| Abstract|| |
The fistula first initiative has rekindled interest in transposition of basilic vein (TBV) in preference to arteriovenous grafts (AVG). TBV is considered to have advantages over AVG. The aim of this study was to analyze the outcome of TBVs in our center comparing them to a historically matched group of patients who had AVG. Thirty-two patients who underwent TBV as a vascular access procedure in Derriford Hospital between January 2010 and October 2014 were included in the study. The historical control group comprised 31 patients who had AVG inserted in the upper arm between January 1999 and December 2010. Patients who had looped AVG were excluded from the study. The primary failure rates were 22% (7/32) and 16% (5/31) for TBV and AVG, respectively (P = 0.7500). AVGs were associated with a higher incidence of infection and steal syndrome, but the differences were not statistically significant (P = 0.286 and P = 0.286, respectively). Twenty-two interventions were undertaken in the TBV group compared to 18 in the AVG group. This study shows that adoption of TBV reduces the need for AVG. To improve TBV access maturation and survival, it is necessary to consider adopting a selection criteria based on findings on vessel mapping.
|How to cite this article:|
Akoh JA. Adoption of transposed basilic vein as access for hemodialysis. Saudi J Kidney Dis Transpl 2018;29:381-5
| Introduction|| |
The increasing prevalence of end-stage renal disease (ESRD) coupled with insufficient donor kidneys for transplantation means that the vast majority of ESRD patients depend on hemodialysis (HD) as peritoneal dialysis, the alternative, is time-limited. The need for long-term HD is associated with the use of more complex vascular accesses. Native or autogenous arteriovenous fistulas (AVF) have better patency rates andrequire fewer interventions to keep them functioning when compared to synthetic or biological grafts.,, Arteriovenous grafts (AVG) are usually required in patients whose superficial vein network do not permit the creation of AVF. Though characterized by higher maturation rates, the poor long-term patency and increased infection rates of AVGs make the need for autologous AVF more imperative.
The fistula first initiative has rekindled interest in transposition of basilic vein (TBV) in preference to AVG. The basilic vein in the upper arm, due to its deep location, is rarely damaged by previous venepuncture and is often of a good caliber. However, the necessity of a maturation period for the TBV makes its use less attractive for patients who require immediate access.
The aim of this paper was to analyze the outcome of TBVs in our center comparing them with a historically matched group of patients who had AVGs.
| Methods|| |
All patients who underwent TBV (whether in one or two stages) as a vascular access procedure in Derriford Hospital between January 2010 and October 2014 were included in the study. Patients were identified retrospectively from procedure billing codes, and supplementary information was obtained from patients’ notes. The historical control group of patients included 31 patients who had prosthetic AV graft inserted in the upper arm in Derriford Hospital between January 1999 and December 2010. Patients who had looped grafts were excluded from the study. Each TBV or AVG inserted was considered a separate clinical event for the purpose of this study. The operations were performed by four different surgeons who used different grafts and techniques for fashioning AVG or TBV.
Information from case notes, renal computer databases (PROTON Information System, Clinical Computing PLC London; PERPS Renal Database (VitalData), Vitalpulse Limited©, Leyland, Lancs, England) that was recorded prospectively, and surgeon's log books were obtained and entered into a pro forma. Data including age, gender, comorbidities (history of hypertension, diabetes, peripheral vascular disease, cause of end-stage renal disease, use of antiplatelets or anticoagulants, body mass index), history of HD, and number of previous central vein catheters were retrieved. Furthermore, data from preoperative vessel mapping, operative notes, and clinic visits were evaluated to ascertain dates of operation, fistula maturation, first successful dialysis, complications and interventions, access outcome, primary failure, and complications. The results were compared with a historical group of patients, who had prosthetic graft in the upper arm in Derriford Hospital.
Descriptive statistics was calculated for all variables. Chi-squared (×2) and Fisher's exact tests were used to compare categorical variables. Data from patients who had patent fistulas at the last follow-up (March 12, 2015) were censored on that date. Descriptive statistics was used for complication events. All reported P values are two-sided, and a P value of 0.05 was considered statistically significant.
| Results|| |
During the study period, 32 patients who underwent TBV (29 single stage, three double stage) were compared to a historical control group of 31 patients who underwent brachio-axillary AVG for HD. The grafts used comprised 28 PTFEs, two Impra, and one Vascutek. [Table 1] shows the two groups were well matched in terms of age and sex distribution, previous vascular access experience, and prevalence of diabetes mellitus. However, there were significant differences in the use of anti-platelets/anticoagulants – higher in the AVG group (χ2 = 4.5982, P = 0.0320). The mean age of patients in the TBV group was 64.44 years compared to 76.16 years in the AVG group (P = 0.9373).The reasons for creating TBV or AVG were similar with 53% (17/32) and 52% (16/31) due to multiple failed accesses, respectively.
The primary failure rates were 22% (7/32) and 16% (5/31) for TBV and AVG, respectively (two-tailed P = 0.7500). AVGs were associated with a higher incidence of infection (3 vs. 1) and steal syndrome (3 vs. 1), but the differences were not statistically significant (χ = 1.137, P = 0.286 and χ2 = 1.137, P = 0.286, respectively). Two (6%) patients who were receiving antiplatelet drugs bled following TBV. As shown in [Table 2], 18.8% (6/31) died with a functioning AVG compared to 9.7% (3/32) of those who had TBV (P = 0.3020 – Fisher's exact test). The AVG group appeared to have more advanced disease as the proportion transplanted was lower than the TBV group although the difference was not statistically significant (χ2 = 1.0585, P = 0.3035).
The interventions to salvage access or deal with complications are shown in [Table 3]. More interventions were undertaken in the TBV group than the AVG group.
| Discussion|| |
Compliance with guidelines published by the NKF-KDOQI Clinical Practice Guidelines for Vascular Access – Update 2006 and the Society of Vascular Surgery coupled with increased use of TBV has resulted in a significant reduction in the use of AVGs in our center. During the period between 2010 and 2014, only five AVGs were used at the author's institution.
The high primary failure rates for both AVGs (16%) and TBVs (22%) highlight the need for careful assessment and thorough vessel mapping before a decision to perform these types of access procedures.,, In another series where only 60% of 71 TBV patients underwent preoperative imaging, the primary or early access failure rate was 31%. For vascular imaging to lead to improvement in maturation of access, it must be accompanied by selection of patients with vessels adjudged to be compatible to access development. Chemla and Morsy showed that by selecting only patients with a basilic vein diameter of >3 mm for TBV, they achieved 100% maturation in six weeks. Although their numbers were small, due consideration should be given to adopting their selection principle.
As shown in [Table 3], there were more interventions in the TBV group. Most agree that autogenous vascular accesses require fewer interventions to keep them functioning.,, Several retrospective studies comparing TBV with different types of prosthetic grafts,, have shown a higher intervention or reoperation rate in the AVG groups. A meta-analysis of 11 studies (10 retrospective, one randomized controlled trials) reported a higher reintervention rate for prosthetic grafts (0.54 per TBV vs. 1.32 per graft). The higher intervention rate in this series is surprising, and the reasons for this are not entirely clear. Factors contributing to this finding may include a generous selection criteria – the high number requiring angioplasty/ stenting might suggest use of small caliber veins. Furthermore, noting that four patients underwent re-exploration or revision, surgeons’ learning curve might also have been an issue as this was largely a “new” procedure at the author's center.
Despite the assertion of “clear superiority in the TBV group” by Basel et al, the results of TBV are comparable to those of the AVG group. A meta-analysis conducted by Lazarides et al showed no difference in the outcome between the two groups at one year.
The limitations of a study of this nature (historical case-controlled comparison) are well recognized. Not only is comparison affected by missing data but also the retrospective nature makes meaningful comparison difficult. Due to incomplete data, it was not possible to compare the survival of the two types of vascular accesses. Despite this, the report shows that TBVs are a useful addition to the vascular access armamentarium.
| Conclusion|| |
This study shows that adoption of TBV reduces the need for AVG. In the absence of proper comparative trials of TBV and AVG, it is important to consider adopting selection criteria similar to Chemla and Morsy that will lead to better access maturation and survival.
Conflict of interest: None declared.
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Dr. Jacob A Akoh
Department of Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8DH
[Table 1], [Table 2], [Table 3]