Brachial vein transposition arteriovenous fistulas for hemodialysis access

• Published in: Journal of vascular surgery 2009-11, Vol.50 (5), p.1121-1126
• Main Authors: Jennings, William C., MD, Sideman, Matthew J., MD, Taubman, Kevin E., MD, Broughan, Thomas A., MD
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Arteriovenous Shunt, Surgical - adverse effects; Arteriovenous Shunt, Surgical - methods; Biological and medical sciences; Brachial Artery - physiopathology; Brachial Artery - surgery; Brachiocephalic Veins - physiopathology; Brachiocephalic Veins - transplantation; Emergency and intensive care: renal failure. Dialysis management; Female; Graft Occlusion, Vascular - etiology; Graft Occlusion, Vascular - physiopathology; Humans; Intensive care medicine; Male; Medical sciences; Middle Aged; Radial Artery - physiopathology; Radial Artery - surgery; Renal Dialysis; Retrospective Studies; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Time Factors; Tissue and Organ Harvesting; Transplantation, Autologous; Treatment Outcome; Vascular Patency; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Young Adult
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2009.07.077

Background An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis, offering lower morbidity, mortality, and cost compared with grafts or catheters. Patients with a difficult access extremity have often lost all superficial veins, and even basilic veins may be obliterated. We have used brachial vein transposition AVFs (BVT-AVFs) in these challenging patients and review our experience in this report. Methods The study reviewed consecutive patients in whom BVT-AVFs were created from September 2006 to March 2009. Most BVT-AVFs were created in staged procedures, with the second-stage transposition operations completed 4 to 6 weeks after the first-stage AVF operation. A single-stage BVT-AVF was created when the brachial vein diameter was ≥6 mm. Results We identified 58 BVT-AVF procedures, comprising 41 women (71.0%), 28 diabetic patients (48.3%), and 29 (50.0%) had previous access surgery. The operation was completed in two stages in 45 operations (77.6%) and was a primary transposition in 13 patients. However, five of these were secondary AVFs with previous distal AV grafts or AVFs placed elsewhere; effectively, late staged procedures. Follow-up was a mean of 11 months (range, 2.0-31.7 months). Primary patency, primary-assisted patency, and cumulative (secondary) patency were 52.0%, 84.9%, and 92.4% at 12 months and 46.2%, 75.5%, and 92.4% at 24 months, respectively. Harvesting the brachial vein was tedious and more difficult than harvesting other superficial veins. No prosthetic grafts were used. Conclusion BVT-AVFs provide a suitable option for autogenous access when the basilic vein is absent in patients with difficult access extremities. Most patients required intervention for access maturation or maintenance. Most BVT-AVFs were created with staged procedures. Cumulative (secondary) patency was 92.4% at 24 months.