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Brachial Versus Basilic Vein Dialysis Fistulas: a Comparison of Maturation and Patency Rates

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Brachial Versus Basilic Vein Dialysis Fistulas: a Comparison of Maturation and Patency Rates From the Society for Clinical Vascular Surgery Brachial versus basilic vein dialysis fistulas: A comparison of maturation and patency rates Kevin Casey, MD, Britt H. Tonnessen, MD, Krishna Mannava, MD, Robert Noll, MD, Samuel R. Money, MD,and W. Charles Sternbergh III, NewMD, Orleans, La Objectives: Although the performance of basilic vein transpositions for dialysis access is well established, the utility and patency rates of brachial vein transpositions are poorly characterized. The brachial vein is being used increasingly as an alternative vein for transposition in an effort to increase the percentage of autogenous fistula utilization. The purpose of this study was to review a single-center comparative experience with these fistulas. Methods: A retrospective chart review was performed on 59 patients who received basilic and brachial vein transpositions between January 2000 and December 2006. Patient demographics, comorbidities, mortality, and morbidity were evaluated. Patency rates were calculated using Kaplan-Meier life-table analysis. Results: Of 59 vein transpositions, there were 42 basilic (71%) and 17 brachial (29%). The 30-day mortality was 0%. for brachial The mean( time to maturation.(049. ؍ Maturation rates were 74% for basilic vein transpositions and 47%P was 11.9؎ 8.8 weeks. Primary patency rates at 12 months were 50% for basilic vein transpositions vs 40% for brachial The mean vein size ؎was 0.9 4.9mm. The mean basilic vein transposition diameter؎ 1.0 ofmm 4.9 and .(115. ؍ P) ) .(39. ؍ brachial vein transposition diameter ؎of 0.85.0 mm were not significantP Conclusions: Despite a higher rate of initial maturation in basilic vein transpositions, brachial and basilic vein transposi- tions had comparable patency rates at 12 months. These preliminary results require further follow-up and a larger cohort of patients for confirmation. Broader use of the brachial vein transposition for dialysis appears justified and can increase the overall percentage of autogenous fistula placement. ( J Vasc Surg 2008;47:402-6.) Dialysis access is a continual challenge for vascularsubcutaneous sur- tunnel, was first described for dialysis access by geons and their patients. Maintaining adequate access Dagherusually et 5 inal 1976. Many studies have since evaluated the requires more than one procedure in life-long hemodialysisefficacy of the basilic vein for long-term dialysis6-16 access. patients. In 1966, Brescia and 1 describedCimino the first Proponents of the basilic vein transposition (BVT) maintain autogenous fistula. Which autogenous fistula is the bestthat isit theis a suitable site for access because, like all autogenous subject of ongoing discussion and debate, and therefistulas, is oftenit has a low incidence of infection, keeps the body free disagreement about which secondary and tertiary procedurefrom isforeign material, and has longer patency rates than the best after a failed initial fistula. polytetrafluoroethylene (PTFE).9,11 An additional advantage The United States has historically lagged behindis thatEu- the surgeon does not “burn any bridges” by attempting rope with respect to the prevalence of autogenousa fistulasBVT; if it fails, then a subsequent ipsilateral graft can be used for dialysis, with a 24% vs 80% usage, respectively,placed. The in initial use of an upper extremity graft may pre- the Dialysis Outcomes and Practice Patterns cludeStudy the creation of a BVT afterwards. (DOPPS).2 In 1997, the National Kidney Foundation–The brachial vein, however, has rarely been studied as a Dialysis Quality Initiative (NKF-DOQI) proposed guide-conduit for an autogenous 16,17fistula. Although it seems lines supporting increased usage of native veins forintuitive dialysis that a brachial vein transposition (BrVT) would access.3 These guidelines have since been revised, possesswith the same advantages as a BVT, this technique may greater emphasis on strategies to increase autogenoushave fis-additional limitations. Concerns about vein diameter tulas. As a result, surgeons have developed innovativeand tech-length available for mobilization, numerous branches, niques and methods for improving autogenous access.and Ingreater depth from the skin may discourage surgeons fact, the drive for autogenous fistulas has led to froma significant using this vein for a transposition. The purpose of this increase in their usage to 46% nationwide4 in 2007.study was to review a single institution’s short-term expe- The basilic vein has long been viewed as an rienceacceptable with BVT and BrVT. conduit for an autogenous fistula. The basilic vein and brachial artery anastomosis, performed by transposing the vein into a MATERIALS AND METHODS From the Ochsner Clinic Foundation. We used our institutional operative record/database to Competition of interest: none. Presented at the Thirty-fifth Annual Meeting of the Society for Clinical identify 59 consecutive patients who underwent BVT or Vascular Surgery, Orlando, Fla, Mar 21-24, 2007. BrVT at the Ochsner Clinic Foundation between January Reprint requests: W. Charles Sternbergh III, MD, Department of Vascular 2000 and December 2006. The study design and protocol Surgery, Ochsner Clinic Foundation, 1514 Jefferson Highway, New were approved by the Institutional Review Board. Retro- Orleans, LA 70121 (e-mail: [email protected]). spectively reviewed data were obtained from inpatient 0741-5214/$34.00 Copyright © 2008 by The Society for Vascular Surgery. charts, outpatient records, operating room notes, dialysis doi:10.1016/j.jvs.2007.10.029 records, and phone calls. Patient characteristics collected 402 JOURNAL OF VASCULAR SURGERY Volume 47, Number 2 Casey et al 403 for the purpose of this study were age, sex, race, and specific comorbidities. The preoperative vein diameter (as deter- mined by vein mapping), number of prior access procedures, and current hemodialysis status were also evaluated. The post- operative rates for 30-day mortality, complications, matura- tion, primary functional patency, and primary-assisted pa- tency were studied. Maturation was defined as the time until the primary fistula was suitable to allow successful cannulation. Primary functional patency was defined as a fistula that remained patent throughout follow-up and was used for hemodialysis. Primary-assisted patency was defined as maintained fistula flow as a result of an adjuvant proce- dure or intervention.18 Patient selection. Patients were eligible for a transpo- sition arteriovenous fistula if the veins were a minimum of 4.0 mm. When the basilic and brachial veins were compa- rable in size, the basilic vein was selected. Primary radioce- phalic or brachiocephalic fistulas were the first choice if a cephalic vein Ն3.0 mm was present. Surgical technique. Doppler studies have been shown to be a reliable and effective evaluation of upper extremity veins.19-22 At our institution, every patient- re ceives preoperative vein mapping in our vascular lab. If no suitable cephalic vein is identifiable for anastomosis with the radial or brachial artery, the basilic and brachial veins are evaluated. Either of these veins will be selected preopera- tively if the diameter Ͼ4 mm. If the diameters are compa- rable, the basilic vein is selected because of greater ease of Fig 1. Anatomy of the upper arm during a basilic vein transposi- tion. Alternatively, the brachial vein could be used as the conduit mobilization and the presence of fewer branches. Vein and anastomosed to the brachial artery. diameter is measured at the mid-humerus and antecubital region for both basilic and brachial veins. Our surgical technique, which is similar to previous de- eral aspect of the arm, distal to proximal. The vein is scriptions of vein transpositions in the 5,7,23literature, is -re carefully oriented and brought through the tunnel on a viewed here (Fig 1). The preferred method of anesthesiagentle curve, is reaching the brachial artery without tension. either general or interscalene block. It is possible to perform The patient is systemically heparinized and the artery is the procedure with conscious sedation and local anesthesia in then mobilized for several centimeters. A standard end-to- a compliant patient. The patient’s upper extremity is circum- side vascular anastomosis is performed. The quality of the ferentially prepared to the axilla. A longitudinal incision is thrill is then assessed. A pulsatile fistula may imply a kink or begun superior and medial to the medial epicondyle of the twist in the vein, constriction from the tunnel, or outflow humerus. This can be placed directly over the brachial artery obstruction. Radial and ulnar pulses are checked, and hep- pulse for a BrVT or more medially if a BVT is planned. arin is reversed with protamine. A two-layer closure is The vein of choice is identified; if vein size is marginal, one performed with running absorbable suture. can look for a more suitable vein through this incision. The Most patients are discharged home the day of surgery median nerve and other cutaneous nerves are carefully identi- or the next day. All procedures were performed by one of fied and spared. The incision is then extended several centi- three attending physicians (W. C. S., B. H. T., S. R. M.) meters at a time while sequentially freeing up the anterior with a resident or fellow (Fig 3). surface of the vein. The incision will usually extend all the way Statistical analysis. The data are expressed as mean Ϯ to the axilla. Small side branches are ligated with silk ties and standard deviation. Patient characteristics were compared clips; larger connections are oversewn with polypropylene using the ␹2 test. Primary and primary-assisted patency monofilament. Additional length can be gained by mobilizing raters were evaluated using Kaplan-Meier plots and com- the vein below the antecubital crease if necessary. pared using log-rank analysis. A value of P Ͻ .05 was The vein is then ligated distally, distended with hepa- considered statistically significant. Statistical analysis was rinized saline with the anterior surface marked, and a Sera- performed using SAS 8.2 software (SAS Institute Inc, Cary, fin clamp is placed A(Fig). A2 , penetrating towel clampNC).
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