Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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Abstract |
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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
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Introduction |
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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.
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Subjects and methods |
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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 1). 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 2
). 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 46 weeks post-operation.
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Results |
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The mean hospital admission time was 3 days (range 24 days). The median follow-up was 13.4 months (range 618 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 5001805 cc/min).
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Discussion |
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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 12 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 25% 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.
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Notes |
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References |
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