artery occlusions. Review of the literature also shows a very low incidence of hand ischemia and infection.
Zhen et al. have shown comparable primary patency rate between radiocephalic and ulnar-basilica fistulas. However, most reports mention primary patency of about 50%–60% which is lower than what is seen with radiocephalic fistula. However, the secondary patency has been similar to that of radiocephalic fistula. Natário  recently reported that excellent secondary patency rates (97% at 1 year) after balloon dilation of nonmaturing ulnar-basilic AV fistulas despite poor primary patency rates (37% at 1 year). The only problem is the cannulation of the forearm basilic vein which requires placing the limb in the flexed-elbow position, which is uncomfortable for many dialysis technicians and patients. However, the elbow can return to its natural resting position for the duration of dialysis treatment once access has been gained and needles secured to the skin.
Thus, ulnar-basilic fistula is a useful alternative to radio-cephalic fistula. It has all the advantages of a distal fistula, has good long-term patency and minimal complications as compared to a proximal fistula. Ulnar-basilica AV fistula should be created before trying elbow fistulas or AV graft.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;275:1089-92.
Hanson JS, Carmody M, Keogh B, O'Dwyer WF. Access to circulation by permanent arteriovenous fistula in regular dialysis treatment. Br Med J 1967;4:586-9.
Kinnaert P, Vereerstraeten P, Geens M, Toussaint C. Ulnar arteriovenous fistula for maintenance haemodialysis. Br J Surg 1971;58:641-3.
Bourquelot P, Van-Laere O, Baaklini G, Turmel-Rodrigues L, Franco G, Gaudric J, et al.
Placement of wrist ulnar-basilic autogenous arteriovenous access for hemodialysis in adults and children using microsurgery. J Vasc Surg 2011;53:1298-302.
Zhen Y, Liu P, Ye Z, Zheng X, Ma B, Fan G, et al.
Long-term results of ulnar-basilic fistula versus radiocephalic fistula for maintenance hemodialysis access. Vasc Endovascular Surg 2017;51:466-9.
Al Shakarchi J, Khawaja A, Cassidy D, Houston JG, Inston N. Efficacy of the ulnar-basilic arteriovenous fistula for hemodialysis: A systematic review. Ann Vasc Surg 2016;32:1-4.
Shintaku S, Kawanishi H, Moriishi M, Bansyodani M, Tsuchiya S. Distal ulnar-basilic fistula as the first hemodialysis access. J Vasc Access 2014;15:83-7.
Keuter XH, Kessels AG, de Haan MH, van der Sande FM, Tordoir JH. Prospective evaluation of ischemia in brachial-basilic and forearm prosthetic arteriovenous fistulas for hemodialysis. Eur J Vasc Endovasc Surg 2008;35:619-24.
Natário A, Turmel-Rodrigues L, Fodil-Cherif M, Brillet G, Girault-Lataste A, Dumont G, et al.
Endovascular treatment of immature, dysfunctional and thrombosed forearm autogenous ulnar-basilic and radial-basilic fistulas for haemodialysis. Nephrol Dial Transplant 2010;25:532-8.
[Figure 1], [Figure 2]