Prevalence of variant brachial-basilic vein anatomy and implications for vascular access planning

Long-Term Patency Between Brachiocephalic and Brachiobasilic Fistulas: A Single Institution Review

BACKGROUND

Dialysis access is a fundamental procedure performed by vascular surgeons. Commonly, upper extremity access is utilized via a brachiobasilic fistula (BBF) or brachiocephalic fistula (BCF). BCF is preferred due to ease compared to BBF without documented improved function. Few studies compare patency outcomes between BBF and BCF over time. Our goal was to evaluate the difference in outcomes between BBF and BCF.

METHODS

This is a retrospective review of patients with BCF or BBF between 2019 and 2022. Patients were split by procedure: BCF and BBF. Data collected included demographics, vein size, tunneled catheter, and previous access. Primary outcomes included primary patency (PP), primary assisted patency (PAP) and secondary patency (SP). Secondary outcomes included 30-day complications, access abandonment, interventions and mortality. Linear regression, Kaplan-Meier, and log-rank test were performed.

RESULTS

Our study had 184 patients, 109 (59%) with BCF and 75 (41%) with BBF. There were no differences in demographics except for body mass index and vein size (BBF: 4 vs. BCF: 3.6 mm, P = 0.020). There was no difference in PP at 1 year (41% vs. 47%, P = 0.547) or SP at 2 years (73% vs. 84%, P = 0.058) in BBF versus BCF. However, PAP was significantly greater in BCF (80% vs. 67%, P = 0.030) at 1 year. Secondary outcomes revealed no difference in wound complications (1% vs. 0%, P = 0.408), access abandonment (35% vs. 28%, P = 0.260), or number of interventions (1 vs. 1, P = 0.712) in BBF versus BCF. Mortality was significantly greater in the BBF patients (19% vs. 6%, P = 0.005). On adjusted analysis, BBF had 43 min longer operative time (P < 0.001) and 22 cc greater blood loss (P < 0.0001).

CONCLUSIONS

In this single center review comparing BBF and BCF, no difference was seen between BBF and BCF in terms of PP or SP. Even with larger vein size, BBF did not confer a benefit in long term patency or access abandonment. Additionally, BBF did not confer decreased procedures to maintain patency and BBF had greater operative length and blood loss, as well as mortality. We believe this study demonstrates that for patients who must use an upper extremity location, when the cephalic vein is satisfactory, using the cephalic vein is preferred as it does not negatively impact long-term patency.

Prevalence and clinical significance of anatomic variant in cephalic arch on preoperative mapping venography

The aim of the current study was to determine the prevalence of anatomic variant in cephalic arch on preoperative mapping venography and evaluate patency rates and predictors of patency in patients with brachiocephalic fistulas. The prevalence of anatomic variant in cephalic arch was retrospectively evaluated in 1004 consecutive patients who underwent bilateral preoperative mapping venography from July 2006 to December 2018 in a single center. The overall prevalence of anatomic variant in cephalic arch was 17.2% (173/1004). For patency analysis, 128 patients with brachiocephalic fistulas were divided into two groups: a standard anatomy (SA) group (n = 97) and a variant anatomy (VA) group (n = 31). There were no significant differences in clinical characteristics between the two groups. The primary patency rate did not differ significantly between the two groups. The secondary patency rate was significantly (p = 0.009) lower in the VA group than in the SA group. Older age (HR 1.03; 95% CI 1.01-1.05; p = 0.007) was a negative predictor of primary patency, and antiplatelet agent (HR 0.53; 95% CI 0.33-0.84; p = 0.007) and large-diameter cephalic vein (HR 0.52; 95% CI 0.31-0.86; p = 0.012) were positive predictors of primary patency. Older age (HR 1.04; 95% CI 1.01-1.07; p = 0.011) and anatomic variant in cephalic arch (HR 2.9; 95% CI 1.19-7.06; p = 0.019) were negative predictors of secondary patency. The current study provides insight into the clinical significance of anatomic variant in cephalic arch. Anatomic variant in cephalic arch should be considered as a potential risk factor for decreased patency of brachiocephalic fistula during preoperative planning.

[Arm Swelling with a Camouflaged Cause]

Arm Swelling with a Camouflaged Cause Abstract. We report on a 72-year-old patient who presented to the emergency department due to a proximal multiple-fragment humeral fracture on the left. Despite correct therapeutic approaches, there was no improvement in the left arm swelling. Further investigations showed a provoked arm vein thrombosis on the left with a post-humeral fracture on the left. After therapeutic anticoagulation, the swelling regressed immediately, but with persistent lymphedema of the left hand.

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.

A longitudinal observational retrospective study on risk factors and predictive model of PICC associated thrombosis in cancer patients

To analyze the incidence of PICC associated venous thrombosis. To predict the risk factors of thrombosis. To validate the best predictive model in predicting PICC associated thrombosis. Consecutive oncology cases in 341 who initially naive intended to be inserted central catheter for chemotherapy, were recruited to our dedicated intravenous lab. All patients used the same gauge catheter, Primary endpoint was thrombosis formation, the secondary endpoint was infusion termination without thrombosis. Two patients were excluded. 339 patients were divided into thrombosis group in 59 (17.4%) and non-thrombosis Group in 280 (82.6%), retrospectively. Tumor, Sex, Age, Weight, Height, BMI, BSA, PS, WBC, BPC, PT, D-dimer, APTT, FIB, Smoking history, Location, Catheter length, Ratio and Number as independent variables were analyzed by Fisher's scoring, then Logistic risk regression, ROC analysis and nomogram was introduced. Total incidence was 17.4%. Venous mural thrombosis in 2 (3.4%), "fibrin sleeves" in 55 (93.2%), mixed thrombus in 2 (3.4%), symptomatic thrombosis in 2 (3.4%), asymptomatic thrombosis in 57 (96.6%), respectively. Height (χ² = 4.48, P = 0.03), D-dimer (χ² = 37.81, P < 0.001), Location (χ² = 7.56, P = 0.006), Number (χ² = 43.64, P < 0.001), Ratio (χ² = 4.38, P = 0.04), and PS (χ² = 58.78, P < 0.001), were statistical differences between the two groups analyzed by Fisher's scoring. Logistic risk regression revealed that Height (β = -0.05, HR = 0.95, 95%CI: 0.911-0.997, P = 0.038), PS (β = 1.07, HR = 2.91, 95%CI: 1.98-4.27, P < 0.001), D-dimer (β0.11, HR = 1.12, 95%CI: 1.045-1.200, P < 0.001), Number (β = 0.87, HR = 2.38, 95% CI: 1.619-3.512, P < 0.001) was independently associated with PICC associated thrombosis. The best prediction model, D-dimer + Number as a novel co-variable was validated in diagnosing PICC associated thrombosis before PICC. Our research revealed that variables PS, Number, D-dimer and Height were risk factors for PICC associated thrombosis, which were slightly associated with PICC related thrombosis, in which, PS was the relatively strongest independent risk factor of PICC related thrombosis.

Arterial compression by an adjacent venous stent graft in a patient undergoing dialysis

BACKGROUND

Stent graft is effective for management of balloon-angioplasty-related complications in hemodialysis access. These complications include post-angioplasty venous rupture, dissection/recoil, and acute formation of pseudoaneurysm.

CASE REPORT

We report a stent-graft complication that caused immediate acute arterial insufficiency by external compression. An 84-year-old woman presented with acute arteriovenous graft thrombosis. During percutaneous balloon thrombectomy, a stent graft was placed because of persistent recoil and mural thrombus, but the flow into the arteriovenous graft immediately ceased. External compression of the brachial artery was observed. A nitinol self-expandable stent was deployed in the brachial artery to oppose the external compression. The flow in the arteriovenous graft was recovered.

CONCLUSION

This case demonstrates the possibility of arterial compression by an adjacent venous stent graft, especially in a patient with a thin habitus and a brachial-brachial arteriovenous graft. Detailed identification of the outflow vein anatomy before stent implantation is mandatory to avoid such a complication.

Anatomical variants of upper arm veins on preoperative mapping venography for hemodialysis access in Korean adults

INTRODUCTION

The number of elderly patients requiring hemodialysis has increased, along with the need for multiple vascular access placements. Thus, the frequency of access creation using the upper arm veins, including transposed basilic arteriovenous fistula, has also increased. The purpose of this study was to identify the prevalence of anatomical variations in the upper arm veins on preoperative mapping venography and to investigate the implications of such variants on access creation.

METHODS

A total of 494 venograms were performed on 251 patients for primary access creation from June 2014 to June 2017 in this single-center, retrospective study. The venograms were classified into eight subtypes, based on the anatomical relationship between the basilic and brachial veins. The presence of bifid cephalic arches and brachial-basilic ladders was also examined.

RESULTS

The presence of bifid cephalic arches and brachial-basilic ladders was identified in 8.7% and 14.0% of cases, respectively. Paired brachial veins joined separately with the basilic vein in 67.4% of venograms, whereas these veins merged into a common brachial vein before connecting to the basilic vein in 13.1% of cases. A single brachial vein was present in 19.3% of cases. 15.7% of cases were considered unsuitable for basilic vein transposition due to the early confluence of the brachial-basilic vein, posing a risk of obliterating the deep venous drainage if transposed.

CONCLUSION

There are significant anatomical variations of upper arm veins, and the recognition of certain variants can affect surgical planning and outcomes of access placement. It is important to identify anatomical variants of the upper arm veins during preoperative vein mapping.

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.

Variation of the cephalic and basilic veins: A case report

Cephalic and basilic veins begin their path from around the wrist and continue towards the area above the forearm. The basilic vein becomes deep around the mid-arm, while the cephalic vein becomes deep around the upper forearm, in deltopectoral groove. The superficial veins are most commonly used for vein puncture, transfusion, bypass graft, and cardiac catheterization. In renal patients, the basilic vein use as an arteriovenous graft or fistula for haemodialysis access. During a routine dissection in the department of anatomy in Isfahan, we observed a variation in the left arm of an infant boy (six months old). The cephalic and basilic veins directly joined together in the middle of the cubital fossa. The brachial vein began from this point and, unlike the normal anatomy location, there was no paired brachial vein; rather, it was one unpaired brachial vein.

Brachial vein transposition is a promising ultimate upper limb autologous arteriovenous angioaccess despite its many pitfalls

OBJECTIVE

The objective of this study was to retrospectively evaluate the possibility of using the brachial veins despite their deep location, small caliber, and thin wall.

METHODS

There were 64 patients without superficial veins who were eligible for two-stage brachial vein transposition (BrVT); 54 patients were on hemodialysis, 9 patients had sickle cell disease, and 1 patient had long-term parenteral nutrition. Preoperative imaging was performed with color duplex ultrasound as well as venography for suspected central vein stenosis. A surgical microscope was used to create an end-to-side anastomosis between the brachial vein (medial, if possible) and artery. No minimum vein diameter was required. Postoperative color duplex ultrasound imaging was scheduled at 1 month. Second-stage superficialization was performed 2 to 3 months later with tunnelization and a new arteriovenous anastomosis.

RESULTS

For the 64 patients, cumulative primary patency rates (± standard deviation [SD]) at 1 year, 2 years, 3 years, and 4 years were 50% (±7%), 42% (±7%), 37% (±8%), and 27% (±11%), respectively. Primary assisted patency rates (±SD) at 1 year, 2 years, 3 years, and 4 years were 60% (±6%), 51% (±7%), 45% (±7%), and 37% (±9%), respectively. Secondary patency rates (±SD) at 1 year, 2 years, 3 years, and 4 years were 60% (±6%), 53% (±7%), 53% (±7%), and 45% (±8%), respectively. Early complications included thrombosis, nonmaturation, and upper arm edema. At the second stage (n = 50), four patients presented with unexplained major fibrosis extending cephalad from the first surgical site and preventing any dissection of the vein. Four patients had more usual complications (one nonmaturation, two occlusions of the brachial vein at the previous arteriovenous graft-vein anastomosis), and two were lost to follow-up. Vein transposition in a subcutaneous tunnel was technically unfeasible in eight patients. Of the 64 patients, 40 (62%) had a functional BrVT that was cannulated for effective dialysis after a median interval of 72 days (15-420 days) from the first stage. Mean cumulative secondary patency rates (from first cannulation) at 1 year, 2 years, and 3 years were 91% ± 5%, 72% ± 8%, and 62% ± 10%, respectively. Overall, 13 patients were lost to follow-up. Secondary complications were low flow and central vein occlusion. Long-term complications were related to stenosis and thrombosis, aneurysms, and puncture site necrosis. Median follow-up from the first stage was 1.62 years (0.02-11.3 years).

CONCLUSIONS

Despite many pitfalls for the surgeon, BrVT offers promising long-term patency.

Angiography of Hemodialysis Fistulas and Grafts

Angiography of the dialysis access is an important procedure in dealing with dialysis arteriovenous access (AVA) dysfunction. It is an integral part and the initiating procedure for all the interventional procedures performed for the management and salvage of dialysis AVA. The performance of this procedure and normal dialysis access-related anatomy including anatomical variants are discussed. In addition, pathology commonly encountered in association with the anatomy is reviewed.

Elbow AVF configurations and indications

INTRODUCTION

Brescia-Cimino radiocephalic arteriovenous fistula (AVF) remains the first-choice vascular access procedure for patients in need of long-term hemodialysis. 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. Elbow fistulas should only rarely be constructed as primary fistulas. The aim of the surgeon must be not only to achieve a functioning fistula, but to avoid possible complications other than failure to mature (FTM), like distal ischemia and cardiac failure and to save the vessels as much as possible for future procedures.

BACKGROUND

Both arterial and venous anatomy of the elbow and upper arm have significant variations. The surgeon must be aware of these variations during the operation, and try not to harm the vasculature of the extremity while trying to construct a functioning fistula. The main advantages of elbow fistulas are the opportunity to have multiple outflows, preservation of the major veins in their original place with no dissection and giving no harm to them, and having a longer outflow tract for cannulation.

CONCLUSIONS

In the elbow, beginning to construct an AVF with the perforating vein is the most advantageous. If the perforating vein is not available or has been used before, median cubital vein, its branches, median antecubital vein or other available nearby veins may be used depending on the anatomy. Perforating vein should be ligated if any other elbow vein is used to prevent flow to deep veins.

Basilic Vein Transposition Used as a Tertiary Vascular Access for Hemodialysis: 15 Years of Experience

INTRODUCTION

The quality of the life in patients requiring long term hemodialysis is directly proportional to the long-term patency of their vascular access. Basilic vein transposition for vascular access (BAVA) represents a suitable option for creating a tertiary native vascular access for hemodialysis on the upper extremities for patients requiring long term hemodialysis. The purpose of the study is to compare BAVAs with arteriovenous grafts (AVG).

METHOD

Data collection was based on selecting all of the patients with BAVA created in the time period in between January 1996 and August 2011. A questionnaire was created and sent to the selected hemodialysis centers. The resulting set of data was statistically analyzed and evaluated.

RESULTS

In the time period between 1 January 1996 and August 2011, arteriovenous access for hemodialysis was created in 6754 patients (7203 procedures in total). Out of these patients, 175 BAVAs were created. Our patient database of those undergoing the BAVA procedure consisted of 98 females (56%) and 77 males (44%) with an average age of 64.5 years. The prevalence of diabetes mellitus was 60% (105 patients). Primary patency after 12 months was 68.8%, 24 months 59.7%, 36 months 53.8, 48 months 53.8%, and 60 months 50%. Primary assisted patency after 12 months was 89.9%, 24 months 84.6%, 36 months 77.8%, 48 months 77.9%, 60 months 70.8%. Secondary patency after 12 months was 89.4%, 24 months 86.9%, 36 months 81%, 48 months 78.9%, 60 months 75.7%. Twenty-nine BAVAs (16.5%) were obliterated.

CONCLUSION

Patients benefit from this type of procedure due to the longer patency of a native arteriovenous access, as well as a lower incidence of infectious complications.

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.

Early Experience With a Novel Hybrid Vascular Graft for Hemodialysis Access Creation in Patients With Disadvantaged Anatomy

Purpose: To describe the use of the Hybrid vascular graft in disadvantaged anatomy for hemodialysis access creation and compare outcomes to standard-wall polytetrafluoroethylene (PTFE) grafts. Methods: In a retrospective analysis, 25 patients (mean age 65±14 years; 13 men) who received the Hybrid graft were compared with 35 contemporaneous patients (mean age 63±12 years; 20 men) who received a standard PTFE graft for hemodialysis access over a 2-year period. Criteria for Hybrid graft placement were (1) exhausted or inadequate peripheral veins for arteriovenous fistula (AVF) creation and concomitant small target veins that precluded conventional PTFE graft placement, (2) previous graft anastomosis or a stent in the venous target at the level of the axilla, or (3) failed brachial-basilic or brachial-brachial upper arm transposition AVF with a small target vein at the axilla. Efficacy, anatomic and clinical considerations, and technique were reviewed; patency rates, complications, and reinterventions were examined. Results: Technical success was achieved in all cases, and all grafts were usable for hemodialysis. Seven of 25 Hybrid patients required stent-graft extensions and 3 patients required angioplasty to improve venous outflow at the time of Hybrid graft insertion. Three of 35 standard PTFE graft patients required angioplasty to improve venous outflow at the time of graft insertion. There was no perioperative mortality or procedure-related morbidity in either group. Median follow-up was 21 months. The patient survival estimate was 66% at 2 years. Estimated primary patency (24% vs 18%, p>0.05), assisted primary patency (34% vs 28%; p>0.05), and secondary patency rates (40% vs 38%, p≥0.05) at 24 months were equivalent for Hybrid vs PTFE grafts, respectively. Venous hypertension was not a complication following Hybrid graft implantation but was seen in 2 patients with the standard PTFE graft. Conclusion: The Hybrid graft offers a safe, technically effective alternative for patients with disadvantaged anatomy requiring hemodialysis access and has comparable outcomes to standard PTFE grafts. Further clinical experience and long-term data are required for determining the proper utility of this device in chronic dialysis-dependent patients.

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.

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.

Ultrasound-Guided Arm Ports: Indications, Techniques, and Management

Purpose: Various venous access devices are available, including peripheral venous lines, peripherally inserted central catheters lines, and subcutaneous port catheters. The latter provides medium-to long-term venous access and includes medical devices that can be inserted either on the chest (chest ports) or in the arm (arm ports). We report the techniques, dedicated indications, and main complications of arm port insertion using the ultrasonography (US) guidance method.

Methods: Tips and tricks of percutaneous real-time US-guided vein access technique in the arm are reviewed, and a brief literature review is reported.

Results: Technical feasibility is almost 99%. US guidance allows depiction of anatomic variants, reduces the number of failed attempts, and increases the technical access rate compared with venography-guided access. Comparison of arm ports to chest ports reveals a higher global complication rate. We also report typical (mechanical) complications and dedicated indications, including contraindications to chest port insertion and selected patients for whom chest ports are not possible (eg, those with breast, head, and neck cancer; obesity; cosmesis; and requiring upright position).

Conclusions: Arm port insertion under US guidance is safe and effective, and has dedicated indications.

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.

Anatomical vascular variations and practical implications for access creation on the upper limb

BACKGROUND

A profound knowledge of vascular anatomy and an understanding of vascular access functionality with respect to possible complications are critical in selecting the site for arteriovenous anastomosis.

METHODS

Outline of vasculature variations of the upper limb with prevalence reported in literature of at least 1%, which may affect access creation, is depicted in this review.

RESULTS

Over a dozen arterial anatomical anomalies of the upper limb, the most common is "high origin" of the radial artery (12-20%). Superficial positions of brachial, ulnar and radial artery as well as accessory brachial are another possible anatomic variants (0.5-7%). The most variable venous layout on the upper arm is seen in the anatomy of the brachial vein and the basilic vein forming the axillary vein. Three types of basilic vein course on upper arm have been described.

CONCLUSIONS

The mapping technique to assess vascular variants facilitate site selection for AVF creation even in cases with previously attempted failed access (misdiagnosed vascular variant could force to secondary options). Thus, a thorough understanding and evaluation of anatomy, taking into consideration the possible vascular variations of the forearm and upper arm, are necessary in the planning of AVF creation and increase the success of AVF procedures.

The venous chiasma between the basilic vein and the brachial vein: a case report

Variations in the venous pattern of the arm are common. In this case report, we are presenting the variations of the brachial vein and the basilic vein.During the routine dissections which were done by medical undergraduate students, we observed some variations in the veins of the upper limb. In the current case, there was only one brachial vein which accompanied the brachial artery. The basilic vein originated from the medial side of the dorsal venous network, ascended along the medial side of the forearm and joined the brachial vein to form the axillary vein at the distal border of the teres major muscle. The basilic vein and the brachial vein joined with one another in the middle of the arm to form a unique venous chiasma.A large number of invasive procedures are carried out by using the veins of the upper limb, particularly in and distal to the axillary region. This type of a venous chiasma may lead to complications in these procedures.