Arrificiol Orpin.\
16(6):623-633. Blackwell Scientific Publications, Inc., Boston 0 1992 International Society for Artificial Organs
Thoughts and Progress It is the goal of this section to publish material that provides information regarding specific issues, aspects of artificial organ application, approach, philosophy, suggestions, and/or thoughts for the future.
sia, provides a long segment of vessel for repeated venipunctures, and has a low incidence of complications. However, in some patients, usually women and children, this fistula cannot be performed because the vessels are inadequate from the beginning or have been used previously for long-term hemodialysis. This group of patients requires secondaryaccess procedures for their survival. Many alternatives to the Brescia-Cimino fistula have been described. These include saphenous vein grafts (l), bovine grafts ( 2 ) , and expanded Teflon grafts ( 3 ) . Each procedure has its advantages and disadvantages. We have tried to create an arteriovenous fistula using the native forearm vessels and have found the transposed basilic vein-brachial artery fistula described by Dagher et al. (4) to be extremely useful for vascular access.
Transposed Basilic Vein-Brachial Arteriovenous Fistula: An Alternative Vascular Access for Hemodialysis A . Hatjibaloglou, D. Grekas, N . Saratzis, A . Megalopoulos, I . Moros, D . Kiskinis, and V . Dalainas from the First Department of Surgery and Renal Unit, University Hospital AHEPA, Thessaloniki. Greece Abstract: Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated oneyear patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachialbasilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels. Key Words: Hemodialysis-vascular access-Transposed basilic vein-brachial AV fistula.
Methods The fate of 25 transposed basilic vein-brachial artery arteriovenous fistulas performed on 22 uremic patients (18 women and 4 men, aged 32 to 69 years) during a three-year period was reviewed. Fistulas were considered functional if they were in use for long-term hemodialysis. Total anesthesia was used in 22 cases and regional in 3 cases. The basilic vein was found by an incision along the course of the vein from elbow to axilla. The tributaries were ligated and divided, and then the vein was divided distally and mobilized from beneath the cutaneous nerve. The basilic vein was cannulated and distended with heparinized normal saline and a Fogarty catheter No. 3 . The brachial artery was found at the antecubital fossa. An end-to-side anastomosis was performed between the distal end of the basilic vein and the anterior aspect of the brachial artery. After anastomosis, protamine sulfate was administered. The palpitation of a strong continuous thrill over the anastomosis means the basilic vein is filling well. The fascia and most of the subcutaneous tissue were sutured under the vein so that the vein was transposed more superficially (Fig. 1). The skin was closed with a continuous suture.
Because of the rapid increase in the number of patients undergoing hemodialysis in recent years, it has become necessary to develop alternative vascular access procedures. The radial artery-cephalic vein fistula introduced by Brescia and Cimino in 1966 has become the most widely used primary access for long-term hemodialysis. This fistula can be performed easily with the patient under local anestheReceived November 1991; revised July 1992. Address correspondence and reprint requests to Dr. A. Hatibaloglou at First Department of Surgery, and Renal Unit, AHEPA General Hospital, 54006 Thessaloniki, Greece.
623
THOUGHTS AND PROGRESS
624
FIG. 1. Completed basilic vein-brachial arteriovenous fistula The fascia is closed under the vein with interrupted sutures
brachial artery brsilic vein
Results A total of 25 transposed basilic-brachial fistulas was performed during the study period. The waiting time until the initiation of venous puncture for the first hemodialysis session was 2-3 weeks. The vein was punctured beside and not through the scar of the skin incision. The duration of good fistula function and the early and late complications are shown in Table 1.
Early complications Diffuse hemorrhage was seen in 2-patients, who were cured with conservative methods. Regional edema with infection developed in one patient, who was treated with drainage and antibiotics. Steal syndrome was found in one woman, but no patient developed high-output cardiac failure. Thrombosis of the fistula developed in 2 cases and required surgical repair. Late complicutions Failure of the fistula was found in 2 cases because of multiple vein stenosis at the site of repeated veni-
punctures. In the first case, a similar fistula was performed to the other hand while the second case was managed by partial vein excision and replacement with expanded polytetrafluoroethylene (PTEE). Late thrombosis of the fistula was shown in two women with low blood pressure. Both cases were managed by reconstruction of a similar fisl ula to the other hand. One patient developed an aneurysmal dilation of the basilic vein at the site of repeated venipunctures, but after surgical repair the vascular access was still functioning. Discussion The results demonstrate that the transposed basilic vein-brachial arteriovenous fistula is a successful second- or third-choice vascular access for hemodialysis patients and is not associated with the infectious complications that are seen in a high rate in bovine grafts or synthetic grafts (3,4). The oneyear accumulated function rate of 81% is comparable to the results of LoGerfo et al., ( 5 ) who used a similar surgical technique, but considerably better than that
TABLE 1. Analysis of patency rate of transposed basilic uein-brachial urteriouenoiis jstulas
Group 1
2 3
Interval (mo)
Arteriovenous fistulas (no.)
Fistulas failing
14-24 9-14
16(6):623-633. Blackwell Scientific Publications, Inc., Boston 0 1992 International Society for Artificial Organs
Thoughts and Progress It is the goal of this section to publish material that provides information regarding specific issues, aspects of artificial organ application, approach, philosophy, suggestions, and/or thoughts for the future.
sia, provides a long segment of vessel for repeated venipunctures, and has a low incidence of complications. However, in some patients, usually women and children, this fistula cannot be performed because the vessels are inadequate from the beginning or have been used previously for long-term hemodialysis. This group of patients requires secondaryaccess procedures for their survival. Many alternatives to the Brescia-Cimino fistula have been described. These include saphenous vein grafts (l), bovine grafts ( 2 ) , and expanded Teflon grafts ( 3 ) . Each procedure has its advantages and disadvantages. We have tried to create an arteriovenous fistula using the native forearm vessels and have found the transposed basilic vein-brachial artery fistula described by Dagher et al. (4) to be extremely useful for vascular access.
Transposed Basilic Vein-Brachial Arteriovenous Fistula: An Alternative Vascular Access for Hemodialysis A . Hatjibaloglou, D. Grekas, N . Saratzis, A . Megalopoulos, I . Moros, D . Kiskinis, and V . Dalainas from the First Department of Surgery and Renal Unit, University Hospital AHEPA, Thessaloniki. Greece Abstract: Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated oneyear patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachialbasilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels. Key Words: Hemodialysis-vascular access-Transposed basilic vein-brachial AV fistula.
Methods The fate of 25 transposed basilic vein-brachial artery arteriovenous fistulas performed on 22 uremic patients (18 women and 4 men, aged 32 to 69 years) during a three-year period was reviewed. Fistulas were considered functional if they were in use for long-term hemodialysis. Total anesthesia was used in 22 cases and regional in 3 cases. The basilic vein was found by an incision along the course of the vein from elbow to axilla. The tributaries were ligated and divided, and then the vein was divided distally and mobilized from beneath the cutaneous nerve. The basilic vein was cannulated and distended with heparinized normal saline and a Fogarty catheter No. 3 . The brachial artery was found at the antecubital fossa. An end-to-side anastomosis was performed between the distal end of the basilic vein and the anterior aspect of the brachial artery. After anastomosis, protamine sulfate was administered. The palpitation of a strong continuous thrill over the anastomosis means the basilic vein is filling well. The fascia and most of the subcutaneous tissue were sutured under the vein so that the vein was transposed more superficially (Fig. 1). The skin was closed with a continuous suture.
Because of the rapid increase in the number of patients undergoing hemodialysis in recent years, it has become necessary to develop alternative vascular access procedures. The radial artery-cephalic vein fistula introduced by Brescia and Cimino in 1966 has become the most widely used primary access for long-term hemodialysis. This fistula can be performed easily with the patient under local anestheReceived November 1991; revised July 1992. Address correspondence and reprint requests to Dr. A. Hatibaloglou at First Department of Surgery, and Renal Unit, AHEPA General Hospital, 54006 Thessaloniki, Greece.
623
THOUGHTS AND PROGRESS
624
FIG. 1. Completed basilic vein-brachial arteriovenous fistula The fascia is closed under the vein with interrupted sutures
brachial artery brsilic vein
Results A total of 25 transposed basilic-brachial fistulas was performed during the study period. The waiting time until the initiation of venous puncture for the first hemodialysis session was 2-3 weeks. The vein was punctured beside and not through the scar of the skin incision. The duration of good fistula function and the early and late complications are shown in Table 1.
Early complications Diffuse hemorrhage was seen in 2-patients, who were cured with conservative methods. Regional edema with infection developed in one patient, who was treated with drainage and antibiotics. Steal syndrome was found in one woman, but no patient developed high-output cardiac failure. Thrombosis of the fistula developed in 2 cases and required surgical repair. Late complicutions Failure of the fistula was found in 2 cases because of multiple vein stenosis at the site of repeated veni-
punctures. In the first case, a similar fistula was performed to the other hand while the second case was managed by partial vein excision and replacement with expanded polytetrafluoroethylene (PTEE). Late thrombosis of the fistula was shown in two women with low blood pressure. Both cases were managed by reconstruction of a similar fisl ula to the other hand. One patient developed an aneurysmal dilation of the basilic vein at the site of repeated venipunctures, but after surgical repair the vascular access was still functioning. Discussion The results demonstrate that the transposed basilic vein-brachial arteriovenous fistula is a successful second- or third-choice vascular access for hemodialysis patients and is not associated with the infectious complications that are seen in a high rate in bovine grafts or synthetic grafts (3,4). The oneyear accumulated function rate of 81% is comparable to the results of LoGerfo et al., ( 5 ) who used a similar surgical technique, but considerably better than that
TABLE 1. Analysis of patency rate of transposed basilic uein-brachial urteriouenoiis jstulas
Group 1
2 3
Interval (mo)
Arteriovenous fistulas (no.)
Fistulas failing
14-24 9-14
