From the Society for Clinical Vascular Surgery

Brachial versus basilic 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 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 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 , 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 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 . 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). is used to temporarily approximate the skin edges, and the vein is draped over the skin in the area of the planned RESULTS tunnel, which is then marked on the Bskin). A(Fig 2The, study comprised 38 men (64%) and 21 women tunneling device is brought subcutaneously, along the lat- (36%), and the median age was 55 years (range, 21-82 JOURNAL OF VASCULAR SURGERY 404 Casey et al February 2008

Fig 4. Primary functional patency. BVT, Basilic vein transposi- tion; BrVT, brachial vein transposition.

The median follow-up in our study was 8 months (range, 0-64 months). The fistulas matured in 39 patients (66%) and failed to mature in 12 patients. Three patients were lost to follow-up before maturation could be assessed. Five patients, two with BVT and three with BrVT, had fistulas that were still awaiting maturation at 0 to 14 weeks after the procedure. The maturation rate was 74% for BVT (n ϭ 31) and 47% for BrVT (n ϭ 8). The difference between the two groups was statistically significant (P ϭ Fig 2. A, Dissection of the upper arm during a vein transposition. .049). The mean time to maturation was 11.7 Ϯ 8.8 weeks B, The same patient, with the distal vein ligated just before the and was not significantly different between the two groups. subcutaneous tunnel. In 78% of patients (18 of 23) whose fistulas matured, vein diameters were larger than the mean (4.9 mm) compared with 50% (12 of 24) whose diameters were smaller than the mean. This was statistically significant (P ϭ .043). The preoperative vein diameter was not found in 12 patients. Early primary functional patency rate at 6 months was 71% in BVTs and 40% in BrVTs. The 12-month functional patency rate was 50% in BVTs and 40% in BrVTs (Fig 4), which was not statistically significant (P ϭ .115). Primary- assisted patency rates (Fig 5) were virtually unchanged and were also not significant (P ϭ .154). No preoperative characteristic, including age, sex, race, vein size, number of previous accesses, presence of diabetes mellitus, hypertension, hyperlipidemia, or smoking was statistically different between the two groups (Fig 6), and none of these factors affected maturation rates or patency rates. The 30-day mortality rate was 0%, although one Fig 3. A successful matured vein transposition seen in clinic. patient was lost to follow-up immediately after the proce- dure. Morbidity was 13%. Early complications included a wound infection in two patients, hematoma in two patients years). These 59 patients underwent 59 vein transpositions, (one which required evacuation in the operating room), of which 42 (71%) were BVTs, and 17 (29%) were BrVTs. and three cases of vascular steal syndrome, each requiring In 19 patients (32%), the transposition was the initial access subsequent distal revascularization and interval ligation procedure (range, 0-3 prior procedures). The mean vein procedures. Each of these patients required a brachial size was 4.9 Ϯ 0.9 mm. The mean BVT diameter of 4.9 Ϯ artery–to–brachial artery bypass. Three different conduits 1.0 mm and BrVT diameter of 5.0 Ϯ 0.8 mm were not were used: reversed saphenous vein, contralateral forearm significantly different (P ϭ .39). vein, and a 6-mm PTFE graft. Finally, one patient pre- JOURNAL OF VASCULAR SURGERY Volume 47, Number 2 Casey et al 405

creating a native transposed fistula to the brachial artery. Less attention has been given to the brachial vein as a conduit for dialysis access. At our institution, we will almost exclusively attempt an autogenous fistula in a patient with suitable veins. Each patient undergoes preoperative vein mapping in our vascu- lar lab. If a suitable cephalic vein is not identified at the level of the radial or brachial , we then evaluate the brachial and basilic veins. For many patients (68% in our cohort), an upper extremity transposition is not the initial access procedure. In appropriately selected patients, how- ever, an upper extremity transposition may be a good first access procedure, particularly if the forearm veins are small. We will choose either the brachial or basilic vein for transposition according to the better vein diameter. If vein diameters are comparable, we select the basilic vein owing Fig 5. Primary assisted patency. BVT, Basilic vein transposition; to the greater ease of mobilization and fewer branches. It BrVT, brachial vein transposition. has also now become our practice to take two measure- ments of these veins, at both the mid-humerus and at the Ͻ 100 antecubital region. Veins that are too small ( 4 mm) at either region are usually excluded from usage. Patients with large upper arm girth may not be suitable 80 candidates for a transposition because the longer tunnel requires additional length of vein. Patients with prior upper 60 arm grafts or transpositions are poor candidates for a sub- % sequent BVT or BrVT because of tunneling issues and the 40 theoretic risk of increased arm edema. In patients with prior upper arm vein transpositions, we do not perform addi- 20 tional ipsilateral transpositions; however, an arteriovenous graft can be subsequently placed if needed. Our experience with BrVT is, to our knowledge, the 0 Diabetes HTN HPL Smoked largest reported review in the literature. We found that the maturation rate was significantly better for BVTs (74%) than BrVTs (47%); however, at 6 and 12 months, the Total BVT BrVT patency rates were not significantly different. These early results are comparable with other 6-16centers. These data Fig 6. Patient characteristics. HTN, Hypertension; HPL, hyper- indicate that most of our matured upper extremity trans- lipidemia. positions remained functional for the duration of this study. Despite these modest results, we believe that in carefully selected patients, an upper extremity transposition is a good sented after surgery with symptomatic ipsilateral edema autogenous access procedure. Another potential advantage that resolved without intervention. of vein transposition is that this procedure rarely precludes Ten patients required 13 additional procedures, all of a subsequent ipsilateral upper arm graft. which were percutaneous venous angioplasties. Six percutane- Our patency rates are somewhat less substantial com- ous interventions were performed in BVTs and seven in pared with recent and historical studies of PTFE BrVTs. Five patients had a successful result from the percuta- grafts.9,11,24-26 Cumulative patency rates in these -retrospec neous intervention (3 BVTs and 2 BrVTs). However, five tive studies were 46% to Ͼ75% at 1 year and beyond; required a subsequent operation to achieve dialysis access. however, these same studies demonstrated a greater need for secondary procedures to maintain graft patency com- DISCUSSION pared with our results. In addition, their patient popula- Radiocephalic or brachiocephalic arteriovenous fistulas tions tended to have a greater number of complications, remain the initial dialysis access procedure of choice; how- including graft infections, development of pseudoaneu- ever, very often patients do not have veins that are suitable rysms, and venous outflow stenoses. for creation of a fistula that will mature. Moreover, patients The NKF-DOQI initiatives have attempted to promote who require long-term access over many years will un- increased use of autogenous veins for fistulas. Autogenous doubtedly require one or more procedures. Opinions differ conduits have greater durability, increased patency, and re- about which type of fistula is ideal for subsequent access. quire fewer procedures to maintain patency. Studies have also The basilic vein has been recognized as a suitable vein for shown that prosthetic grafts are more likely to become in- JOURNAL OF VASCULAR SURGERY 406 Casey et al February 2008

fected, require more complex revisions, and are associated 7. Hibberd AD. Brachiobasilic fistula with autogenous basilic vein: surgi- with a greater number of hospitalizations and increased3 calcost. technique and pilot study. AustNZJSurg 1991;61:631-5. The addition of BrVT in our algorithm for hemodialy- 8. Rivers SP, Scher LA, Sheehan E, Lynn R, Veith FJ. Basilic vein trans- position: an underused autologous alternative to prosthetic dialysis sis access was clearly related to the NFK-DOQI “push” for angioaccess. J Vasc Surg 1993;18:391-6. greater autogenous accesses. A more difficult question to 9. Coburn CC, Carney WI. Comparison of basilic vein and polytetrafluo- answer is whether 1-year patency rates of 40% to 50% of roethylene for brachial arteriovenous fistula. J Vasc Surg 1994;20:896- transposition arteriovenous fistulas are competitive enough 904. 10. Butterworth PC, Doughman TM, Wheatley TJ, Nicholson ML. Arte- with results of prosthetic bridge grafts to routinely recom- riovenous fistula using transposed basilic vein. Br J Surg 1998;85: mend their preferential use. Because BrVT was limited to 653-4. 17 patients, the role of this particular fistula in the hemo- 11. Matsuura JH, Rosenthal D, Clark M, Frederick WS, Kirby L, Shotwell dialysis access algorithm is still uncertain. Longer follow-up M, et al. Transposed basilic vein versus polytetrafluoroethylene for with a more robust sample size may further clarify the role brachial-axillary arteriovenous fistulas. Am J Surg 1998;176:219-21. 12. Murphy GJ, White SA, Knight AJ, Doughman T, Nicholson ML. of BVT and BrVT. Long-term results of arteriovenous fistulas using transposed autologous basilic vein. Br J Surg 2000;87:819-23. CONCLUSION 13. Taghizadeh A, Dasgupta P, Khan MS, Taylor J, Koffman G. Long-term Early results from this study demonstrate that BVT has outcomes of brachiobasilic transposition fistula for haemodialysis. Eur J Vasc Endovasc Surg 2003;26:670-2. statistically greater maturation rates compared with BrVT; 14. Rao RK, Azin GD, Hood DB, Rowe VL, Kohl RD, Katz SG, et al. however, BVT and BrVT are comparable with respect to early Basilic vein transposition fistula: a good option for maintaining hemo- primary functional patency and primary assisted patency rates. dialysis access site options? J Vasc Surg 2004;39:1043-7. Larger studies comparing the two fistula types with prosthetic 15. Wolford HY, Hsu J, Rhodes JM, Shortell CK, Davies MG. Outcome grafts are needed to evaluate their relative efficacy in the after autogenous brachial-basilic upper arm transpositions in the post- National Kidney Foundation Dialysis Outcomes Quality Initiative era. dialysis population. Given the benefits of autogenous fistulas, J Vasc Surg 2005;42:951-6. further investigations of this type will be beneficial. 16. El Sayed JF, Mendoza B, Meier GH, LeSar CJ, DeMasi RJ, Glickman MH, et al. Utility of basilic vein transposition for dialysis access. AUTHOR CONTRIBUTIONS Vascular 2005;13:268-74. 17. Bazan HA, Schanzer H. Transposition of the brachial vein: a new source Conception and design: KC, CS, SM, BT for autologous arteriovenous fistulas. J Vasc Surg 2004;40:184-6. Analysis and interpretation: KC, BT 18. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M, et al. Data collection: KC Recommended standards for reports dealing with arteriovenous hemo- Writing the article: KC, BT dialysis accesses. J Vasc Surg 2002;35:603-10. Critical revision of the article: KC, BT, CS, BT, RN 19. Nonnast-Daniel B, Martin RP, Lindert O, Mugge A, Schaeffer J, v d Lieth H, et al. Colour Doppler ultrasound assessment of arteriovenous Final approval of the article: KC, BT, CS, KM, RN, SM haemodialysis fistulas. Lancet 1992;339:143-5. Statistical analysis: KC 20. Rutherford RB. The value of noninvasive testing before and after Obtained funding: Not applicable hemodialysis access in the prevention and management of complica- Overall responsibility: KC tions. Sem Vasc Surg 1997;10:157-61. 21. Tardoir JH, deBruin HG, Hoeneveld H, Eikelboom BC, Kitslaar P. Duplex ultrasound scanning in the assessment of arteriovenous fistulas REFERENCES created for hemodialysis access: comparison with digital subtraction 1. Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis angiography. J Vasc Surg 1989;10:122-8. using venipuncture and a surgically created arteriovenous fistula. N Engl 22. Silva MB, Hobson RW, Pappas PJ, Jamil Z, Araki CT, Goldberg MC, et J Med 1966;275:1089-92. al. A strategy for increasing use of autogenous hemodialysis access 2. Pisoni RL, Young EW, Dykstra DM, Greenwood RN, Hecking E, procedures: impact of preoperative noninvasive evaluation. J Vasc Surg Gillespie RL, et al. 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