Video-assisted basilic vein transposition for haemodialysis vascular access: preliminary experience with a new technique

Jan H. M. Tordoir, Ruben Dammers and Maurits de Brauw

Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands



   Abstract
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Background. The brachio-basilic vein arteriovenous (AV) fistula is increasingly used as a secondary method for haemodialysis vascular access. The conventional surgical technique of brachio-basilic vein AV fistula creation consists of a long incision with dissection of the basilic vein and transposition of it to a subcutaneous anterior position in the upper arm. The aim of this study was to investigate whether minimal invasive basilic vein dissection with an endoscopic technique is feasible.

Methods. In 12 patients, brachio-basilic vein AV fistulas were created by means of a video-assisted technique with semi-closed dissection and harvesting of the basilic vein with the use of an endoscope and standard endoscopic instruments. All patients underwent pre- and post-operative duplex ultrasound investigation.

Results. In all patients, a successful endoscopic dissection was possible without peri-operative complications. One patient suffered from post-operative thrombotic occlusion, which was successfully treated by thrombectomy. One patient developed a haematoma in the upper arm. No wound complications occurred and all AV fistulas could be used satisfactorily for dialysis treatment.

Conclusions. Video-assisted basilic vein transposition is a feasible minimal invasive technique to create secondary vascular access for haemodialysis.

Keywords: basilic vein transposition; duplex scanning; endoscopy; haemodialysis; vascular access



   Introduction
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
A well-functioning vascular access site remains the lifeline for patients with end-stage renal disease, who are treated by chronic intermittent haemodialysis. Vascular access by means of the creation of a radiocephalic arteriovenous (AV) at the wrist (Brescia/ Cimino (BC) AV fistula) has been the method of first choice during past decades and when it is initially successful, BC fistulas have few complications and high patency rates. Nevertheless, an increasing number of usually elderly patients will either lack suitable vessels for BC AV fistula construction or have developed irreversible thrombosis of such a fistula. As an alternative, second choice vascular accesses usually invoke the implantation of prosthetic bridge-grafts in the forearm or elbow and upper arm AV fistulas, anastomosing the brachial artery to the cephalic vein or the transposed basilic vein [16]. Reported patency rates of brachio-basilic vein AV fistulas range from 70 to 86% after 2 years. The incidence of thrombotic occlusion and infection is relatively low compared with prosthetic AV fistulas [79].

The conventional surgical technique of basilic vein transposition consists of dissection and mobilizing the basilic vein at the medial side of the upper arm. After dissection, the basilic vein is transposed to a subcutaneous tunnel on the anterior surface of the arm and anastomosed to the brachial artery [10,11]. The large incision needed for this operation with the excessive vein dissection may result in post-operative wound infection, skin necrosis, lymphatic leakage and nerve injury.

With peripheral arterial bypass surgery and coronary artery revascularization, minimal invasive techniques for harvesting of the saphenous vein have been shown to be technically feasible and were associated with fewer wound complications [1214].

In this report we outline the first experience with a minimally invasive video-assisted method for basilic vein dissection and transposition for the creation of brachio-basilic vein AV fistulas.



   Subjects and methods
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Patients
In a total of 12 patients, brachio-basilic vein AV fistulas were created, because of previously failed vascular accesses (mean number 3.1; range 1–6). The patients' characteristics are outlined in Table 1Go. All patients underwent pre-operative assessment of upper extremity arteries and veins by means of duplex ultrasound investigation. The diameters and patency of the brachial, radial and ulnar arteries were determined, and cephalic and basilic vein diameter and continuity in the forearm and upper arm were also assessed. AV fistula volume flows were measured 2 months post-operatively by means of duplex ultrasound.


View this table:
[in this window]
[in a new window]
 
Table 1. Characteristics and co-morbidities of patients with basilic vein transposition

 

Operative technique
Video-assisted vein dissection is carried out with the use of a video monitor, situated at the head side of the patient. For the basilic vein harvesting, a special reusable hook has been manufactured with a channel suitable for introduction of a 5 mm 30° endoscope (Storz Vianen, The Netherlands) (Figure 1Go). A transverse incision is made at the medial site just above the elbow and the basilic vein is localized and dissected. Then the hook is introduced along the vein and a blunt dissection performed with continuous visualization of the vein (Figure 2Go). Standard endoscopic scissors and dissection clamps are used to facilitate the dissection. The median cubital nerve must be identified and eventually freed from the basilic vein. The side-branches are carefully dissected and clipped with a disposable 5 mm clip instrument (Auto Suture Europe S.A. Den Bosch, The Netherlands). Furthermore, a small longitudinal incision is made in the axilla and the basilic vein is removed after complete circumferential dissection and transection at the elbow level. The proximal part of the vein remains attached to the deep vein. Subsequently the anterior surface of the vein is marked to avoid rotation during tunnelling and the quality and diameter of the vein is tested by injecting saline. A subcutaneous tunnel is created anterior in the upper arm, and the vein is brought through the tunnel and anastomosed in an end-to-side fashion to the brachial artery with a running 7-0 polypropylene (Prolene®) suture. Completion angiography is performed to determine technical problems. Needle puncturing for haemodialysis is permitted after 4–6 weeks post-operation.



View larger version (77K):
[in this window]
[in a new window]
 
Fig. 1. Reusable hook with channel for 5 mm endoscope.

 


View larger version (132K):
[in this window]
[in a new window]
 
Fig. 2. View on the arm of the patient. An especially manufactured long hook has been introduced through an incision at the level of the elbow.

 



   Results
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
The mean total operation time was 146 min (range 110–240 min). The mean time for the endoscopic vein dissection was 42 min, ranging from 30 to 90 min. A mean of 4.6 side-branches (range 2–7 side-branches per patient) were clipped with endoscopic instruments. No conversions to an open technique or specific complications of the video-assisted dissection were noticed. One patient developed early post-operative thrombosis, necessitating surgical revision. The same patient experienced a temporary sensory loss in the forearm, probably due to dissection of the cutaneous nerve away from the basilic vein. After 2 months this was fully recovered. There were no post-operative wound complications or infections. One patient developed a haematoma in the subcutaneous tunnel, necessitating surgical exploration with salvage of the access. Three out of 12 patients experienced slight pain in the extremity during the first post-operative week.

The mean hospital admission time was 3 days (range 2–4 days). The median follow-up was 13.4 months (range 6–18 months). There were two late elective interventions after 6 and 13 months in the same patient because of a lowered blood-flow through the AV fistula, as measured by Transonic flowmetry. This patient was successfully treated by percutaneous transluminal angioplasty of a significant venous outflow stenosis at the level of the axilla. The primary, assisted-primary and secondary patency rates after 12 months of follow-up were 75, 92 and 100%, respectively. All AV fistulas were patent at the time of the last follow-up and were used satisfactorily as vascular access for haemodialysis treatment.

The mean AV fistula volume-flow, measured by duplex scanning 6 weeks post-operatively, was 1250 cc/min (range 500–1805 cc/min).



   Discussion
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
The basilic vein in the upper arm is relatively large and has been called the ‘hidden’ vein because it is not visible by simple inspection and palpation. Therefore, it has escaped the damage inflicted by repeated iatrogenic vein punctures or intravenous lines. The use of the native basilic vein offers certain advantages: (i) a high flow through the large vein is possible; (ii) only one anastomosis is required and the distal venous anastomosis, usually the site for stenoses in polytetrafluoroethylene (PTFE) graft AV fistulas, is avoided; and (iii) the risk on infection is low and does not necessitate removal of the native vein AV fistula.

These days, the indication to perform a basilic vein transposition for vascular access is usually failure of previous BC AV fistulas or forearm prosthetic bridge-grafts. In the case of lack of a suitable cephalic vein in the upper arm, a suitable basilic vein may often be detected by duplex scanning and used as an access site. In patients with active infections or a high risk on infection, as documented in two of our patients (HIV-positive and immunosuppressive treatment), the avoidance of implantation of foreign-body materials such as prosthetic grafts is essential. For these patients a native brachio-basilic vein AV fistula may offer a good solution.

The patency rates of transposed basilic vein AV fistulas, as reported from the literature, range from 70 to 90% after 1 year, 70 to 86% after 2 years and 50 to 60% after 3 years of follow-up and are likely to be better compared to PTFE grafts. Also the incidence of thrombotic occlusion (18% vs 80% in the first post-operative year), infection (3% vs 16%) and aneurysm formation (3% vs 6%) seems to be significantly lower compared with prosthetic grafts [46].

The technique of creation of brachio-basilic AV fistulas was initially described by Dagher et al. [10] in 1974 and until now many physicians have adopted and used this same operative method. Basilic vein transposition can be performed as either a one- or two-stage procedure. In the one-stage construction the basilic vein is dissected, mobilized and transposed to a subcutaneous anterolateral position and anastomosed to the brachial artery during one and the same operation. The advantage of this technique is the single operation that is needed for creation of the vascular access. In the two-stage operation the brachio-basilic anastomosis is created in the first instance and after 1–2 months the dilated basilic vein is mobilized and transposed to a superficial subcutaneous tunnel. The merit of two-stage construction is that it allows for the creation of a native AV fistula in patients with suboptimal vessels. It provides a reliable point of access with good blood flow through an anastomosis between already dilated vessels.

On the other hand, large incisions are needed to dissect the basilic vein from the elbow up to the axilla. The risk of cutanuous nerve damage, haematoma, wound complications and in particular post-operative pain is not insignificant. Also, lymphoedema due to the extensive dissection required may occur. This oedema may hamper successful needling of the AV fistula. An incidence of 2–5% post-operative wound infections and lymphatic problems has been reported using the conventional operation [15]. No data on cutanuous nerve damage and persistent oedema can be found in the literature.

Video-assisted basilic vein transposition may have several advantages compared with open basilic vein dissection. It avoids a large wound with all the risks associated with wound complications. Perfect continuous visualization of the vein is possible with a good view of structures such as the median cutaneous nerve and basilic vein side-branches, which makes adequate dissection easy. And certainly the most important advantage of this minimally invasive technique is the fact that patients have no or only slight pain after the operation.

In conclusion, video-assisted basilic vein transposition is a valuable surgical technique for the creation of secondary vascular access in patients undergoing haemodialysis treatment. Prospective studies are needed to prove the value of this new technique for the prevention of wound complications and post-operative pain.



   Notes
 
Correspondence and offprint requests to: Dr J. H. M. Tordoir, Department of Surgery, University Hospital Maastricht, P. Debyelaan 25, Postbox 5800, 6202 AZ Maastricht, The Netherlands. Back



   References
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 

  1. Hibberd AD. Brachiobasilic fistula with autogenous basilic vein: surgical technique and pilot study. Aust NZ J Surg1991; 61: 631–635[ISI][Medline]
  2. Hatjibaloglou A, Grekas D, Saratzis N, Megalopoulos A, Moros I, Kiskinis D, Dalainas V. Transposed basilic vein-brachial arteriovenous fistula: an alternative vascular access for hemodialysis. Art Organs1992; 16: 623–625[ISI]
  3. Rivers SP, Scher LA, Sheehan E, Lynn R, Veith FJ. Basilic vein transposition: an underused autologous alternative to prosthetic dialysis angioaccess. J Vasc Surg1993; 18: 391–397[ISI][Medline]
  4. Coburn MC, Carney WI. Comparison of basilic vein and polytetrafluoroethylene for brachial arteriovenous fistula. J Vasc Surg1994; 20: 896–904[ISI][Medline]
  5. Stonebridge PA, Edington D, Jenkins AM. Brachial/basilic vein transposition for vascular access. J Royal Coll Surg Edinb1995; 40: 219–220
  6. Butterworth PC, Doughman TM, Wheatley TJ, Nicholson ML. Arteriovenous fistula using transposed basilic vein. Br J Surg1998; 85: 653–654[ISI][Medline]
  7. Kherlakian GM, Roedersheimer LR, Arbaugh JJ, Newmark KJ, King LR. Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis. Am J Surg1986; 152: 238–243[ISI][Medline]
  8. Tordoir JHM, Herman JM, Kwan TS, Diderich PM. Long-term follow up of the polytetrafluoroethylene (PTFE) prosthesis as an arteriovenous fistula for haemodialysis. Eur J Vasc Surgery1988; 2: 3–7
  9. Ascher E, Gade P, Hingorani A, Mazzriol F, Gunduz Y, Fodera M, Yorkovich W. Changes in the practice of angioaccess surgery: Impact of dialysis outcome and quality initiative recommendations. J Vasc Surg2000; 31: 84–92[ISI][Medline]
  10. Dagher FJ, Gelber R, Ramos E. The use of the basilic vein and brachial artery as an A-V fistula for long term hemodialysis. J Surg Res1976; 20: 373–376[ISI][Medline]
  11. Logerfo FW, Menzoian JO, Kumaki DJ, Idelson A. Transposed basilic vein–brachial arteriovenous fistula. Arch Surg1978; 113: 1008–1010[Abstract]
  12. Folliguet TA, Le Bret E, Moneta A, Musumeci S, Laborde F. Endoscopic saphenous vein harvesting versus open technique. A prospective study. Eur J Cardiothorac Surg1998; 13: 662–666[Abstract/Free Full Text]
  13. Allen KB, Griffith GL, Heimansohn DA, Robison RJ, Matheny RG, Schier JJ, Fitzgerald EB, Shaar CJ. Endoscopic versus traditional saphenous vein harvesting: a prospective randomized trial. An Thor Surg1998; 66: 26–31[Abstract/Free Full Text]
  14. Robbins MR, Hutchinson SA, Helmer SD. Endoscopic saphenous vein harvest in infrainguinal bypass surgery. Am J Surg1998; 176: 586–590[ISI][Medline]
  15. Humphries AL, Colborn GL, Wynn JJ. Elevated basilic vein arteriovenous fistula. Am J Surg1999; 177: 489–491[ISI][Medline]
Received for publication: 20. 3.00
Revision received 10. 8.00.



This Article
Abstract
FREE Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Search for citing articles in:
ISI Web of Science (5)
Disclaimer
Request Permissions
Google Scholar
Articles by Tordoir, J. H. M.
Articles by de Brauw, M.
PubMed
PubMed Citation
Articles by Tordoir, J. H. M.
Articles by de Brauw, M.