Lipectomy as a new approach to secondary procedure superficialization of direct autogenous forearm radial-cephalic arteriovenous accesses for hemodialysis

Background

The depth of veins can discourage surgeons from creating radial-cephalic arteriovenous accesses for hemodialysis in obese patients. Elevation and tunneled transposition are the two techniques that have been described to superficialize these veins and make them accessible for cannulation. Unfortunately, such manipulation of veins has potential drawbacks. We report lipectomy, a new technique that removes subcutaneous fat and does not mobilize the vein.

Methods

This single-center prospective study included 49 consecutive patients (17 men, 32 women) who underwent second-stage lipectomy after creation of a radial-cephalic fistula. Mean patient age was 54 years, 36% had diabetes, and the mean body mass index was 31 ± 5.6 kg/m². Subcutaneous fatty tissues were removed after two transverse skin incisions under regional anesthesia and preventive hemostasis. Cannulation was first allowed 1 month later, after clinical and color duplex ultrasound evaluation. Technical success was defined as the ability to remove the fat and to palpate the patent vein immediately under the skin at the end of the operation. Clinical success was defined as the ability to perform at least three consecutive dialysis sessions with two needles. All patients were checked systematically every 6 months by the surgeon.

Results

Technical and clinical success rates were 96% (47 of 49) and 94% (46 of 49), respectively. Mean vein depth decreased from 8 ± 2 to 3 ± 1 mm according to duplex ultrasound imaging. The mean vein diameter increased from 6 ± 1 to 8 ± 2 mm. In one patient, vein tortuosity that was overlooked required conventional repeat tunneling. One extensive hematoma resulted in loss of the fistula. One patient died before the fistula could be used. Primary patency rates were 71% ± 7% and 63% ± 8% at 1 and 3 years, respectively, and secondary patency rates were 98% ± 2% and 88% ± 7%. Delayed complications were treated by surgery (n = 7) or by endovascular procedures (n = 10).

Conclusion

Lipectomy is a safe, effective, and durable approach to make deep arterialized forearm veins accessible for routine cannulation for hemodialysis in obese patients. It might even be hypothesized that incident obese dialysis patients will eventually have the highest proportion of radial-cephalic fistulas because they often have distal veins that have been preserved by their fat from previous attempts at cannulation for blood sampling or infusion.