Selective two-stage basilic and cephalic vein transpositions can significantly improve the rate of fistula construction

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.

Efficacy and comparison of elevation transposition and lipectomy for superficialization of cephalic arteriovenous fistula veins

OBJECTIVE

Substantial percentages of cephalic arteriovenous fistulas are situated too deep and require superficialization before use for hemodialysis. The superficialization techniques are diverse: tunnel transposition, elevation, elevation transposition, and lipectomy. Since the fistula veins are not mobilized during lipectomy, it is believed that lipectomy produces better outcomes than other techniques. However, no available report directly compares lipectomy with other techniques. The objective of this report is to compare the outcomes of cephalic elevation transposition with lipectomy.

METHODS

The clinical data of patients who underwent second-stage cephalic elevation transposition or lipectomy at an ambulatory surgery center from 2009 to 2017 were analyzed ( n = 153).

RESULTS

Comparing the cephalic elevation transposition group ( n = 125) with the lipectomy group ( n = 28), the mean body mass index was 36.8 ± 7.6 versus 38.1 ± 7.2 ( p = 0.41); the percentage of upper arm fistulas was 84% versus 61% ( p < 0.01); the mean follow-up was 20.1 ± 17.5 versus 38.6 ± 24.4 months ( p < 0.01); the primary patency rates of the whole fistula conduits were 42% versus 50% at 1 year ( p = 0.08); the secondary patency rates were 99% versus 100% at 1 year ( p = 0.22); the primary patency rates of the superficialized vein segments were 73% versus 68% at 1 year ( p = 0.72); and the mean number of percutaneous interventions required for the superficialized vein segments was 0.49 ± 1.10 versus 0.43 ± 0.71 per access-year ( p = 0.74).

CONCLUSION

Cephalic elevation transposition and lipectomy are both reliable techniques for superficialization of cephalic fistula veins and their outcomes are comparable.

Hemodialysis Vascular access Construction in the Upper Extremity: A Review

Purpose

This article reviews the conventional vascular access types in the upper extremities for hemodialysis.

Methods

We performed a literature search for autogenous arteriovenous fistula in the upper extremities.

Results

The upper extremities have four potential sites: radio-cephalic or radio-basilic transposition in the forearm, and brachio-cephalic or brachio-basilic transposition in the upper arm. A pre-operative Duplex ultrasound provides valuable information regarding arterial inflow and venous outflow. The surgical approach to fistula formation and final product depends on vein diameter and length as well as proximal vein patency. The discussion focuses on access outcomes and management of common complications.

Conclusions

The upper extremity arteriovenous fistula is the preferred access for hemodialysis. A number of arteriovenous fistulas can be created in the upper extremities. The Duplex ultrasound identifies suitable arteries and veins for successful arteriovenous hemodialysis fistula creation. Arteriovenous hemodialysis fistula has the best long-term patency outcomes and the lowest associated morbidity and mortality. Early detection and intervention can save the fistula when complications occur.