| Abstract|| |
Primary use of the autogenous arteriovenous access is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines. In spite of troublesome comorbidities associated with basilic vein transposition (BVT), it is still the most preferred technique when autologous veins are not suitable to construct radio-cephalic fistula (RCF) and brachiocephalic fistula (BCF), arteriovenous fistula (AVF). The present study highlights our experience with BVT, with small incision technique, over a period of two years with excellent outcome. This retrospective study included all the patients who underwent BVT at our tertiary care center between March 2013 and March 2015. It was performed in patients with failed previous RCF or BCF or who had small caliber or thrombosed cephalic veins. The patients with minimum 3 mm basilic vein diameter on Doppler were only included in the study. A 3-cm horizontal incision was made in antecubital fossa to expose brachial artery and basilic vein. Multiple longitudinal separate second skin incisions (2–3 cm) were made to explore proximal part of basilic vein. Side branches of the vein were isolated and ligated. The divided basilic vein in antecubital fossa was brought over fascia through newly created subcutaneous tunnel followed by end-to-side anastomosis. A total of 18 (12 males and 6 females) underwent BVT in the two years period. The mean fistula maturation time was 42 ± 10 days. Maturation rate was 100%, and the postoperative flow rate was 290 ± 22 (mL/min). No bleeding, thrombosis, failure, pseudo aneurysm, or rupture occurred in our patients. Arm edema occurred in ix (33%) patients, infection in three (17%), and lymphorrhea in five (28%). The mean follow-up was six months. BVT is an alternative method with excellent initial maturation and functional patency rates requiring less extensive skin incision and surgical dissection. It is the most durable hemodialysis access procedure for those patients having multiple forearm AVF surgeries.
|How to cite this article:|
Chipde SS, Agrawal S, Kalathia J, Mishra U, Agrawal R. Basilic vein transposition: A viable alternative for multiple failed arteriovenous fistulas - A single center experience. Saudi J Kidney Dis Transpl 2017;28:336-40
|How to cite this URL:|
Chipde SS, Agrawal S, Kalathia J, Mishra U, Agrawal R. Basilic vein transposition: A viable alternative for multiple failed arteriovenous fistulas - A single center experience. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2019 Apr 26];28:336-40. Available from: http://www.sjkdt.org/text.asp?2017/28/2/336/202781
| Introduction|| |
The number of patients requiring hemodialysis (HD) has been increasing globally because of the rise in the prevalence of end-stage renal disease (ESRD). The arteriovenous fistula (AVF) is the most frequently used method for HD in these patients.
The Kidney Disease Outcome Quality Initiative (KDOQI) recommends autologous radiocephalic or brachiocephalic AVF as a primary method of choice in HD patients, but for the patients with failed radio-cephalic fistula (RCF) or brachiocephalic fistula (BCF) or with smaller caliber superficial veins, vascular access becomes difficult. Therefore, the basilic vein transposition (BVT) as a secondary option is recommended in those patients.,
The BVT is a time consuming and technically challenging procedure with significant perioperative morbidity due to long incisions and extensive surgical dissection. The conventional BVT requires long incision over the medial aspect of the arm to dissect the basilic vein up to axillary vein. It is then cut in the cubital fossa and transposed into the subcutaneous tissue by multiple small incisions to perform the end to side basilic vein brachial artery anastomosis. In our institute, we use two to three small incisions to dissect the basilic vein and then it is tunneled into the subcutaneous tissue over the fascia. This retrospective study aims to evaluate the patency and complication rates of BVT performed with this small incision technique.
| Materials and Methods|| |
This is a retrospective study including all the patients who underwent BVT in our Tertiary Care Institute, between March 2013 and March 2015. The BVT was done in those patients who had either failed previous RCF or BCF or who had small caliber or thrombosed cephalic veins. All patients underwent color Doppler of the upper limb before surgery. The minimum vein diameter of 3 mm was taken up as a cutoff value to undergo this procedure. All the patients underwent one-stage BVT where a 3-cm horizontal incision was made in antecubital fossa to expose the brachial artery and basilic vein. Multiple longitudinal separate second skin incisions (2–3 cm) were made to explore proximal part of basilic vein. The side branches of the vein were isolated and ligated. The basilic vein was divided in antecubital fossa and brought over fascia through the newly created subcutaneous tunnel. The end-to-side anastomosis of basilic vein was done with brachial artery [Figure 1]. All the patients were evaluated for the patency rates and complications for the six months.
|Figure 1: (a) Basilic vein mobilization up to axilla through dissection with small longitudinal incisions ligated and divided at cubital fossa. (b) Subcutaneous tunneling. (c) After closure (blue line shows course of BV in subcutaneous tunnel).|
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| Results|| |
A total of 18 (12 males, mean age 44.2 ± 14 and 6 females, mean age 42.6 ± 12) patients underwent BVT of 2 years at our institute from March 2013 to March 2015. Out of all the patients, 11 (61%) were previously operated on at our institute and the seven (39%) patients with failed AVF surgery were referred at our tertiary care. The characteristics of the patients including mean age, duration of ESRF, number of AVFs, patency duration, comorbidities and diameter of the basilic vein, and brachial artery are shown [Table 1]. The mean operative time for BVT was 185 ± 12 min. The patients were followed for six months.
The fistula maturation rate was 100%, and the mean postoperative flow rate was 290 ± 22 mL/min [Table 2]. The patency was observed at discharge, at six weeks and six months. There was no primary failure in these patients. The mean maturation time was 42 ± 10 days. Six (33%) patients had arm edema, and three had infections (17%), which were treated with arm elevation and antibiotics. There were five (28%) patients who had lymphorrhea which completely stopped in a month with conservative management, including aspiration and dilute betadine instillation [Figure 2]. No bleeding, thrombosis, failure, pseudoaneurysm, or rupture occurred in our patients.
|Figure 2: Matured BV in subcutaneous tunnel (red arrow), anastomotic site incision (black arrow), and small longitudinal incisions with lymphorrhea (green arrow).|
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| Discussion|| |
The establishment and maintenance of hemodialysis vascular access for the ESRD patient is a costly modality with significant associated morbidity. AVF surgery to supply extracorporeal blood flow during HD has been performed for many years.
According to the National Kidney Foundation’s KDOQI, “radial-cephalic (RC) and brachial-cephalic (BC)” fistulae should be the first and second choices for vascular access, respectively, and in the absence of adequate veins or after failed RC/BC access, a brachial-basilic fistula or arteriovenous graft should be considered. “BVT was first described in 1976 and has been increasingly accepted as a viable option for secondary or tertiary vascular access. Although the peri-operative morbidity associated with BVT is higher, it is increasingly the access procedure of choice when a superficial arm vein is unavailable. The conventional BVT required longer incisions, but with modified technique of two to three small incisions for dissecting the basilic vein and then tunneling it in the subcutaneous plane, the morbidity is minimal in our series.
In a single-stage procedure, basilic vein can easily twist during tunneling and cause immediate thrombosis or stenosis in the vein near the axillary and basilic junction (swing point) but no such event encountered in our series during tunneling. Few studies in the literature have compared different techniques for BVT.,, Kakkos et al compared one-stage and modified two-stage BVT and found fistula maturation was 85.5% in Group 1 and 81.6% in Group 2. They concluded that there was no significant difference between the groups. In this study, all the patients underwent single-stage BVT with better fistula maturation rate.
Reported complication rate for BVT remains high (between 47% and 71%) when long incisions were used to dissect the vein, but this can be reduced with technique of transposition. The complications in this study were lymphorrhea in 28%, infection in 17%, edema in 33%, and hematoma in 6% which probably were due to the excess dissection but all were managed conservatively. Early postoperative acute arm swelling is a combination of the larger dissection, coupled with the higher venous flow seen after BVT. The edema may hamper successful needling of the AV fistula. The lymphorrhea resulting from lymphedema due to extensive dissection was managed with arm elevation. Few of the patients required intermittent aspiration and dilute betadine instillation. The postoperative wound infections occurred mostly in diabetic patient but were successfully treated with daily dressings. Almost all the patients had resolved edema and lymphorrhea by the time of maturation of fistula. Thus, early complications do not seem to have any impact on fistula outcome. There was no thrombosis, failure, rupture, or pseudoaneurysms that occurred in our patients.
The main limitations of the study are the retrospective design, short follow-up time and the mean diameter of the basilic vein that underwent BVT was predetermined. It is well known that many factors influence fistula maturation,,, but in terms of improving fistula outcome and technical success rates, the preoperative assessment of basilic vein quality and caliber using duplex ultrasound has been increasingly advocated.
| Conclusion|| |
In our experience, the BVT is technically feasible and having excellent fistula patency. It is the most durable HD access procedure for those patients having multiple forearm AVF surgeries. With small incisions for exteriorization and followed by subcutaneous tunneling of the basilic vein, the operative complications are minimal.
Conflict of interest:
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Saurabh Sudhir Chipde
Department of Urology and Kidney Transplantation, Sri Aurobindo Institute of Medical Sciences, Indore
[Figure 1], [Figure 2]
[Table 1], [Table 2]