The National Kidney Foundation Dialysis Outcomes Quality Initiative and the National Vascular Access Improvement Initiative “Fistula First” recommend arteriovenous fistulas (AVF) as the preferred vascular access for hemodialysis. AVFs have lower morbidity and mortality rates in addition to lower yearly Medicare cost profiles, as opposed to grafts or catheters. Complex medical illnesses and previous failed access operations leave some individuals with a difficult access extremity, confronting surgeons with obliterated cephalic and basilic veins. Brachial vein transposition AVFs (BVT-AVF) have been reported with mixed results in these patients. We review our experience and techniques with BVT-AVFs.
Methods
We analyzed the records of consecutive patients in our vascular access database who had BVT-AVFs constructed from September 2006 to December 2008. Most BVT-AVFs were created in staged procedures. The second stage transposition operations were generally completed 4 to 6 weeks after the first stage AVF operation. A single stage BVT-AVF was utilized when the brachial vein diameter was ≥ 6 mm. All patients were evaluated with pre and post-operative ultrasound examinations by the operating surgeon.
Results
52 BVT-AVF procedures were identified. Of these, 35(67.3%) were women, 25(48.1%) were diabetic, and 26 (50.0%) had previous access surgery. 46 operations were completed in two stages and 6 as a single procedure. Follow-up was 1-25 months (mean = 6 mos). Primary patency, primary assisted patency, and cumulative (secondary) patency were 33.5%, 79.8%, and 91.7% at 12 months and 25.1%, 79.8%, and 91.7% at 24 months, respectively. No prosthetic grafts were used in any patient.
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 one or more interventional procedures. Cumulative (secondary) patency was 91.7% at 24 months.
University of Oklahoma College of Medicine, Tulsa, Tulsa, OK
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