Abstract

Background: This study aims to discuss the outcomes of superficialization of basilic vein technique in brachiobasilic arteriovenous fistula formation and to present our experience.

Methods: Between January 2006 and January 2012, 170 patients (74 males, 96 females; mean age 60.7±9.1 years; range 31 to 83 years) who underwent basilic vein superficialization surgery in our clinic were included. All patients were examined under Doppler ultrasonography preoperatively. Demographic data of the patients, maturation time and complications were recorded. The mean follow-up was 12 months.

Results: Non-dominant upper limb was preferred for surgery. Of the 170 patients who were operated, 166 (97.6%) underwent hemodialysis. The mean maturation time was 61 days. Massive bleeding in the postoperative period occurred in two patients (1.2%). Wound infection was observed in eight patients (4.7%) in the early postoperative period. The most common reason for primary failure was thrombosis, which was observed in 48 patients (28.2%). The primary and secondary patency rates of the fistulas were 77% and 82%, respectively at one-year.

Conclusion: Arteriovenous fistula formation through superficialization of the basilic vein offers satisfactory results in chronic hemodialysis patients with reasonable postoperative complication rate.

End-stage renal disease (ESRD) is becoming an important health problem, and the long-term survival for patients with chronic renal failure can result in multiple operations for vascular access. The National Kidney Foundation’s Dialysis Outcomes Quality Initiative (NKF-NDOQI) primarily recommends autogenous arteriovenous access for chronic hemodialysis patients,[1] but the Brescia-Cimino fistula is still used the most followed by the brachiocephalic arteriovenous fistula at the elbow level. Basilic vein transposition was first described in 1976 and is a reliable procedure for secondary vascular access.[2,3] Whenever the forearm vessels are not suitable for arteriovenous fistula creation or when these fistulas have failed, the options for vascular access are either the brachial-basilic arteriovenous fistula or a prosthetic graft;[4,5] however, basilic vein transposition has fewer complications and better patency rates than the grafts.[6]

In this study, the superficialization of the basilic vein technique was utilized to achieve brachiobasilic arteriovenous fistula access at a single institution, and the results were then analyzed.

Methods

Between January 2006 and January 2012, 170 consecutive patients (74 males, 96 females; mean age 60.7±9.1 years; range 31 to 83 years) who underwent basilic vein superficialization for brachiobasilic arteriovenous fistula access at a single institution were included in this study. All patients in the study group had previously undergone failed radialcephalic and brachial-cephalic arteriovenous fistula operations. Non-dominant left upper extremities were preferred in 112 patients (65.9%). The most frequently associated diseases with this procedure were hypertension in 88 patients (51.8%), diabetes in 72 (42.4%), and peripheral arterial disease (PAD) in 36 others (21.2%). The demographic data of the patients and their maturation times are detailed in Table 1.

Table 1: Demographic data of the patients and maturation time

Preoperatively, all of the patients were examined via Doppler ultrasonography (USG) for vein mapping. In addition, the basilic, cephalic, subclavian, and jugular veins were evaluated for stenosis and occlusion.

The operations were performed under local anesthesia using 20-40 ml 2% prilocaine. At the beginning, a 3 cm incision was made in the antecubital fossa, and the brachial artery and basilic vein were explored (Figure 1). In addition, a separate 6-8 cm skin incision was also made to explore the proximal part of the basilic vein. Next, the side branches of the basilic vein were ligated, and the vein was transected as distally as possible. In doing so, the median antebrachial cutaneous nerve was carefully spared to avoid disturbing this nerve. The basilic vein was then divided at the level of the antecubital fossa and transported over the deep fascia under the skin. Following this, it was gently dilated with heparinized saline for enlargement. Anastomosis was completed using an end-to-side technique with 7/0 polyproylene sutures (Figure 2), and a minivac drain (Bıçakçılar, İstanbul, Turkey) was inserted through a subcutaneous tunnel in each patient. Afterwards, the deep fascia was reapproximated with separated sutures under the vein, and the skin was closed. The patients were discharged the day after the surgery.

Figure 1: Skin incision for basilic vein superficialization.

Figure 2: Schematic view for basilic vein superficialization.

Surgical success was achieved if there was the presence of a bruit or thrill on the arteriovenous fistula. Primary patency is defined as the point at which the fistulas were functioning for dialysis up to the time of the first failure, and secondary patency is defined as the interval from the time of access placement until access abandonment, regardless of the number of interventions required to maintain patency.[2] All of our patients were followed up for 12 months postoperatively, and any complications and related interventions were recorded.

Statistical analysis
Statistical analyses were performed with the SPSS for Windows version 11.0 (SPSS Inc., Chicago, IL, USA) software program, and the data was analyzed with the Kaplan-Meier test to determine the primary and secondary patency rates.

Results

Of the 170 patients who were operated on for basilic vein superficialization, 166 (97.6%) underwent hemodialysis. Poor flow rates were detected in the other four patients, and another arteriovenous fistula access via a different upper extremity location was performed in them. The mean period for the first needling was 61 days (range 45-72).

Postoperative complications following the superficialization of the basilic vein fistula are listed in Table 2. Massive bleeding in the postoperative period occurred in two patients (1.2%), with the source in both being bleeding from the anastomotic line. However, this was easily controlled with an additional 7/0 polypropylene, and all of the fistulas were patent after the surgery.

Table 2: Postoperative complications following the superficialization of the basilic vein fistula

Wound infection in the early postoperative followup was observed in eight patients (4.7%), and all of these cases were treated with antibiotics. Hence, no additional surgical revision was required.

In the routine follow-up of the patients, the most common reason for primary failure was thrombosis, which was observed in 48 patients (28.2%), and all of them underwent a thrombectomy or segmental access replacement under local anesthesia. After exploring the arterial and venous segments of the fistula, the thrombectomy was performed. In eight patients, we observed a stenotic venous segment close to the anastomotic region. After the procedure, this venous segment was removed, and a 6 mm polytetrafluoroethylene (PTFE) graft measuring 2-4 cm in length was interposed for the segmental access replacement in order to maintain the flow through the arteriovenous fistula. In the remaining 32 patients, only a thrombectomy was necessary. The operation was successful in 40 of the patients. In the remaining eight, another arteriovenous fistula was created. In six patients (3.5%), severe arterial steal syndrome occurred, and these underwent a reoperation for banding. In addition, upper extremity edema developed in 26 patients (15.3%), and 24 of these were transient in nature. Ligation of the fistula was only necessary in one patient due to massive arm edema. At the one-year follow-up, the primary patency of the fistula was 77% and the secondary patency was 82%.

Discussion

Autologous arteriovenous hemodialysis has been the gold standard for the treatment of chronic hemodialysis patients,[7] and a radiocephalic fistula in the nondominant arm is the first choice for arteriovenous fistula operations.[8] However, access via a brachiobasilic arteriovenous fistula is increasingly becoming the procedure of choice when a superficial arm vein is unavailable.[7] The basilic vein is long, deeply positioned, and generally free of puncture with a relatively large diameter and higher venous flow along with high patency and maturation rates.[7] The main disadvantage of this technique is the location of the fistula on the inner aspect of the upper arm.

In complicated cases, a surgeon must sometimes decide between a prosthetic graft and a native arteriovenous fistula for vascular access, with the fistulas having a lower incidence of infection and longer patency rates.[6,9-12] The disadvantages of basilic vein superficialization include the possibility of vein injury during exploration and mobilization, wound complications related to the extensive dissection, longer operating times, and injury to the median and cutaneous nerves.[9,13] At our facility, native arteriovenous fistulas are our first choice for vascular access.

The basilic vein superficialization operation can be planned as a single-stage or a two-stage procedure,[14,15] and elevation allows for the use of a longer and straighter length of fistula.[15] Bronder et al.[15] reported on fistula elevation procedure results in 295 cases and found no difference in the number of complications compared with fistulas transposed through a separate tunnel. Kakkos et al.[16] suggested an individualized approach in choosing the method for performing the basilic vein transposition and also indicated that the two-stage basilic vein transposition fistula through two skip-arm incisions was superior to the established one-stage procedure due to less morbidity. However, this procedure is performed at the cost of a second operation and longer access times. We planned and performed elevation and anastomosis via the singlestage method for the patients in this study, with the elevation of the basilica vein being performed after the dissection of the deep fascia.

A preoperative evaluation of the upper extremity veins and subclavian vein by Doppler USG is highly recommended,[17] and preoperative vein mapping should be performed, especially for patients with no obviously useful superficial veins or those who have previously undergone the creation of an upper arm fistula.[14] This may improve the outcome of the fistula operation with regard to postoperative success rates.[17] Additionally, venography and multislice spiral computed tomography angiography can also be used to evaluate vascular structures. At our facility, we routinely perform vein mapping for all of our patients using Doppler USG.

Conclusion

Basilic vein superficialization is a viable alternative for dialysis access in patients with chronic renal failure. In addition, arteriovenous fistula surgery via the superficialization of the basilic vein offers satisfactory results in chronic hemodialysis patients with reasonable postoperative complications.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

References

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