Excellent performance of one-stage brachial–basilic arteriovenous fistula

Xavier H. A. Keuter1,6, Frank M. van der Sande2, Alfons G. Kessels3, Michiel W. de Haan4, Arnold P. G. Hoeks5,6 and Jan H. M. Tordoir1,6

1 Department of Surgery, 2 Department of Nephrology, 3 Department of Clinical Epidemiology and 4 Department of Radiology, University Hospital Maastricht and 5 Department of Biophysics, 6 Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, The Netherlands

Correspondence and offprint requests to: Xavier H. A. Keuter, Department of Surgery, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands. Email: xha.keuter{at}ah.unimaas.nl



   Abstract
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Background. According to the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) and the European Guidelines, the first and second choice for vascular access for haemodialysis are the radial–cephalic and brachial–cephalic arteriovenous fistula (AVF). Autogenous fistulas have a longer functional lifetime, less thrombotic complications and a lower infection risk compared with prosthetic implants. If it is impossible to create a brachial–cephalic AVF or after failure, either a brachial–basilic (BB) or a prosthetic forearm loop AVF may be considered. To determine the outcome of BB-AVFs, we retrospectively surveyed the results of this type of vascular access.

Methods. All BB-AVF patient records over a 6 year period were subtracted from an academic hospital registry. Primary failure and primary, assisted primary and secondary patency rates were calculated with the Kaplan–Meier method. Sex, diabetes mellitus (DM), pre-operative duplex diameters, complications and interventions were recorded and correlated with the patency rates.

Results. A total of 31 BB-AVFs were created in a one-stage surgical procedure. Of the patients, 36% were male and 19% had DM. Only one patient had a primary failure, leaving 30 (97%) of the BB-AVFs functional for dialysis treatment. Four patients died within 1 year after the operation, one of them from a catheter sepsis. Primary, assisted primary and secondary patency rates after 1 year were, 58, 83 and 90%, respectively. Patient characteristics and pre-operative duplex parameters did not influence patency rates.

Conclusion. The BB-AVF is an excellent third choice option for vascular access.

Keywords: brachial–basilic arteriovenous fistula; haemodialysis; retrospective study; vascular access patency



   Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
A well functioning vascular access is a major necessity for adequate haemodialysis treatment. However, in the present dialysis population with various co-morbidities, it becomes extremely difficult to create an autogenous radial or brachial–cephalic arteriovenous fistula (AVF), as recommended by European and American guidelines. A brachial–basilic (BB) AVF or prosthetic graft implants are considered to be acceptable alternative methods, although the creation of an autogenous fistula still remains in favour [1,2].

The basilic vein can be transposed or elevated subcutaneously, making it accessible for cannulation and haemodialysis. Both one-stage and two-stage basilic vein transposition procedures have been reported with generally good results [3,4]. However, the risk of non-maturation of BB-AVFs may be considerable compared with prosthetic graft AVFs [5].

To elucidate these aspects, we retrospectively studied the performance of BB-AVFs.



   Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
All patient records of patients with a BB-AVF over a 6 year period were recalled from a computer database. Age, sex, previous access procedures, pre-operative arterial and venous dimensions, complications and interventions were recorded. Pre-operative duplex ultrasound investigation (SSD-2000, Aloka Co. Ltd, Tokyo, Japan) was performed according to a standard protocol by experienced vascular technicians, measuring the diameters of brachial, radial and ulnar arteries and cephalic and basilic veins in the fore- and upper arm. Patients were operated on using regional or general anaesthesia. A one-stage surgical technique was executed in all patients, with vein transposition and arteriovenous anastomosis in one session. In six patients, minimal invasive basilic vein dissection was carried out using endoscopy. Intraoperative angiography was performed to exclude technical problems. Cannulation of the fistula was allowed after 4–6 weeks, when wound healing was completed and haematoma disappeared.

Statistical analysis
Data were collected in a spreadsheet and analysed. The patency rates were calculated with the Kaplan–Meier life-table method. Clinical criteria were used for non-maturation, e.g. inability to cannulate the AVF or to obtain sufficient dialysis flow. We used patency rate definitions as described by Sidawy et al. [6]. The log-rank test was used to search for clinical and duplex parameters that may affect the patency rates. Statistical analyses were performed in SPSS 11.0. A P-value <0.05 is considered to be statistically significant.



   Results
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Autogenous BB-AVFs were created in 31 patients. Characteristics of the patient group are outlined in Table 1. Of the study population, 80% had had a previous vascular access. During the study period, eight patients died and two had kidney transplantation. In these patients, the BB-AVF was functioning well. Non-maturation occurred in one BB-AVF (3%). This AVF was never used and was abandoned. There were three post-operative complications; two patients developed haematomas requiring surgical evacuation [one due to a high International Normalized Ratio (INR) caused by oral anticoagulation]. One patient died 19 days post-operatively from a catheter sepsis due to a non-tunnelled central vein catheter. A total of 22 interventions were performed within 1 year after the operation, including five surgical thrombectomies [one after operation, two after failed percutaneous transluminal angioplasty (PTA) and two late thrombectomies]. Only two thrombectomies were successful, with salvage of the access site. Eight PTAs were performed for stenosis formation, with in addition two stent placements for stenosis recoil and central venous obstruction. Vein rupture occurred during two PTAs (68 and 144 days after the creation of the AVF). One was resolved with a covered stent implantation and the other was surgically revised. One surgical intervention for pseudoaneurysm was performed 58 days post-operatively. Within 1 year after the operation, three (10.3%) patients developed high-output cardiac failure due to high volume flows in the fistula. Distal radial artery extension (two patients) or interposition of a 4 mm diameter polytetrafluoroethylene (PTFE) graft (one patient) was performed to reduce access flow.


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Table 1. Clinical characteristics of patients

 
Two (6.5%) patients developed symptoms of ischaemia. Symptoms developed after 69 days and 2.5 years and were due to low flow in diseased radial and ulnar arteries. Conservative treatment and distal revascularization with an interval ligation (DRIL) procedure, and a finger amputation were needed, respectively. Symptomatic venous hypertension due to central vein obstruction occurred in three patients, necessitating stent implantation in two and conservative treatment in one patient.

Primary, assisted primary and secondary patency rates after 1 year were 58, 83 and 90%, respectively. Two year patency rates for primary, assisted primary and secondary patencies were 47, 83 and 90%, respectively (Figure 1). The log-rank test for gender, diabetes, previous central vein catheter, previous access and video-assisted endoscopic method showed no correlation with the patency rate of the BB-AVF. Pre-operative duplex parameters did not influence the patency rates.



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Fig. 1. Primary, assisted primary and secondary patency of the BB-AVF (n = number at risk).

 


   Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
These results show low non-maturation and high patency rates after 1 and 2 years in patients who had previous vascular access in most cases.

Today, creation of a functional radial–cephalic or brachial–cephalic AVF becomes difficult due to damaged and/or diseased vessels in patients with various co-morbidities. The upper arm basilic vein is usually in a non-harmed condition because of its deep location, protecting it from iatrogenic damage. Therefore, the BB-AVF seems to be an attractive alternative conduit to initiate an autogenous AVF.

A BB-AVF can be created either by transposition or elevation of the basilic vein. Due to its more medial location, the elevated basilic vein may be difficult to cannulate, making it prone to haematoma formation and thrombosis [7]. Transposition and elevation can be executed as a one- or two-stage procedure [4,7]. In the one-stage technique, the risk of twisting in the subcutaneous tunnel may be considerable, while the small diameter of the vessels may increase the risk of early failure. In the two-stage procedure, the basilic vein has time to enlarge, making it less vulnerable to iatrogenic damage when transposed or elevated. The longer period needed before the newly created fistula can be cannulated in the case of the two-stage procedure might be a disadvantage.

Although 80% of the patients had a previous vascular access, the non-maturation was low (3%) compared with those reported in the literature (15–38%) [8,9]. An explanation could be that in the case of a previous ipsilateral forearm vascular access, the basilic vein diameter has already been increased. On the other hand, high maturation rates were also reported in diabetics, in which only 15% had previous accesses [10].

Ascher et al. [11] have found a negative correlation between previous vascular access and long-term patency of the BB-AVF. We could not find this correlation and calculated excellent 1 and 2 year secondary patencies compared with those reported in the literature (47–92 and 41–86%, respectively) [8,9,12–15]. This high secondary patency underlines the functionality of the BB-AVF and may be enhanced by access surveillance. In our study, pre-emptive intervention was performed according to certain monitoring parameters (access flow decrease of 25%) or if patients had significantly longer bleeding time or increased venous pressure. PTA is the first option for stenosis treatment, but it is not without risk, since the vessel may rupture. Higher risk of rupture of upper arm veins (14.9%), mainly at the entrance of the cephalic vein into the subclavian vein and at the end of the transposition, in BB-AVFs has been reported [16]. Restenosis may occur; in our series, one patient had 16 PTAs in 2.5 years. Surgical revision with patchplasty should be considered if stenosis appears within a few weeks after the creation and when restenosis occurs frequently after PTA. Stenoses of the basilic vein just before the confluence with the deep system are frequently seen. These lesions may be caused by scar formation at the entrance to the subcutaneous tunnel, motion of the arm at that point or iatrogenic damage from vein distention at surgery [14]. Scar formation at the entrance of the subcutaneous tunnel can possibly be prevented if the entrance is created more gradually, into the subcutaneous tissue.

The incidence of ischaemia has been reported to be higher in proximal AVFs. Only two patients in this study had symptomatic ischaemia, of which one needed to be surgically treated. Limiting the length of the arteriovenous anastomosis may possibly prevent the occurrence of ischaemia [17].

The increased cardiac output (CO) due to the high flow can cause left ventricular hypertrophy and ultimately cardiac decompensation. The CO, measured during haemodialysis, is a good parameter to review the workload of the heart. It has been shown that left ventricular dilatation can be reversed after ligation of the fistula [18]. If the BB-AVF should fail after all, Matsuura et al. showed that it is possible to insert a prosthetic graft in 89% of the cases [13]. Therefore, we recommend reserving the prosthetic implant as a final option.

In conclusion, the BB-AVF is a good option for vascular access, resulting in high primary and long-term functional rates. One of the major disadvantages of the BB-AVF is the high access flow which can cause cardiac failure and ischaemia of the hand.



   Acknowledgments
 
This study was supported by a grant from the Dutch Kidney Foundation.

Conflict of interest statement. None declared.



   References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

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Received for publication: 24. 2.05
Accepted in revised form: 10. 6.05





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