|Year : 2020 | Volume
| Issue : 4 | Page : 411-414
Single-Staged arm basilic vein transposition for arteriovenous fistula surgery - clinical pearls and outcomes
Consultant Vascular and Endovascular Surgeon, Puducherry. Department of Surgery, Indira Gandhi Government Medical College and Research Institute, Puducherry, India
|Date of Submission||01-Aug-2020|
|Date of Decision||07-Aug-2020|
|Date of Acceptance||02-Nov-2020|
|Date of Web Publication||24-Dec-2020|
Consultant Vascular and Endovascular Surgeon, Puducherry. Department of Surgery, Indira Gandhi Government Medical College and Research Institute, Puducherry
Source of Support: None, Conflict of Interest: None
Background: Arm basilic vein transposition (aBVT) is a well-established arteriovenous (AV) access modality for the end-stage renal disease (ESRD) to ensure hemodialysis. Purpose: The purpose was to discuss the clinical pearls and evaluate the outcomes of single-stage aBVT procedure. Methods: This was a retrospective case series Results: Twenty-four patients with ESRD underwent single-stage aBVT as an AV access procedure. A majority (58.33%) of patients aged between 45 and 65 years. Diabetic nephropathy was the most common cause of renal failure. The patency achieved was 83.33% at the end of a 12-month follow-up period. Conclusion: The single-stage procedure is a safe, efficient, and cost-effective option for these patients, especially in the developing regions of the world. Here, we elaborate on the simple tips and pointers to ensure an effective single-stage procedure to minimize complications of kinks, thrombosis, or early failure and achieve faster time to cannulation and a longer cannulation length.
Keywords: Arteriovenous fistula, basilic vein transposition, single-stage procedure
|How to cite this article:|
Baliga K. Single-Staged arm basilic vein transposition for arteriovenous fistula surgery - clinical pearls and outcomes. Indian J Vasc Endovasc Surg 2020;7:411-4
|How to cite this URL:|
Baliga K. Single-Staged arm basilic vein transposition for arteriovenous fistula surgery - clinical pearls and outcomes. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jan 20];7:411-4. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/411/304623
| Introduction|| |
Access creation for the purpose of hemodialysis in end-stage renal disease (ESRD) patients is part of a regular workday in any vascular surgical unit. A landmark initiative to improve the vascular access care happened in 2003; the ESRD networks formed and implemented a National Vascular Access Improvement Initiative called the Fistula First Initiative. A native arteriovenous fistula (AVF) is preferred over synthetic AV graft or central venous catheter because of low rates of thrombosis and infection. The common upper limb sites such as radiocephalic and brachiocephalic AVF may not be available due to poor-quality unsuitable veins, calcified and diseased radial artery, thrombophlebitis, or previously attempted and failed sites. In such scenarios, the basilic vein can be used to create a brachicobasilic AVF (BBAVF). This vein is often called the “virgin” vein because unlike its cephalic vein and medial cubital vein counterparts, it is hardly ever used by nursing staff as regular intravenous access. Hence, the risk of thrombophlebitis or trauma to the basilic vein is rare. Its medial location in the upper limb anatomy enables it to be well preserved even in chronically hospitalized patients. However, the problem with this vein as an option for AVF creation is two-fold.
When created as a regular AVF at the elbow level, the fistula matures on the medial aspect and the access lies over the brachial artery course all through. Needless to say, the dialysis technicians can accidentally cause arterial cannulations leading to bleeding/pseudoaneurysms, morbidities that can be devastating for an ESRD patient. Second, the position of medial arm-based cannulations is uncomfortable for the patients during long dialysis hours. This has led to the practice of routing the basilic vein anteriorly and transposing it in the arm, to enable easier and safer cannulation helping patients and technicians alike.
| Methods|| |
In this retrospective review of medical records from January 2017 to May 2019, 24 patients underwent single-staged arm basilic vein transposition (aBVT) procedure by the same surgeon. Inclusion criteria - All patients who underwent single-staged basilic vein transposition during the study period were included in the study. Exclusion criteria - Patients who did not return to follow-up after the procedure were excluded from the study.
All patients were screened by physical examination and duplex ultrasound imaging before AVF creation. The BVT as an AV access procedure was performed in patients with failed radiocephalic and/or brachiocephalic AVFs or poor distal vein status. The surgical outcomes were evaluated at the end of 3 months, 6 months, and 1 year in terms of patency, maturation failure, and complications noted according to the guidelines by society for vascular surgery.
Primary patency was defined as the interval from the time of access creation until the first access thrombosis or any intervention to maintain or to restore blood flow. Secondary patency included any surgical or interventional radiology procedures to maintain or to restore patency. Primary failure was defined as the immediate failure of BVT within 72 h of surgery. Maturation failure was defined as occlusion of AV access or unsuitable for hemodialysis, 8 weeks after its creation.
Single-stage arm basilic vein transposition
The aBVT AVF is a well-established technique practiced widely which remains a well-documented and feasible option in creating vascular access., The often debated topic here is single-stage versus two-stage basilic vein AVF creation. In the traditional BBAVF, an end-to-side anastomosis is made between the basilic vein and brachial artery which requires the basilic vein to be dissected out and tunneled through subcutaneous tissue for superficialization, a procedure that is technically challenging and often causes arm swelling. Patients with multiple access surgery and a smaller basilic vein diameter are more likely to need a two-stage BBAVF procedure. In the two-stage approach, a first procedure is used to create the AV anastomosis through a cubital fossa incision. This is followed subsequently by another procedure later to superficialize and transpose the arterialized vein. A new AV anastomosis may or may not be required. In addition, the handling of the larger developed vein is easier and kinks are rarer in the tunneling process in the two-stage approach. Obviously, the need for a second operation and the long waiting time for fistula cannulation continue to be the drawbacks of the two-stage procedure. Few studies suggest a higher maturation rate and a better primary and secondary functional patency as well as cost-effectiveness associated with the two-stage approach. However, others have found no significant differences in patency rates between the two surgical procedures.,,
- The single stage is easier for the patient as it is a one-time surgery, and fewer visits to the hospital and decreased overall cost
- The single stage is easier on the surgeon too as the second stage procedure done on a matured fistula can be troublesome with every tributary of the vein arterialized and dissection and tunneling can be time-consuming
- Some technicians can give a “try” to cannulate the working AVF in the time duration between the first stage and second stage leading to an inadvertent brachial artery injury
- Many times, if the first stage AVF surgery is done just or above the elbow level, then the second stage anterior routing of the AVF can decrease the segment of AVF available for cannulation.
In view of all the above, the single-stage procedure is the preferred approach. It is safe, easier to perform, less time-consuming, and at a lower cost. Most of the issues can be addressed with careful steps and techniques practiced.
- Basilic vein harvest must be started at least 4–5 cm distal to the cubital fossa – the extra length of basilic vein obtained by this manoeuvre helps to get a longer cannulation length and a tension free anastomosis as well [Figure 1]
- Injury to the medial cutaneous nerve of the forearm can be easily prevented by pulling the vein from under the nerve bridge after it is disconnected distally [Figure 2]a
- Ligating the deep perforator in the axilla helps to maximize length and in-line flow
- Gentle dilatation of the vein will increase its diameter, before tunneling. The presurgery scan may show a size of <3 mm size for the vein, but with gentle normal saline injection, the vein can be dilated to a near 4 mm or more diameter on the table itself [Figure 2]b
- A 7-F infant feeding tube can be inserted into the basilic vein up to the axillary vein and fixed at the distal end of the vein. This can help infusion of heparinized saline for stepwise dilatation as well as act as a “stent” in place to prevent twisting during the tunneling/transposition process. The cannula running all through the vein will prevent any major 180° twisting and also the constant dripping of blood “back bleed” from the cannula's distal end (during and after tunneling) helps to ensure that no major kinks in the vein route [Figure 2]c
- This method does not require marking the vein with a pen on the anterior wall when inflated with saline which is usually done to prevent kinking in the tunnel
- The “stent” cannula inserted and fixed earlier, is removed from the vein only at the time of performing the AVF anastomosis. The above tips and techniques can help create a safe and proper functioning single-stage brachiobasilic transposed AVF and give ESRD patients durable access for dialysis.
|Figure 1: (a and b) Schematic diagram showing an increase in the length of the transposed basilic vein (dotted lines) following a harvest 4–5 cm distal to the cubital fossa|
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|Figure 2: Intraoperative photograph showing (a) Basilic vein harvest beginning 4-5 cm distal to the cubital fossa and the medial cutaneous nerve of forearm (yellow arrow) bridge over the basilic vein. (b) The vein dissected off its anatomical bed and places over the skin of the arm in its proposed track and curvature with indwelling cannula. (c) Post-tunnelling prominent transposed basilic vein (white arrows) with a 7F infant feeding tube in situ (blue arrow). (d) Wound closure|
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| Results|| |
Twenty-four patients underwent aBVT procedure [Table 1]. There were 18 (75%) males and 6 (25%) females. About 95% of the cases underwent the aBVT surgery due to failed previous radiocephalic or brachiocephalic AV access procedure. Diabetic nephropathy was the most common cause of ESRD. The comorbidities were hypertension in 17 cases (70.8%), ischemic heart disease in 6 cases (25%), and cerebrovascular disease in one patient (4.1%). The aBVT patency was 100% at 3 months, 95.8% at 6 months, and 83.33% at the end of 12 months follow-up [Table 2]. None of the patients developed any primary or maturation failure, postoperative infection, or steal syndrome. Four BVT cases had a secondary patency of 7 months, 9 months, and two at 11 months, respectively.
| Discussion|| |
aBVT can be performed effectively as a single-staged procedure. This approach eliminates the need for a second operation to achieve the fistula, with decreased time to cannulation, decreased morbidity and cost. Ghaffarian et al. compared the effectiveness between single- and two-staged BVT procedures and found that the only difference between the groups was a trend toward reduced thrombosis rates among patients with a two-stage operation, possibly the result of handling an arterialized vein as opposed to a thin-walled, friable, nonmatured basilic vein. However, in this retrospective study, many of the patients (95.83%) have had a previously running distal AVF that had indirectly helped in partial maturation of basilic vein to a diameter of >2.5–4 mm in the arm over the months or years. Minimal mobilization and delicate handling of a thin-walled basilic vein can minimize its predisposition to ischemia, injury, or kinking, improving its maturation and patency rates. The previous meta-analysis has shown that there was no difference in the patency and failure rates between the groups. Patients with smaller basilic veins (<2.5 mm) demonstrated on ultrasound Doppler may benefit from a two-staged approach before considering a graft or stent procedure for creating an AV access. Furthermore, a large, potentially morbid, upper arm incision can be avoided in patients who may not mature a brachial-basilic fistula during the first stage of a two-stage operation. The limitations of this study include a small sample size, variable selection criteria, retrospective observational design, and no control arm for confounding. A well-designed prospective randomized control trial will be required to confirm these findings and settle the question as to which staged procedure is better.
| Conclusion|| |
Single-stage aBVT can be performed safely with acceptable long-term patency and few complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]