Comparison of Outcomes of One-Stage Basilic Vein Transpositions and Two-Stage Basilic Vein Transpositions

Risk factors for thrombosis in dialysis patients: A comprehensive systematic review and meta-analysis

AIM

To identify the factors associated with thrombosis in dialysis patients.

BACKGROUND

Thrombosis is a leading cause of vascular access failure in dialysis patients. Numerous risk factors contribute to thrombosis in this population.

METHODS

A systematic search was conducted across international databases using standardized keywords. The quality of the selected studies was assessed using the STROBE and CONSORT checklists. The findings were summarized in a Garrard table. Meta-analysis was performed using CMA software. The study adhered to the guidelines outlined in the PRISMA statement.

RESULTS

A total of 180 articles were reviewed. The odds ratio for thrombosis in patients with arteriovenous grafts compared to arteriovenous fistulas was 10.93 (95 % CI: 9.35-12.78), demonstrating statistical significance (P = 0.001). Similarly, hemodialysis patients had an odds ratio of thrombosis 3.60 times higher than non-hemodialysis patients (95 % CI: 3.54-4.19), with statistical significance (P = 0.001). Patients undergoing single-stage basilic vein transposition had a 1.89 times higher risk of thrombosis compared to those undergoing two-stage transposition (95 % CI: 1.04-3.46), also demonstrating statistical significance (P = 0.038).

CONCLUSIONS

Thrombosis in patients with end-stage renal disease undergoing dialysis was significantly associated with various factors, including graft access, single-stage basilic vein transposition, and hemodialysis. Additional contributing factors to thrombosis included diabetes, elevated homocysteine levels, female gender, age over 50, access location, and low access blood flow velocity. The analysis revealed a higher incidence of thrombosis in end-stage renal disease patients undergoing hemodialysis compared to those not undergoing dialysis, as well as in patients with arteriovenous grafts compared to those with arteriovenous fistulas. These findings underscore the importance of recognizing and managing these risk factors to prevent thrombotic events and enhance patient care within the dialysis setting.

Cost-effectiveness analysis of endovascular vs surgical arteriovenous fistula creation in the United States

OBJECTIVE

In the United States, an estimated $2.8 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation is a novel, minimally invasive alternative to traditional surgical AV fistula (sAVF) creation in ≤60% of patients. Although cost effective in single-payer systems, the clinical and financial impact of endoAVF in the United States remains uncertain.

METHODS

We constructed a decision tree followed by a probabilistic cohort state-transition model to study the cost effectiveness of endoAVF vs sAVF creation. We conducted a systematic review to obtain input parameters including technical success, maturation, patency, and utility values. We derived costs from the Medicare 2022 fee schedule and from the literature. We used a 5-year time horizon, an annual discount rate of 3% for costs and utilities (measured in quality-adjusted life-years [QALYs]), and the common willingness-to-pay threshold of $50,000. One-way and Monte Carlo probabilistic sensitivity analyses were performed varying technical success, patency, reintervention, cost, and utility parameters.

RESULTS

In the base-case scenario, endoAVF ($30,129 average per-person costs, 2.19 QALYs gained, 65% patent at 5 years) was not cost effective compared with sAVF ($12.987 average per-person costs, 2.11 QALYs gained, 66% patent at 5 years), generating an incremental cost-effectiveness ratio of $227,504 per QALY gained. In one-way sensitivity analyses, endoAVF becomes cost effective when the initial cost of sAVF creation exceeds endoAVF by ≥$600 (eg, if endoAVF creation costs ≤$3000 relative to the base-case sAVF cost of $3600), the additional QALYs gained from endoAVF exceeds 0.12 QALYs/year (eg, 0.81 QALYs gained/year from endoAVF compared with base-case sAVF 0.69 QALYs/year), the endoAVF maturation rate is >90% (base case 78%), or the sAVF maturation rate is <65% (base case 78%). Probabilistic sensitivity analysis demonstrated that sAVF remained the optimal strategy in 71% of iterations.

CONCLUSIONS

EndoAVF is not cost effective compared with sAVF when modeling 5-year outcomes. The main driver of sAVF remaining cost effective is the four times higher up-front cost for endoAVF creation, as well as a relatively low additional increase in quality of life for endoAVF. It will be important to establish how the endoAVF learning curve contributes to upfront costs and, given the annual cost attributed to vascular access nationally, a randomized controlled trial is warranted.

Comparison of wound complications between one-stage and two-stage brachiobasilic arteriovenous fistula: A meta-analysis

Research assessing the outcome of brachiobasilic arteriovenous fistulas (BB-AVF) after a one- and two-stage technique was conducted. A strict review of the comprehensive literature up to May 2023 was carried out using four databases-PubMed，Embase, Cochrane Library and web of science. Inclusion and exclusion criteria developed for the study were then applied to assess the quality of the literature, it was decided to review 12 interrelated studies.95% confidence intervals (Cl) and odds ratios (OR) were calculated using fixed effects models. The data were meta-analysed using RevMan 5.3 software. The results showed that two-stage technique with BB-AVF reduced surgical site haematoma (SSH) formation, (OR, 2.28; 95% CI, 1.24-4.17, p = 0.008), and also reduced surgical site wound infection (SSWI) (OR, 1.86; 95% CI, 1.17-2.94, p = 0.008). There are, however, several small sample sizes in the selected studies for this meta-analysis, so caution should be used when processing their values. There are more high-quality studies with large sample sizes that should be considered for future meta-analyses.

Two-Stage Offers No Advantages over Single-Stage Arteriovenous Creation: An Analysis of Multicenter National Data

BACKGROUND

Traditionally, arteriovenous fistulas (AVF) involving the basilic vein (BV) have been created in 1 or 2 stages to allow time for the vein to enlarge before superficialization for potential better fistula maturation. Previous single institution studies and meta-analyses have found conflicting outcomes between single-stage and 2-stage procedures. Our study aims to use a large national database to assess the difference in outcomes between single-stage and 2-stage procedures for dialysis access.

METHODS

We studied all patients undergoing BV AVF creation in the Vascular Quality Initiative (VQI) from 2011 to 2021. Patients were split into single-stage or a planned 2-stage procedure for dialysis access. Primary outcomes included dialysis use with index fistula, maturity rate, and number of days from surgery to fistula use. Secondary outcomes included patency (defined by physical exam or imaging on follow-up), 30-day mortality, and postoperative complications (bleeding, steal syndrome, thrombosis, or neuropathy). Logistic regression models were used to assess the association between staged dialysis access procedures and primary outcomes of interest.

RESULTS

The cohort consisted of 22,910 individuals of which 7,077 (30.9%) had a 2-staged dialysis access procedure and 15,833 (69.1%) had a single-staged procedure. Average follow-up was 345 days in the single stage and 420 days for 2-stage. Baseline characteristics were significantly different between the 2 groups in terms of medical comorbidities. Primary outcomes were significant for more patients in the 2-stage group undergoing dialysis with the index fistula compared to single stage (31.5% vs. 22.2%, P < 0.0001), significant decrease in days to use in current dialysis patients (103.9 days single stage versus 141.0 days 2-stage, P < 0.0001), and no difference in maturity at follow-up (19.3% single-stage and 17.4% 2-stage, P = 0.354). Secondary outcomes revealed no difference in 30-day mortality or patency (89.8% single-stage and 89.1% 2-stage, P = 0.383), but a significant difference in postoperative complications with a 2-stage procedure compared to 1-stage (1.6% vs. 1.1%, P = 0.026). Finally, a spline model was used to determine that a preoperative vein of 3 mm or less could be a cutoff in which a 2-stage procedure might be beneficial.

CONCLUSIONS

This study demonstrates that when dialysis access fistulas are created using the BV, there is no difference in maturity rate or 1-year patency when assessing single-stage versus 2-stage procedures. However, 2-stage procedures significantly delay the time of first use of the fistula and increase postoperative complications. Therefore, we suggest performing single stage procedures when the vein is of appropriate diameter to minimize multiple procedures, complications and expedite time to maturity.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

One- versus two-stage transposed brachiobasilic arteriovenous fistulae: A review of the current state of the art

In the absence of suitable cephalic vein, the brachiobasilic vein complex represents the best option for arteriovenous access. However, the basilic vein is too deep to cannulate and requires transposition to be accessible. Transposition can be performed during fistula creation (single-stage BBTx) or at a second operation after initial fistula creation (two-stage brachiobasilic transposition (BBTx)). The best approach is unknown. A PubMed search using “Basilic vein transposition” as the primary search term was performed to identify articles addressing this controversy. Meta-analysis was then performed using those papers that provided the inspected data points with student’s t-test used to compare maturation and patency rates between the groups. A total of 37 manuscripts were judged of adequate quality for analysis. Based on the available data, overall maturation rates, 1-year primary patency rates, and overall complication rates seem to be equivalent between single- and two-stage BBTx, while 1-year secondary patency is greater in the two-stage group (79% vs 85%). A large prospective randomized clinical trial with clear definitions of maturity, patency, and complications is needed to definitively answer the question of whether one strategy is better than the other.

Review of Patency Rates between One-Stage and Two-Stage Brachial-Basilic Transposition Arteriovenous Fistulae Creation in an Asian Population

Objective: To compare patency rates between one- and two-stage (first-stage arteriovenous anastomosis followed by second-stage superficialization) creation of brachial-basilic transposition arteriovenous fistula (BBT-AVF) in an Asian population.

Methods: A retrospective review of BBT-AVFs was conducted between July 2008 and March 2015. Kaplan–Meier survival analysis and log-rank test were used to evaluate patency.

Results: In total, 103 BBT-AVFs were created in 86 patients (mean age, 61 years; men, 57%). The overall primary, assisted primary, and secondary patency rates at 12, 24, 36, and 48 months were 70%, 48%, 38%, and 35%; 86%, 70%, 62%, and 59%; and 90%, 77%, 70%, and 63%, respectively. There was no significant difference in demographics and preoperative vessel caliber between the groups. The primary failure rate was 24% in the one-stage group, compared with 21% in the two-stage group (p=0.803). There were no statistically significant differences in primary, assisted primary, and secondary patency rates between the groups.

Conclusion: There was no significant difference in primary failure and patency rates between the two groups. Both one-stage and two-stage procedures conferred good outcomes with overall 12-month primary patency, secondary patency, and primary failure rates of 70%, 90%, and 23%, respectively.

Transposed Brachial-Basilic Arteriovenous Fistula for Vascular Access in Japan

As more than 320,000 patients are currently receiving hemodialysis treatment in Japan, the creation and maintenance of hemodialysis access is a major concern. The national guidelines recommend autogenous arteriovenous hemodialysis, and the brachial-basilic arteriovenous fistula has been the focus of attention, because the need for secondary, tertiary, or even more vascular access is growing. Although favorable results have been reported in terms of patency and access-related complication, this fistula involves various unsolved or controversial issues, with limitations including complex procedures, which might contribute to the lower prevalence at this point in Japan. This review addresses those issues and discusses the role of fistula in Japan.

Multiple Skip Incisions Versus Single Long Incision for Single-stage Basilic Transposition Arteriovenous Fistula: A Cohort Study

BACKGROUND

Basilic vein transposition via single long incision is a renowned technique despite its known wound-related complications. Contrary to that, multiple skip incisions technique is thought to have relatively lower wound-related complications. But to the best of our knowledge, these 2 techniques have never been formally compared. Therefore, we conducted this study to compare both.

MATERIAL AND METHODS

This was a retrospective cohort study. Patients who underwent basilic vein transposition arteriovenous fistula (AVF) from January 2011 till May 2016 at Aga Khan University Hospital, Pakistan were eligible for inclusion in the study. Study population was divided into 2 groups; one group comprising of patients who underwent fistula formation through single long incision and the other group had the procedure carried out via multiple skip incisions. Wound-related complications including wound infection and dehiscence, fistula maturation time, duration of surgery, and primary patency at a follow-up of 12 months were recorded.

RESULTS

Both the groups were comparable regarding baseline variables. Incidence proportion of wound infection, hematoma, and dehiscence was higher in long incision group; however, it was statistically insignificant. Primary patency at 12 months in skip versus long incision group was 73.0% vs. 69.7% (P-value: 0.62). The mean maturation time for fistula was 42.8 ± 9.5 days and 44.3 ± 10.4 days in skip and long incision group, respectively (P-value:0.31). Duration of surgery was comparable in both.

CONCLUSIONS

Although skip technique does not have significant benefit over long incision technique based on these results, but it is a valid alternative. Randomized control trial is required to better differentiate between these two.

Outcomes of relocation of basilic vein in brachiobasilic fistulas in chronic renal failure

BACKGROUND

In patients without or with injured cephalic vein, using the basilic vein for creating arteriovenous fistula (AVF) is the best way for hemodialysis. In order to create AVF, the basilic vein should be superficialized and lateralized. This study sought to examine outcome of relocation of basilic vein in brachiobasilic fistulas in patients with chronic renal failure (CRF).

METHODS

We evaluated the outcome of creation of brachiobasilic fistula with transposition of basilic vein in 27 patients (14 males and 13 females with mean age of 60.03 ± 8.04 years) with CRF. The success rate and complications were recorded during the follow-up period. The fistula was regarded efficient if cannulation was feasible conveniently and a minimum flow rate of 250 ml/min for 4 h at least for 3 consecutive hemodialysis sessions through both lines was documented 30 days postoperatively.

RESULTS

The mean time gap between previous AVF creation or try and the relocation of basilic vein was 3.55 months. Thirty days postoperatively, 85.2% of the created AVFs were efficiently working. There were postoperative complications in 40.7% of patients including venous hypertension (14.8%), bleeding (7.4%), hematoma (7.4%) and distal paresthesia (11.1%).

CONCLUSIONS

Brachiobasilic AVF fistula provides a suitable option for vascular access in cases with failed previous AVF. Relocation of basilic vein for brachiobasilic AVF is technically feasible, safe and with excellent patency in short-term and complication rates are acceptable.

Brachiocephalic and Basilic Fistula

Introduction

Brescia-Cimino radiocephalic arteriovenous fistula (AVF) remains the first choice vascular access procedure for patients in need of long-term hemodialysis. Brachiocephalic fistulas are considered as a secondary option in almost all published guidelines. Recently in many reports, elbow and upper arm fistulas are recommended to be used as primary fistulas especially in elderly, diabetic, hypertensive patients. Elbow fistulas (brachiocephalic and brachiobasilic) should only rarely be constructed as primary fistulas. Forearm AVFs should be tried first to give a chance to the patient, because it is not the maturation-patency rates per se but also lowering the complication rates and saving the vessels for future use are equally important.

Background

The average life expectancy of patients receiving hemodialysis has increased in recent years and many patients now live longer and require secondary or tertiary procedures.

Conclusions

When forearm fistulas have failed, brachiocephalic AVF is usually preferred first, because of cephalic vein's appropriate anatomy for easy cannulation and ease of the operation. Operative procedure is less invasive compared to brachiobasilic AVF, therefore BC should be the procedure of choice when both veins are available.

Review of Transposed Basilic Vein Access for Hemodialysis

Background

There is ongoing debate about the use of transposed basilic vein (TBV) fistula and the choice between it and prosthetic arteriovenous graft (AVG). This paper reviews the available literature relating to TBV fistula in terms of surgical technique, patency rates, complications, access survival and compares it with prosthetic AVG for hemodialysis (HD).

Methods

Review of English language publications on TBV during the last two decades.

Findings

The rate of fistula maturation was higher in the two-stage group, although the mean diameter of the basilic vein was smaller. Dialysis via central venous catheters at time of surgery was most prevalent in patients undergoing staged procedures—14% in one-stage TBV and 43% in two-stage TBV. Several authors report 1-year cumulative patency rate of 47% to 96% and 59% to 90% for TBV and AVG, respectively. TBV provides a more cost-effective option and should be considered the next choice when primary autogenous fistulae are not possible, whereas AVGs are easier to create, can be punctured earlier and have a greater reintervention rate if the access fails.

Conclusions

This analysis shows that TBV has several advantages over AVG and provides a valuable access for HD but raises the need for a comparative trial between TBV and the newer generation AVGs. There is no clear superiority of the one-stage over the two-stage procedure.

One-stage vs. two-stage brachio-basilic arteriovenous fistula for dialysis access: a systematic review and a meta-analysis

INTRODUCTION

A brachiobasilic arteriovenous fistula (BB-AVF) can provide access for haemodialysis in patients who are not eligible for a more superficial fistula. However, it is unclear whether one- or two-stage BB-AVF is the best option for patients.

AIM

To systematically assess the difference between both procedures in terms of access maturation, patency and postoperative complications.

METHODS

Online search for randomised controlled trials (RCTs) and observational studies that compared the one-stage versus the two-stage technique for creating a BB-AVF.

RESULTS

Eight studies were included (849 patients with 859 fistulas), 366 created using a one-stage technique, while 493 in a two-stage approach. There was no statistically significant difference between the two groups in the rate of successful maturation (Pooled risk ratio = 0.95 [0.82, 1.11], P = 0.53). Similarly, the incidence of postoperative haematoma (Pooled risk ratio = 0.73 [0.34, 1.58], P = 0.43), wound infection (Pooled risk ratio = 0.77 [0.35, 1.68], P = 0.51) and steal syndrome (Pooled risk ratio = 0.65 [0.27, 1.53], P = 0.32) were statistically comparable.

CONCLUSION

Although more studies seem to favour the two-stage BVT approach, evidence in the literature is not sufficient to draw a final conclusion as the difference between the one-stage and the two-stage approaches for creation of a BB-AVF is not statistically significant in terms of the overall maturation rate and postoperative complications. Patency rates (primary, assisted primary and secondary) were comparable in the majority of studies. Large randomised properly conducted trials with superior methodology and adequate sub-group analysis are needed before making a final recommendation.

Basilic vein transposition: review of different techniques

This is a review of the basilic vein procedure and changes that have evolved to improve outcomes. This includes reviewing data on the one-stage vs. two-stage technique as well as elevation for the basilic vein. The review discusses data that help the surgeon decide which technique he should evaluate.

Elbow Arteriovenous Fistulae

Multiple superficial veins in different anatomical configurations exist in the elbow. The resulting variety of elbow arteriovenous fistulae (AVFs) is described in this paper. A classification of elbow AVF in nontransposed AVF, transposed AVF and multiple outflow AVF is proposed. The nontransposed brachiocephalic AVF has the lowest primary failure rate and a good medium-term survival particularly in the elderly. The simplest technique is an end-to-side anastomosis of the median cubital vein to the brachial artery. In cases of small upper arm veins, a perforating vein AVF, using multiple outflow tracts, may be helpful to lower primary failure risk. In the era of vein mapping with portable ultrasound elbow AVF should be made when forearm veins are exhausted or too small. A side-to-side AVF in order to enhance retrograde flow in the median forearm vein seems rarely indicated, in particular considering the greater risk of steal and venous hypertension. A transposed brachiobasilic AVF is a tertiary access procedure after the simpler alternatives have been exhausted. There is conflicting evidence of the benefits of one-stage versus two-stage procedures. Therefore, the type of operation should be tailored to the individual patient.