Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 216-221

Brachiobasilic arteriovenous fistulas: A comparative outcome of different operative techniques


1 Department of CTVS, Jawahar Lal Nehru Medical College and Hospital, AMU, New Delhi, India
2 Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
3 Department of General Surgery, F.H Medical College, Tundla, Uttar Pradesh, India

Date of Submission02-Aug-2020
Date of Acceptance09-Oct-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Mayank Yadav
Department of CTVS, Jawahar Lal Nehru Medical College and Hospital, AMU, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_111_20

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  Abstract 


Introduction: Brachiobasilic arteriovenous fistula although little complex to create provides a suitable alternative to radiocephalic and brachiocephalic fistula, due to its autogenous nature and protective deep-seated anatomy of basilic vein. The purpose of this study was to evaluate the outcome among various techniques of brachiobasilic fistula (BBF) in terms of patency and complication rates. Methods: We retrospectively identified 50 patients in which BBFs were constructed between January 2015 and January 2018. The basilic vein was transposed in 16 patients and elevated in 34 patients: 14 as a single-stage technique and 20 with a two-stage (delayed elevation) technique. Results: The mean age of patients in this study was 50.8 years, with 72% of them having diabetes mellitus. There was no significant difference in the primary and secondary patencies among various techniques at 6, 12, 18, and 24 months. Neither there was any significant difference found in the complication rates between different techniques used to create BBF. The overall primary patency rates are 78% and 60% and secondary patency rates are 82% and 68% at 1 and 2 years, respectively. Conclusion: BBF can be considered as a true alternative before prosthetic grafts in patients with exhaustive cephalic veins.

Keywords: Brachiobasilic fistula, outcome, patency rate


How to cite this article:
Yadav M, Singh SP, Haseen MA, Yadav R, Beg MH. Brachiobasilic arteriovenous fistulas: A comparative outcome of different operative techniques. Indian J Vasc Endovasc Surg 2021;8:216-21

How to cite this URL:
Yadav M, Singh SP, Haseen MA, Yadav R, Beg MH. Brachiobasilic arteriovenous fistulas: A comparative outcome of different operative techniques. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:216-21. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/216/320608




  Introduction Top


There has been a rapid incline in the patients with chronic renal failure (CRF) in the recent time, with hemodialysis (HD) being the mainstay of this growing pool of CRF patients for improved survival and a higher life expectancy.[1]

An appropriate vascular access site is the major concern and challenge in patients requiring long-term HD. Autogenous arteriovenous fistulas (AVFs) in the form of radiocephalic and brachiocephalic AVFs are the first line and the most preferred longterm vascular access in above patients, as they are associated with significant decreased risk of systemic sepsis and cardiovascular mortality in comparison to central venous catheters (CVCs).[2],[3]

The other alternatives for unsuitable cephalic vein are brachiobasilic fistula (BBF) and prosthetic graft.[4],[5] Superior long-term patency, less fistula failure, subsequent use of prosthetic graft if fistula failure occurs, reduced risk of vascular steal, and avoidance of neointimal hyperplasia at venous anastomotic site are some of the advantages of BBF over prosthetic graft.[6],[7]

Moreover, due to the deep anatomy of basilic vein, it is prevented from repeated venipuncture and cannulation, making it a suitable and genuine conduit option.[8]

Although there are different techniques and timing of construction of BBF, Dagher et al. in 1976 first described it by transposition of the divided and well-mobilized basilic vein by rotating it anterolaterally through a subcutaneous tunnel in the arm.[9]

Another technique includes elevation of vein and making it superficial to deep fascia. The procedure can be performed in a single stage or two stages where the delayed second stage consists of superficialization of the vein.

As the creation of BBF is a little complex, requiring longer incision with significant surgical dissection, a longer operative time, and sometimes even requiring a general anesthesia, is it worth to consider it as a true alternative to radiocephalic and brachiocephalic AVFs. On this background, the aim of this study is to evaluate and compare the outcome of different types of BBF.


  Methods Top


The study consists of 50 patients and is being conducted at a single center over a span of 3 years from January 2015 to January 2018. This is an observational and retrospective study, with all the data being obtained from the hospital record section.

Patient division in groups

Patients were divided into three groups depending on the technique used for creation of BBF as transposed single-stage, single-stage elevation, and two-stage delayed elevation of basilic vein. Surgery was done by two experienced surgeons, with transposed single stage being preferred by one and the elevated single stage by the other. Two-stage delayed elevation was done when, while attempting brachiocephalic fistula, cephalic vein was found to be unsuitable for fistula formation or when the caliber of basilic vein was small. The second stage was performed after 2 weeks from the first stage.

Exclusion/inclusion criterion

Only those patients who completed their 2 years of follow-up were included in the study. Patients who expired during the 2year followup period, even with functional fistula were excluded from the study, to prevent any discrepancy in the results.

Preoperative consideration

All patients underwent duplex scanning preoperatively, and basilic vein diameter of 2 mm was taken as a minimum threshold for creation of BBF. Apart from this, all the essential clinical and demographic data of patients were recorded from patient record sheets.

Operative consideration

All the patients were operated under local or regional anesthesia. A curvilinear incision is made over antecubital fossa, brachial artery and basilic vein dissected, and basilic vein mobilized till axillary vein with preservation of median cutaneous nerve of the forearm. In transposition method, the basilic vein is tunneled subcutaneously, with a Roberts' forceps maintaining its axial orientation. In single-stage elevation technique, the entire length of the basilic vein is mobilized, a "subcutaneous flap" is created, and the vein is positioned anterolaterally into the flap. An end-to-side arteriovenous anastomosis to the brachial artery is performed [Figure 1]. In the second stage, only elevation of basilic vein superficially into the subcutaneous flap is done. The created BBF is denied for HD access for 6 weeks, allowing it to mature.
Figure 1: Operative picture of brachiobasilic fistula done with single-stage elevated vein technique and preserving the median cutaneous nerve of the forearm

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Postoperative consideration

Patients who were operated in a single stage were kept admitted for a day, and those who were admitted on a two-stage basis were discharged on the same day. All the patients were started on 75 mg aspirin daily. All the patients were followed up for 24 months.

Definition of variables

Primary patency (intervention-free access survival) was defined as the interval from time of BBF creation to any intervention required to maintain or re-establish patency.[10]

Secondary patency (access survival until abandonment) was defined as the interval from the time of BBF creation to its abandonment.

An AVF was considered functional not on the basis of its patency, but if it was able to deliver, the desired flow rate (350–400 ml/min) required to perform dialysis.[10]

Primary failure of an AVF was considered when it was never used for dialysis, which includes inadequate maturation, early thrombosis, failure of the first cannulation, and other complications, such as infection or distal ischemia, preventing its use.

Statistical analysis

The statistical analysis included descriptive techniques, Chi-square test for proportions, and Student's t for continuous variables. Kaplan–Meier survival curves were used to estimate the rates of primary, assisted primary, and secondary patency during follow-up. P ≤ 0.05 is considered statistically significant.


  Results Top


The study consists of a total of 50 patients in which BBFs were created for vascular access for HD. Out of 50 patients, 16 were operated under transposition technique, 14 patients under single-stage elevation technique, and 20 patients under two-stage delayed elevation technique.

Demographic and clinical characteristics

The mean age of patients in this study was 50.8 years. Other demographic data and clinical characteristics observed in these patients are summarized in [Table 1].
Table 1: Demographic and clinical characteristics of patients

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Vascular characteristics

Brachial artery and basilic vein diameters were recorded preoperatively, as listed in [Table 2].
Table 2: Vascular characteristics of patients

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Patency

The primary patency and secondary patency rates of all the three techniques were evaluated and are listed in [Table 3] and [Table 4], respectively. Their respective patency rates as analyzed via Kaplan–Meier curve are depicted in [Figure 1] and [Figure 2]
Table 3: Primary patency of different techniques

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Table 4: Secondary patency of different techniques

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Figure 2: Primary patency (%) of different techniques using Kaplan–Meier curve

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.

As shown in [Table 3], the primary patency rate at 6, 12, 18, and 24 months was 81%, 75%, 69%, and 63%, respectively, in the transposition group. It was 79%, 79%, 64%, and 57%, respectively, in the single-stage elevation group, and it was 85%, 80%, 70%, and 60% in the two-stage elevation group, respectively.

As shown in [Table 4], the secondary patency rate at 6, 12, 18, and 24 months was 88%, 81%, 75%, and 69%, respectively, in the transposition group. It was 86%, 79%, 71%, and 64%, respectively, in the single-stage elevation group, and it was 90%, 85%, 75%, and 70% in the two-stage elevation group, respectively.

The Kaplan–Meier analysis of primary and secondary patencies of all the three techniques is depicted in [Figure 2] and [Figure 3], respectively.
Figure 3: Secondary patency (%) of different techniques using Kaplan–Meier curve

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Cumulative patency

The cumulative primary patency in our study of all the three techniques was 78% and 60% at 1 and 2 years, respectively, whereas the cumulative secondary patency at 1 and 2 years was 82% and 68%, respectively, as shown in [Table 5].
Table 5: Cumulative primary and secondary patencies of all techniques

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Primary failure

Out of a total of 50 BBFs, 1 fistula (2%) from the single-stage elevated technique group could never be used for HD as it failed because of spontaneous thrombosis within the first 6 weeks postoperatively.

Loss of fistulas

At the end of 1 year, there was a total loss of 9 fistulas (18%). Seven fistulas (14%) had thrombosis: 2 each from the transposition and single-stage elevated groups and 3 from the two-stage elevated technique group. Two fistulas (4%), one each from transposition and single-stage elevated technique, were ligated due to the development of venous hypertension. By the end of the 2nd year, 7 more fistulas (14%) were lost due to thrombosis: 2 each from the transposition and single-stage elevated groups and 3 from the two-stage elevated technique group, making a total of 16 fistulas (32%) nonfunctional at the end of 24 months.

Complications

As shown in [Table 6], thrombosis is the most common eventual complication affecting the patency of the fistula, leading to its failure. The most common early postoperative complication following BBF is arm edema, which got resolved conservatively. Two fistulas, one each from transposition and single-stage elevated technique, developed venous hypertension for which fistula ligation was done. Other complications such as infection, lymph leak, hematoma, and steal phenomenon were also managed conservatively. Although hematoma and thrombosis were found to be more in elevated technique as compared to the transposition technique, the difference was not statistically significant.
Table 6: Postoperative complications of the fistulas

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  Discussion Top


In the recent time, the trend of patient population with ESRD has changed gradually, affecting more of younger and diabetic patients.[11],[12] The same pattern can be seen in our study, with the mean age of patient cohort being around 51 years and 72% of them having diabetes mellitus.

Being an autologous arteriovenous fistula, BBFs have better patency and less complications, which recommend their use in preference to prosthetic grafts.[6],[13],[14]

The technique for creation of BBF has evolved with time. Several studies in the past have compared the single-stage and the two-stage techniques in terms of patency and complications, however, which technique is superior remains unclear.[5],[6],[9],[15]

The results of our study suggest no significant difference in the primary and secondary patencies at 1 and 2 years between the two techniques, which are in concordance with the study done by Hossny,[16] although some other major studies by Vrakas et al. and El Mallah have clearly predicted the superiority of two-stage technique over single stage in terms of patency.[17],[18]

A comparison of our study with other major studies, regarding the patency of different techniques, is compiled in [Table 7].
Table 7: Comparison of outcome of different studies with brachiobasilic fistula creation using both single-stage and twostage techniques

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The cumulative primary patency of BBF with all the techniques in our study is comparable to the results of other major studies published in the last decade.[25],[26],[27],[28]

The secondary patency rate of prosthetic grafts in the previous studies has been reported in the ranges from 65% to 70% at 1 year and 49% to 51% at 2 years, which is significantly less than the overall cumulative secondary patency of BBF in our study, 82% and 68% at 1 and 2 years, respectively.[6],[7]

Moreover, a prosthetic conduit can be used at the same site[7] if BBF failure occurs, as done by Matsuura et al., where they inserted prosthetic graft in around 90% of their patients in which BBF eventually failed.[6]

Only one out of total of 50 patients (2%) had primary failure of fistula due to spontaneous thrombosis within 6 weeks of its creation, which is similar to other studies done by Hossny (5.7%), Silva et al. (8%), and Garg et al. (2.5%).[16],[29],[30]

The advantage of single-stage procedure is early cannulation and shorter time of CVC in situ, thereby decreasing the risk of endovascular infection. Other advantages are avoidance of damage to the medial antebrachial cutaneous nerve and the medial cutaneous nerve of the forearm.

The main disadvantage lies with the mechanical problems related to the superficialization and transposition of a nonarterialized vein like vein kinking, twisted, or compressed by any hematoma and tunnel bleeding affecting maturation and patency.[31]

Another major underreported disadvantage of single-stage procedure is due to poor placement of vein beneath the scar making the cannulation difficult, requiring multiple puncture attempts and frequent needle displacement, sometimes leading to hematoma and pseudoaneurysm formation.[31],[32],[33]

The advantage of twostage procedure is that it shorten the operative time, dissection is done around arterialized thickwalled vein is easier, allows assessment of fistula so that any correctable changes can be done in the second stage or else it can be abandoned.

The overall complication rate in patent BBF fistula in our study was 58% which is concordance with previous reported complication rate, ranging from 43% to as high as 73%.[5],[16],[34] As reported by Vrakas et al., our study too did not show any significant difference in the complication rates between single-stage and two-stage procedures.[17] Kakkos et al., however, had a difference in opinion where they found that the complication rate was significantly higher in the one-stage operation.[34] On the other hand, a study by Hossny had a completely different say in which he reported a significantly higher complication rate in the two-stage elevation group.[16]

Most of the BBFs made in our study already had a procedure before or they had exhaustive cephalic vein, making it a secondary access procedure in majority of the cases. A study by Casey et al. has shown that in cases with poor forearm vein, BBF has proved to be a good first access procedure on the upper extremity.[35]

Limitations

The present study has got a small cohort size. The nonrandomized and retrospective nature of the study itself incorporates selection bias. It is further influenced by the personal preference of the technique used by the two surgeons. Moreover, patients with smaller caliber of basilic vein were usually considered for two-stage procedure.


  Conclusion Top


BBF, although little complex to create, provides a suitable and viable secondary native AVF option before prosthetic grafts with acceptable primary and secondary patency rates in patients requiring maintenance HD with no or poor cephalic vein caliber. Our study shows no significant difference between various techniques used to create BBF in terms of patency and complication rates. They are usually associated with significant morbidity and complications, however, most of them can be managed conservatively without any surgical intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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