Brachial versus basilic vein dialysis fistulas: A comparison of maturation and patency rates

A novel approach to autogenous hemodialysis access: paired brachial vein transposition in series

Autogenous arteriovenous fistula (AVF) creation is the preferred method for long-term hemodialysis access. This report describes the novel use of paired brachial veins for the creation of an autogenous AVF in a patient without a traditional superficial venous conduit available. Application of this general concept might serve to expand the options for autogenous AVF creation.

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.

Comparison between internal jugular vein access using midline catheter and peripheral intravenous access during cardiopulmonary resuscitation in adults

Objectives

Vascular access is an important procedure for drug administration during the resuscitation of a patient with cardiac arrest; however, it can be challenging under emergent conditions. This study aimed to investigate the efficiency of ultrasound-guided internal jugular venous access using a midline catheter versus peripheral intravenous access during cardiopulmonary resuscitation.

Methods

This was a prospective single-center observational study among patients who received cardiopulmonary resuscitation. The primary outcomes were the success rate of first attempt and the time taken for vascular access via the internal jugular and peripheral veins. We also measured the diameter of the internal jugular and peripheral veins at the access point and the distance from the access point to the heart.

Results

In all, 20 patients were included in the study. Internal jugular and peripheral venous access had a first-attempt success rate of 85% and 65%, respectively (p = 0.152). The time to access the internal jugular and peripheral veins was 46.4 ± 40.5 s and 28.8 ± 14.7 s, respectively (p = 0.081). The diameter of the internal jugular and peripheral veins was 10.8 ± 2.6 mm and 2.8 ± 0.8 mm, respectively (p < 0.001). The distance from the vascular access point to the heart was 20.3 ± 4.7 cm and 48.8 ± 13.1 cm for the internal jugular and peripheral veins, respectively (p < 0.001).

Conclusions

There was a trend toward higher success rates in the internal jugular vein rather than the peripheral intravenous approach, which was not statistically significant.

Comparison between autogenous brachial-brachial upper-arm elevated direct arteriovenous fistulas and prosthetic brachial-antecubital indirect forearm arteriovenous grafts

OBJECTIVES

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines recommend forearm arteriovenous grafts (AVGs) as an alternative procedure to transposed basilic vein fistulas for providing secondary access during hemodialysis. Recently, autogenous elevated brachial-brachial vein fistulas (BVE) have become increasingly popular. The aim of this study was to compare the outcomes of BVE and forearm loop AVG (AVG) for secondary access in hemodialysis.

METHODS

We retrospectively reviewed the medical records of patients who had received a BVE or forearm AVG at a single center from January 2015 to April 2019. In total, 19 BVE were created via two-stage operations and two via a one-stage operation; 53 forearm AVG's were performed.

RESULTS

The AVG group was twice as likely to suffer loss of primary patency compared with the BVE group (odds ratio [OR], 2.666; 95% confidence interval [CI], 1.108-6.412; p = 0.029) per the multivariate analysis. The primary patency and primary assisted patency of the BVE group were superior those of the AVG group, except for secondary patency (p = 0.02, p = 0.07, p = 0.879, respectively). In subgroup analysis, there were no significant differences in primary, primary assisted, or secondary patency between AVG and BVE when brachial vein was used for AVG outflow. In addition, no significant differences were noted regarding the infection rate (12.5% vs 12.3%, p = 0.331, severity >0), postoperative bleeding rate (14.5% vs 3.5%, p = 0.191, severity >1), early thrombus rate (0.0% vs 10.5%, p = 0.122), and early failure rate (7% vs 4.8%, p = 0.591).

CONCLUSIONS

The primary patency and primary assisted patency rates of BVE were significantly better than those observed in AVGs, but the complication rates were similar. The appropriate procedure to provide vascular access should be determined by the individual patient's condition and the surgical skill of the operating surgeon.

Forearm brachial artery to brachial vein looped arteriovenous grafts: A single center, single surgeon observational study

BACKGROUND

Long-term hemodialysis (HD) treatment requires the establishment of a cannulatable vascular access (VA) point. While the arteriovenous fistula (AVF) is considered the gold standard, the arteriovenous graft (AVG) is a viable alternative especially in patients with poor superficial venous anatomy. Few studies have assessed the efficacy of the brachial-brachial arteriovenous graft (BB-AVG) for long-term HD access. By analyzing one surgeon's experience in creating, surveilling and maintaining BB-AVGs, this retrospective study aims to add to the body of literature in assessing patency outcomes of BB-AVGs.

METHODS

We identified 57 BB-AVGs that met inclusion criteria and were created between October 6, 2005 and May 1, 2019 by a single surgeon in 54 patients. We analyzed primary failures, patency, complications and interventions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and interventions were expressed as number of events per person-year.

RESULTS

A total of 54 patients (median age of 65 years) were analyzed. Primary patency rates at 12, 24, and 36 months were 20.4% 7.4%, and 5.0%. Primary assisted patency rates at 12, 24, and 36 months were 46.7%, 33.5%, and 15.1%. The secondary patency rates at 12, 24, and 36 months were 81.8%, 63.8%, and 60.1%, respectively. The incidence of complications and interventions was 2.164 per person-year. Most complications and interventions were due to stenosis (1.202 per person-year) or thrombosis (0.802 per person-year).

CONCLUSION

In patients with poor superficial veins, the brachial vein is a reasonable alternative to use as the venous outflow. However, in order to achieve acceptable patency rates, close monitoring of the VA, as well as aggressive treatment of complications within the brachial vein is necessary. Overall, the BB-AVG should be considered in patients who lack adequate superficial veins and require preservation of the more proximal veins.

Outcome of Permanent Vascular Access with Vein ≤ 2.2 mm in Diameter

OBJECTIVE

End-stage renal disease patients with vein diameter of ≤2.2 mm can undergo autogenous arteriovenous fistula (AVF) formation with the acceptable results.

METHODS

This observational retrospective study of prospectively collected data analyzed end-stage renal disease patients with a vein diameter of ≤ 2.2 mm, who underwent AVF formation at Shifa International Hospital Islamabad from January 2009 to December 2017. The fistulae were observed for immediate success and maturity at 3 months. The chi-square test was used to determine the effect of vein diameter on final maturity. All data were analyzed using SPSS.

RESULTS

The total number of patients with vein diameter of ≤2.2 mm was 38, with a mean age of 46.76 ± 12.790 years. Vein diameters ranged from 1.6 to 2.2 mm. Immediate success was observed in 35 (92.1%) cases. Veins of 31 (81.6%) patients showing maturity at 3 months and were used for hemodialysis. The overall success rate for the small caliber veins was 82%.

CONCLUSION

Although end-stage renal disease patients present late with very small diameter veins, these veins should still be accommodated for permanent vascular access, because their maturity rates are still acceptable, even though these are lower than those of patients with adequate sized veins.

A systematic review of the brachial vein arteriovenous fistulas as a viable option for haemodialysis access

OBJECTIVES

International guidelines recommend the use of autogenous vascular access. Where suitable superficial veins are unavailable deeper veins may be used as an option. In most cases, basilic veins are used when cephalic veins are unavailable; arteriovenous fistulas using the brachial vein from the deep venous network are rare. Therefore, the purpose of the present study was to conduct a systematic review of the available literature evaluating the use of the brachial vein in arteriovenous fistulas.

METHODS

Systematic literature search of electronic databases in accordance with PRISMA was conducted. The primary outcomes of this study were primary and secondary patency rates for brachial vein arteriovenous fistulas; the secondary outcomes were the rates of access thrombosis, steal syndrome, pseudo-aneurysm and infection.

RESULTS

The 1-year primary, assisted, and secondary patency was recorded at (24%-77%), (45%-85%) and (45%-96%), respectively. The 2-year primary, assisted and secondary patency rate was recorded at (12%-46%), (19%-75%) and (19%-92%), respectively. However, the consistency regarding the reports and definitions used were highly variable. The incidence rate of infection, thrombosis and steal syndrome was 5% (0%-12%), 15.9% (9.5%-35%) and 3% (2%-6%), respectively.

CONCLUSION

Available studies support the use of brachial veins as a reliable access option in patients with non-accessible superficial veins where an autologous option is required.

Percutaneous creation of proximal radio-radial arteriovenous hemodialysis fistula before secondary brachial vein elevation

Objective:

We evaluate the creation of a percutaneous proximal radial artery–radial vein arteriovenous fistula with Ellipsys® instead of the usual first-stage brachial artery fistula prior to a second-stage brachial vein elevation, in patients with inadequate cephalic and basilic veins.

Methods:

Single center study of eight patients (six males, mean = 54 years) who underwent a two-stage brachial vein elevation procedure between May 2017 and October 2019. Inclusion criteria were life expectancy > 6 months, patent brachial and proximal radial artery (>2 mm in diameter) absent/inadequate cephalic and basilic veins, existence of a brachial vein >3 mm in diameter, and in continuity with a proximal radial vein > 2 mm in diameter.

Results:

Technical success was 100%. Four patients required angioplasty of a juxta-anastomotic stenosis, accounting for a 6-month primary and secondary patency rates were 68% and 100%, respectively. Access flow averaged 982 mL/min (range 768–1586) at final follow-up evaluation. There were no significant adverse events related to the procedures. All fistulae were elevated at 4–12 (mean: 8) weeks post creation and were successfully cannulated with two needles after healing was completed (2–4 weeks after elevation). No patients developed hand ischemia or arm edema.

Conclusions:

Percutaneous creation of a proximal radial artery–radial vein fistula followed by brachial vein elevation is a safe and reliable option for autogenous access creation in patients with inadequate cephalic or basilic veins. Minimally invasive radial artery inflow and longer available length of the targeted brachial vein available for elevation are the main advantages in skilled hands.

Brachial vein transposition: an alternative to hemodialysis arteriovenous graft

Background

There is currently a worldwide effort to increase the options for autogenous hemodialysis access.

Objectives

To evaluate patency and complications of brachial vein transposition compared to other autogenous hemodialysis accesses.

Methods

A retrospective evaluation of 43 patients and 45 procedures. Patients who did not have adequate superficial veins according to duplex scanning were allocated to brachial vein transposition. The sample was thus divided in two groups, as follows: A: brachial vein transposition n=10 and B: other autogenous accesses n=35.

Results

There were no statistical differences between the two groups in terms of age diabetes, systemic arterial hypertension, dyslipidemias, arteriopathies, neoplasms, kidney disease stage, donor artery diameter, recipient vein diameter, systolic blood pressure in the operated limb, postoperative ischemia, hematoma, or infection. There were no statistical differences in terms of patency on day 7: A 80% vs. B 90% p=0.6, on day 30: A 80% vs. B 86% p=0.6, or on day 60: A 60% vs. B 80% p=0.22. There were statistical differences between the groups for number of previous fistulae A 1.0 ± 0.44 vs. B 0.6 ± 0.3 p = 0.04 and upper limb edema A: 20% x B 0% p = 0.04. A vein with diameter of less than 3 mm was associated with an increased risk of early occlusion (RR = 8 p = 0.0125). During the study period there were no procedures using grafts.

Conclusions

Transposition of brachial vein is an alternative to arteriovenous graft.

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.

The forearm arteriovenous graft between the brachial artery and the brachial vein as a reliable dialysis vascular access for patients with inadequate superficial veins

OBJECTIVE

The arteriovenous fistula (AVF) is recommended as the preferred hemodialysis access. However, placing an AVF in all patients may result in poor access outcomes and increased central venous catheter (CVC) use because of increased comorbid conditions, age, and suboptimal vessels. In patients with inadequate superficial veins for AVFs, the use of the brachial veins for creation of forearm arteriovenous grafts (AVGs) has received limited attention. This retrospective study aimed to evaluate outcomes of forearm brachial-brachial AVGs (BB-AVGs) placed in patients with poor superficial veins.

METHODS

We identified 111 BB-AVGs created in 111 consecutive patients, using standard-walled polytetrafluoroethylene grafts, between January 2010 and December 2015. After excluding 6 patients (non-dialysis initiation, missing information, and death within 1 month), we included 105 patients from 21 dialysis centers. We analyzed primary failures, time to cannulation, patency, complications, and revisions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and revisions was expressed as number of events per person-year.

RESULTS

A total of 105 patients (median age, 69 years) were followed up for a median time of 21.2 months (interquartile range, 9.2-36.5 months). Of the patients, 72.4% were on chronic hemodialysis and had previously undergone one or more access procedures. At the time of BB-AVG placement, prior accesses were 39 AVFs, 20 tunneled CVCs, and 17 AVGs. BB-AVG rates of primary failure and revision before cannulation were 7.6% and 5.7%, respectively. BB-AVGs were cannulated after a median time of 3.4 weeks (interquartile range, 2.8-4.1 weeks). Primary patency rates at 12, 24, and 36 months were 49.5%, 29.5%, and 19.5%. Secondary patency rates at 12, 24, and 36 months were 76.3%, 62.7%, and 54.6%. After cannulation, the incidence of complications and revisions was 1.054 and 0.649 per person-year, respectively. Most complications and interventions were due to thrombosis (0.527 per person-year) or stenosis (0.381 per person-year) and related interventions (0.490 per person-year). A minority of patients experienced AVG infections (0.052 per person-year), with only two requiring access removal.

CONCLUSIONS

In patients with poor superficial veins, the forearm BB-AVG is a reliable access because of low access-related morbidity and considerable long-term access survival. BB-AVG placement has the advantage of preserving proximal vessels. In these patients, such an approach can delay both rapid exhaustion of vascular sites and early recourse to CVC permanent use.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

The forearm basilic vein looped transposition fistula as a tertiary option for upper limb vascular access

Introduction:

The forearm basilic vein can serve as an option for haemodialysis access but may not be possible in cases where the wrist arteries are unsuitable. In this setting, the forearm basilic vein can be used in a looped transposition with a brachial artery anastomosis.

Aims:

The aims of this study were to assess the outcome of forearm basilic vein looped transposition as an option for vascular access.

Material and methods:

Data from January 2007 to December 2010 were prospectively collected and analysed. Outcome measures were operative success, complications, maturation and primary and secondary patency following 5 years of follow-up.

Results:

From a total of 583 patients receiving autologous vascular access for haemodialysis, 24 (4.1%) underwent a forearm basilic vein looped transposition. The median age was 60 years (range, 27–80 years), with a slight male predominance (13 male:11 female). Mean follow-up was 34 months (1–60 months). Two patients died and other three were transplanted with subsequent fistula closure. All procedures were successful (100%); however, maturation failure occurred in one case (4.2%). No serious perioperative complications were observed. In two cases, we observed late false aneurysm formation requiring intervention. Primary patency at 1, 2, 3 and 5 years was the following: 77%, 62%, 21% and 10%, whereas secondary patency was the following: 81%, 71%, 61% and 32%, respectively.

Conclusion:

Autologous forearm basilic vein looped transposition is an effective surgical procedure for the creation of access for haemodialysis. This may be a useful option in patients with compromised peripheral arterial diameter or flow and should be considered in patients with a suitable forearm basilic vein.

The Brachio-Brachial Arteriovenous Fistula: Mid-Term Results

Objective

To evaluate the mid-term results of the brachio-brachial arteriovenous fistula in patients without adequate superficial venous circulation in the upper limb.

Methods

Retrospective analysis included 49 patients, in whom a brachio-brachial fistula had been created in an end-to-side configuration. After the maturation period (1 month), the brachial vein was transposed into the subcutaneous tissue. Follow-up study was performed in patients with functional brachio-brachial fistula after the superficialization.

Results

Forty-nine patients underwent 49 brachio-brachial fistula constructions. All fistulas were functional. One month after surgery, 40 (81.6%) of these patients had a functional fistula, but in only 39 (79.6%) cases was the fistula suitable for hemodialysis (HD) following transposition to subcutaneous tissue. During the 1–month maturation period, the fistula became occluded in nine patients, and in one case the vein was permeable, so the fistula was functional, but too small to permit HD. Seventeen patients developed temporary edema of the forearm during the first month, in three cases the edema was extended to the entire arm, but no other complications were associated with the procedure. Follow-up lasted 18.0 ± 11.1 (3–37) months, during which 7/39 patients presented with fistula occlusion. Three patients died and another three were out of the study for various reasons.

Conclusions

the brachio-brachial fistula is a good alternative to prosthetic grafts in patients without superficial venous circulation in the upper limb.

Graft for Immediate use as First Stage of a Native Fistula

The majority of patients in the United States begin hemodialysis with a catheter. Many have immature or inadequate fistulae. At 90 days 77% of these patients are still using a catheter or a graft. The morbidity and mortality from prolonged catheter use have been well delineated. Although most of us adhere to the DOQI and Fistula First tenets, a fistula at all costs can seem counterproductive. A new paradigm is needed. The techniques described in this paper offer a novel approach to circumvent the problems of increasing catheter use and long fistula maturation times. The graft for immediate use is placed in the forearm and allows the proximal vessels to mature while providing dialysis access without a catheter. When these vessels meet maturation guidelines, or when surveillance indicates impending graft failure, a native fistula can be constructed and used in a 2–3 week period. This approach minimizes or circumvents catheter use altogether.

Measurement of Vein Diameter for Peripherally Inserted Central Catheter (PICC) Insertion: An Observational Study

Choosing an appropriately sized vein reduces the risk of venous thromboembolism associated with peripherally inserted central catheters. This observational study described the diameters of the brachial, basilic, and cephalic veins and determined the effect of patient factors on vein size. Ultrasound was used to measure the veins of 176 participants. Vein diameter was similar in both arms regardless of hand dominance and side. Patient factors-including greater age, height, and weight, as well as male gender-were associated with increased vein diameter. The basilic vein tended to have the largest diameter statistically. However, this was the case in only 55% of patients.

Vein Diameter for Peripherally Inserted Catheter Insertion: A Scoping Review

Background: The risk of venous thromboembolism (VTE) may be reduced if a vein of appropriate diameter is used for peripherally inserted central catheter (PICC) insertion. However, clinicians may have predilections to cannulate certain vein types and use particular insertion sites (eg, right or left arm) and therefore do not necessarily assess all veins available to determine the most optimal vessel to introduce a catheter. It is important that clinicians have an understanding of the diameter of veins used for PICC insertion and the effect of patient factors such as hand dominance on vein size to determine whether their clinical practice is appropriate.

Methods: A scoping review of published literature was performed to determine existing knowledge regarding the diameters of veins used for PICC insertion and the influence of patient factors such as hand dominance and laterality (left or right arm) on vein size.

Results: There was limited published research about the diameters of the basilic, brachial, and cephalic veins at the midupper arm, with only 6 studies identified. Three of the 6 selected articles focused on vein diameter measurement to inform arteriovenous fistula development. Only 1 study included participants undergoing PICC insertion. Scant research examined the effect of laterality on vein diameter and 1 study was identified that reported the influence of hand dominance or vein type on the diameter of veins used for PICC insertion.

Conclusions: This review found that there is a paucity of studies that have examined the veins used for PICC insertion. Nevertheless, it appears that the basilic vein has the largest diameter (with smaller brachial and cephalic veins), although this is not always the case. Laterality and hand dominance does not seem to influence vein diameter. Further research about the vasculature used for PICC insertion is needed to inform clinical practice.

Brachial Artery-Brachial Vein Fistula for Hemodialysis: One- or Two-Stage Procedure-A Review

Purpose The purpose of the study was to investigate the patency rate of the brachial vein transposition-arteriovenous fistula [BVT-AVF] and to review the available literature regarding the comparison of the one-stage with the two-stage procedure. Methods A multiple electronic health database search was performed, aiming to identify studies on brachial vein superficialization. Case reports and series with five or less patients were excluded from the study. End points of the study were the patency rates at 12, 24, and 36 months of follow-up. The patency of the one- or two-stage BVT-AVF procedure was investigated. Results Overall, 380 BVT-AVFs were analyzed. The primary patency rate at 12 months ranged between 24 and 77%. Rate of early fistula malfunction or failure of maturation of the fistula resulting in loss of functionality ranged from 0 to 53%. Forearm edema, hematomas, wound infection, and early thrombosis were among the most common complications. Limited data were available for the comparison of patency rates between the one- and the two-stage procedure because of the absence of sufficient comparative studies. However, series with one-stage procedure presented a lower patency rate at 12 months compared to series with two stages. Conclusion Patency rates after BVT-AVF, although not excellent, has encouraging results taking into account that patients undergoing these procedures do not have an accessible superficial vein network; failure of maturation and the increased rate of early postoperative complications remain a concern. The BVT-AVF is a valuable option for creating an autologous vascular access in patients lacking adequate superficial veins.

Superficialization of Segmentally Matured Brachial Vein Complex as the Last Possible Native, Upper arm Vascular Access for Hemodialysis

Purpose

We present a case report on superficialization of the segmentally matured brachial vein complex as the last possible native vascular access for hemodialysis in the upper arm.

Methods

A 57-year-old, female patient was hemodialysed for 14 years. Due to multiple failures of her previous forearm and upper arm vascular access for hemodialysis, the last attempt at the creation of upper arm native vascular access was planned in terms of the formation of a two-stage autogenous brachial-brachial arterio-venous fistula (ABBA). The second stage exposure of the brachial vein – 4 weeks after anastomosis with the brachial artery showed an unusual intraoperative situation. Segmental maturation of both brachial veins, connected by a bridging vein was encountered. Both the mature segments of the brachial veins, connected by the bridging vein were elevated/superficialized into a subcutaneous bed. Immature parts of brachial veins were left near their anatomical position.

Results

Superficialized venous conduit was easily accessible and provided adequate parameters of uncomplicated hemodialysis for 6 months. In month 7, thrombosis of the fistula caused by an embolus due to an atrial fibrillation episode required thrombo-embolectomy. The fistula is still in use 13 months after its creation.

Conclusions

Our technique is feasible in cases of unusual, segmental maturation of both brachial veins during two-stage ABBA formation. Selective superficialization of matured segments only may provide suitable access for hemodialysis. Vascular access surgeons should be aware of possible anatomical variations and be prepared to perform unusual access configurations as dictated by the local anatomy.

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.

[Ulnar-basilic arteriovenous fistula in two renal dialysis patients at CHU, Yaounde: report of 2 cases]

La fistule ulno-basilique est une éventualité peu sollicitée dans le choix des abords vasculaires pour hémodialyse. Elle est construite sur la veine basilique qui est souvent la seule veine épargnée par les ponctions veineuses de routine dans les services de médecine. De par l'existence de nombreuses complications comme l'infection des prothèses et des cathéters centraux, les thromboses, les patients hémodialysés chroniques nécessitent plus d'un accès veineux au cours de leur suivi médical. Les fistules artério-veineuses natives présentent moins de risques de complications que les prothèses d'une façon générale et une plus longue durée de vie. La confection d'une fistule sur une topographie proximale compromet le recourt à cette veine sur une localisation distale ultérieurement. Il existe donc une hiérarchisation dont il faut tenir compte pour une utilisation optimale du capital veineux disponible. Nous rapportons ici deux observations concernant des patients chez qui deux fistules ulno-basiliques ont été réalisées avec succès au CHU de Yaoundé.

Early use of brachial-basilic arteriovenous fistula

PURPOSE

The aim of this study was to evaluate the long-term patency rate and complications associated with the use of the BBAVF in the early period.

METHODS

The records of all patients undergoing BBAVFs for hemodialysis access between June 2001 and June 2011 were retrospectively evaluated. We allowed the use of the BBAVF beginning two weeks after the fistula creation. The primary and secondary patencies were estimated using the Kaplan-Meier method.

RESULTS

A total of 44 BBAVFs were created for 41 patients. Most (73.2%) of the patients had previously been on hemodialysis. A previous history of AVG creation was noted in 36.6% and previous insertion of a catheter was reported for 72.7% of the patients, respectively. The mean time to the first cannulation of the BBAVF was 18.8 days (13-42 days). In two cases, the BBAVFs were not used. Postoperative complications were noted in 2 cases, and included prolonged arm edema and thrombosis. There was no infection of the wound or steal syndrome. The primary and secondary patency rates were 68.1% and 84.2% at 1 year, 55.0% and 80.7% at 2 years, and 38.1% and 70.1% at 5 years, respectively.

CONCLUSIONS

In this study, the patency rates following the early use of the BBAVFs were not inferior to the previously reported patency rates in the literature. In cases where the patients already have an inserted central catheter, the early use of the BBAVFs decreases the complications associated with catheters.

Two-Stage Combined Basilic-Brachial Vein Transposition

In the present report, we describe a two-stage technique of combined basilic and brachial vein transposition. Our patient had a brachial-basilic vein fistula created, but during the second stage for the transposition, a low basilic-brachial vein confluence was found. Instead of abandoning the procedure, the brachial vein was mobilized and transposed to primarily constitute a usable fistula, which subsequently was successfully used for hemodialysis. A detailed description of our technique is provided. Surgeons should be aware of this alternative procedure to maximize fistula creation rates.