Staging of brachiobasilic Arteriovenous fistula, does it worth effort?

Staging of brachiobasilic Arteriovenous fistula,does it worth effort?

Mohamed E. El Sherbeni M.D., Abdelrahman M. Gameel M.D.,Medhat El-Leboudy M.D. and Waleed A. Sorour M.D.Vascular surgery unit, faculty of medicine ZagazigUniversityE mail: [email protected]

Objective: The purpose of this study is toassess various techniques of brachio-basilicarteriovenous fistulae (BBAVF) as regard thedifferences in long term patencies, functional maturation andpostoperative complications. Patient and methods: 106 BBAVF were performed in104 patients in Zagazig university hospitals,Patients were scheduled to have basilic veintransposition (BVT), as a one-stage (n=28), atwo-stage procedure (n=38) or two stagedsuperficialization (n=40).Then patients werefollowed up in the surgery clinic until theaccess was fully functional for dialysis.Results: the study was conducted on 49 male and55 female with mean age 46.8± 10.1 years, numberof complicated fistulae were 14(50%), 16(42.1%),21(52.5%) in the 3 groups respectively with theincidence of venous hypertension and steal weresignificantly higher than that present in the twoanother staged groups (p value <0.05).As regard1ry patency rates, one stage transposition groupshowing significantly lower patency (p value <0.05) than the two stages transposition group,the difference between the 1ry patency of thestaged superficialization and two stagestransposition or one stage transposition groupwas not statistically significant. Also as regard

2ry patency rates, there was no statisticallysignificant difference between the 3 groups.Conclusion: one stage BVT group has lessoperation time and can be cannulated earlier butwith lower patency rates than other two groups.Although staged BVT has good patency rates withearly use of the fistula and fewer postoperativecomplications than superficialization but stillwith more effort in performing an extraanastomosis.

IntroductionHemodialysis was developed in 1944 as a

successful temporary treatment for patients withend stage renal disease (ESRD) awaitingtransplantation.1,2 The Kidney Dialysis OutcomesQuality Initiative (DOQI) as published by theNational Kidney Foundation, set forthrecommendations as a part of the nationalconsensus, that practitioners avoid percutaneouscatheter-based hemodialysis in favor ofautogenous arteriovenous (AV) access, andfollowed by prosthetic AV access as a secondpreference. 3

Unlike other veins in the arm, the basilicvein is naturally deep and protected from damagecaused by previous venepuncture making it anideal hemodialysis conduit.

The BBAVF was first described by Cascardo in1970 and Dagher in 1976. The original descriptionby Dagher in 1976 described surgery on an out-patient basis under local anaesthesia, throughthree incisions the basilic vein was mobilized,relocated through a subcutaneous tunnel andanastomosed end-to-side with the brachial artery.Two weeks was allowed for the fistula to mature

and this technique was known as basilic veintransposition (BVT) 4,5.

In 1986, Davis et al modified Dagher’soperative procedure by elevating the basilic veinsuperficial to the surgically reapproximated deepfascia and subcutaneous tissue of the arm insteadof routing it through a subcutaneous tunnel, andthis technique was known as basilic veinelevation or superficialization also it can bedone as one or two stages procedure. 6, 7

Staging of BVT was suggested sometime ago; in1998 El Mallah randomized 40 patients to a one-stage or a two-stage BVT procedure with primarypatency rates were 50% and 80%, respectively, ata median follow-up of 15 months8

Advantages are that it produces a long lengthof straight, superficial autogenous fistula witha high flow rate. It involves the formation ofonly one vascular anastomosis, maintains anatomiccontinuity with the axillary vein. Thedisadvantages are that it necessitatingsuperficialization either in the same setting(one stage operation) or in separate settings(two stage operation) with more effort and longerincisions.

In our institute many surgeons preferperforming the technique as a two stageprocedure. The staged procedure may give the veintime to arterialize and strengthen in order towithstand superficialization and may be lessprone to thrombosis.

In 2010 kokkos et al.9 presented a modifiedtwo-stage technique for BVT, in which twoanastomosis are done one with creation of thefistula at the first stage and the other at thesecond stage after tunneling of the vein.

The purpose of this study is to determine thedifferences in long term patencies, functionalmaturation and postoperative complications amongvarious techniques of BBAVF. Patients and methods

During the period from October 2011 toDecember 2012, a 106 BBAVF were performed in 104patients in Zagazig university hospitals. Allpatients were examined thoroughly andpreoperative duplex was performed for venousmapping whenever needed. We preferredbrachiobasilic AVF over prosthetic grafts.

Inclusion criteria:Patients were eligible when 1) A distal

forearm fistula cannot be created with noadequate superficial vein in the upper arm, 2)when they had a suitable basilic vein size (>2.5mm) on ultrasound, and brachial artery size (>3mm) confirmed by intra-operative findings.

Exclusion criteria:Patients were excluded from the study when 1)

Basilic vein diameter <2.5mm on duplex mapping,2) Failure of the BBAVF to mature in stagedgroups, 3) Patients developed steel or massivevenous hypertension after creation of thebrachiobasilic shunt and failed to be corrected,4) Patients refusing performing 2nd stage or lostfrom us in the follow up after the 1st stage wasconducted.

Patients were scheduled to have BVT, as a one-stage (Group A), a two-stage procedure (Group B)or two staged superficialization (Group C) basedon the patient's or surgeon’s preference.

In group A (one stage BVT) The basilic veinwas exposed from the antecubital fossa to the

axilla using a single incision or a series ofsmaller “Skip” incisions. The medial cutaneousnerve of the forearm was protected from injury.The basilic vein was dissected completely freewith the branches ligated. The basilic vein wasgently dilated with heparinized saline, marked tohelp maintain the proper orientation, and wrappedwith a heparin-soaked sponge. The brachial arterywas then exposed immediately proximal to theantecubital fossa and controlled. The basilicvein was then carefully tunneled immediatelybelow the skin in a nice, gentle curve with anextent depended upon the length of the availablevein. The vein was tunneled while distended toavoid twisting. A 3 to 4mm arteriotomy is made inthe brachial artery, and the anastomosis isconstructed in an end to side fashion using a 6-0polypropylene suture then the wound is closed.

In groups B and C, The BBAVF was constructedusing a two-stage approach, with the first stagebeing simply the creation of the AVF under localanesthesia. Three to six weeks after, the secondstage being the transposition orsuperficialization was performed.In group B, the second stage involvesmobilization of the basilic vein through twolongitudinal skip incisions (Fig. 1a), one overthe distal part of the basilic vein near itsanastomosis and one at the level of the proximalarm to allow full mobilization of the basilicvein up to its confluence with the brachial vein;the anterior surface of the arterialized fistulais marked and the proximal part of the vein nearthe anastomosis is controlled with a bulldogclamp followed by vein transection (Fig. 1b); thebasilic vein was mobilized by dividing all

tributaries. Subsequently, a superficialanterolateral arm tunnel is made between the twoincisions (Fig. 2a), with care taken not to makethe tunnel too deep; the vein was retracted offthe proximal incision, dilated with theheparinized solution and placed inside thetunnel. Then, the two ends of the fistula are re-anastomosed with 6/0 polypropylene suture (Fig.2b).

Inthreecasesduringthesecondstagethe veinwas

intraoperatively not fully mature with weakthrill so revision of the fistula was done by

Figure (2): a- Basilic vein mobilization Left. b- Re-anastomosis Right

Figure (1) a-Two skip skin incisions Left. b- Division of the Basilic vein near the fistula Right

connecting the basilic vein to the brachialartery through a new arteriotomy.

In group C superficialization operation wasdone by mobilizing the basilic vein using acontinuous incision, this may requiressacrificing a branch of the medial cutaneousnerve of the forearm. The concerns about woundbreakdown and graft exposure can be eliminated orreduced by creating a subcutaneous pocket for thevein by undermining the lateral skin edges.

Follow upThe patency and flow rate of the fistula were

evaluated and recorded by Doppler US on the firstday after surgery. Patients were followed up inthe surgery clinic until the access was fullyfunctional for dialysis then monthly visits wasadvised to the patient. Fistulae were used forhemodialysis not sooner than the 21 days afterlast procedure, and the choice to use them wasbased on the results of a physical examination,presence of thrill, and duplex findings whennecessary.

Patency was determined by ability to accessthe fistula for hemodialysis. Primary patency wasdefined as the time (months) with uninterruptedpatency and without intervention. Secondarypatency was the period from the original AVFconstruction, regardless of interventions orthrombosis, until abandonment of the access oruntil completion of the study period 10.

While operative ligation was classified asfailure, death with functioning fistula was

considered as lost to follow-up when the cause ofdeath was not related to the fistula.

In this study, our end points were either lossof the patient or inability to cannulate the veinafter 12 weeks of the fistula creation whichindicate failure of maturation. Statistical analysisStatistical analysis was performed with SPSS(version 17.0 for Windows; SPSS Inc), with Pvalue < 0.05 was considered statisticallysignificant. Differences between the groups inpatient demographics were analyzed using one-wayANOVA and Fisher Exact tests. 1ry and 2ry patencyof all Fistulae were analyzed by using Kaplan-Meier survival analysis for the 3 groups, where alog-rank test using pairwise comparison betweeneach 2 separate groups, showed statisticallysignificant values as regard patency rates. Results:

106 Brachiobasilic AVF were created in 104patients (49 male and 55 female). Clinical dataof the patients were presented in table (1), meanpatient age was 48.7 years (range, 12-77). Theright arm was used in 42 cases (39.6%), while theleft arm was used in the other 64 cases (60, 4%).Catheter at the same side was detected in 13(46.4%) cases in group A, 20 (52.6%) cases ingroup B and in 25 (62.5%) cases in group C withno statistical significance between the threegroups. Also there were no significantstatistical differences between the three groupsin relation to preoperative co-morbidity.

Table (1): Demographic criteria of the patients ofthe three study groups

Group AN=28

Group B N=38

Group CN=40

Significance

N % N %

N %

MaleFemale

1315

46.453.6

2018

52.647.4

1624

40 60

NsNs

Age (mean)DiabetesHypertensionHypotensionCHDSystemic

lupusCatheter at

the sameside

RightLeft

43.6±11.913 46.416 57.1

48.4±10.219 5022 57.8

47.5±8.4 23 57.5 26 65

NsNsNsNsNsNs

NsNsNs

350

131216

10.717.80

46.442.957.1

252

201622

5.2 13.1 5.2

52.6 42.2 57.8

272

251426

5 17.5 5

62.5 35 65

CHD; coronary heart disease, Ns; non significant (p value< 0.05)

Excluding patients in pre-hemodialysis orothers lost in the early postoperative period orshunts failed to mature, mean time to use thefistula (measured from the time of accessplacement to the first functional dialysiscannulation) for group A, B and C was 45 (36-78days), 52 (49-112 days) and 66 (45-135 days)respectively.

Table (2): postoperative complications in thethree groups (some patients had more than onecomplications).

Group AN=28

Group BN=38

Group CN=40

Significance

N % N % N %Number ofcomplicated fistula

14 50 16 42.1 21 52.5

Wound hematomaindicatingexploration

2 7.1 3 7.9 4 10 Ns

Wound dehiscenceor infection

2 7.1 4 10.5 8 20 Ns

Thrombosis 5 17.8 7 18.4 8 20 NsSteal syndrome 2 7.1 0 0 0 0 .043Venoushypertensionindicatinginterference

4 14.2 0 0 1 2.5 .017

Aneurysms 2 7.1 4 10.5 6 15 NsFailure to mature 6 21.4 3 7.9 6 15 NsTotal number ofcomplications

23 21 33

Ns; non significant (p value < 0.05)

Postoperative complications are shown in Table(2). The percentage of complicated cases was 50,42.1 and 52.5% in group A, B and C respectively.Because some patients had more than onecomplication, the overall numbers ofcomplications in group A, B and C were 23, 21 and33 respectively. In one stage procedure theincidence of venous hypertension and steal (14.2%and 7.1% of cases respectively) and this valueswere significantly higher than that present inthe two another staged groups.

In three patients with venous hypertension,the fistula was ligated. The other two patients

were one in group A and another case in group Cwhere there was outflow stenosis which wascorrected by interposition graft.

Two patients in group A suffered frompostoperative steal, ligation of the fistula wasthe end point.

It was also noted that incidence of woundcomplications were higher in group C (10% and 20%for wound hematoma and wound infectionrespectively). Wound complications weresuccessfully managed either by re-exploration orby conservative measures except in 1, 3 and 5cases in group A, B and C respectively where itwas mandatory to ligate the fistula.

In our follow up period (12 months) there wasonly one patient died in group A while 3 and 4patients died in group B and C respectively. Alldeaths were not related to the fistulas and wereconsidered as lost to follow up.

Five patients were lost from our follow up oneat group A and two cases in group B and anothertwo cases in group C

In the present study 15 fistulae failed tomature, eight of them were due to postoperativethrombosis with or without wound infection (onein group A, two in group B and five in group C),while in another 7 cases (five in group A, one ingroup B and one in group C) cannulations failedin spite of presence of the thrill. One case ingroup C presented by anastomotic aneurysm whichmandate urgent ligation before cannulation.

Figure (2): Kaplan-Meier test showing 1ry patencyrates of the 3 groups of the study

Table (3) pairwise comparison 1ry patency betweeneach 2 groups

Operation

one stagetransposition

two stagestransposition

stagedsuperficialization

Chi-Square Sig.

Chi-Square Sig.

Chi-Square Sig.

Log Rank (Mantel-Cox)

one stagetransposition

4.506 .034 1.644 .200

two stagestransposition

4.506 .034 .997 .318

stagedsuperficialization

1.644 .200 .997 .318

By revising table (3) showing the pairwise comparison between the three groups as regard 1rypatency, it was found that one stage transposition group showing significantly lower patency (p value < 0.05) than the two stages transposition group. The difference between the 1ry patency of the staged superficialization and two stages transposition or one stage transposition group was not statistically significant (P value =.318 and .200 respectively)

Figure (3): Kaplan Meier test showing 2ry patencyrates of the 3 groups of the study

Operation

one stagetransposition

two stagestransposition

stagedsuperficialization

Chi-Square Sig.

Chi-Square Sig.

Chi-Square Sig.

Log Rank (Mantel-Cox)

one stage transposition

4.849 .028 .855 .355

two stages transposition

4.849 .028 2.265 .132

staged superficialization

.855 .355 2.265 .132

Table (4) pairwise comparison of 2ry patencybetween each 2 groups

By revising table (4) showing the pairwise comparison between the three groups as regard 2rypatency, it was found that one stage transposition group showing significantly lower patency (p value < 0.05) than the two stages transposition group.

DiscussionThe radial-cephalic fistula which is routinely

used as a primary fistula because of its goodlong-term results has reported 1 year primarypatency rates of 70–91% although a recent meta-analysis suggests that the rate may actually beas low as 62.5% 11,12,13,14.

Another alternative option for hemodialysis inthe absence of suitable cephalic vein issynthetic PTFE grafts in different sites.Nevertheless patency rates of BBAVF is superiorto that of PTFE grafts in many comparative

studies15, the high rate of postoperativecomplications in PTFE grafts makes BBAVF a veryvaluable option.

Different techniques were described inconducting BBAVFs, in a study done by Hossny 200370 BBAVFs were constructed, transposed in 30patients and elevated in 40 patients (20 in one-stage and 20 in two-stages). Cumulative secondarypatency rates at 1 year were 87, 90 and 84% inthe transposed, elevated in one-stage andelevated in two-stage groups, respectively 16.

In our study, we tried to assess the efficacyof a modification described by Kakkos et al 9,using two skip incisions to perform two stagebasilic vein transposition (group B) comparingthe results of this modification with another twogroups of patients performing standard BVT (groupA) and two staged superficialization (group C).

Primary failure rates (failure to mature) inGonzalez et al study was 18% in brachiobasilicgroup which was less than in radiocephalic group(39%)14, in our study failure to mature wassignificantly lower in group B (7.9%) incomparison to group A and C (21.4% and 15%)respectively.

In our study primary patency rates at 12 monthwere 40, 62 and 53% in group A, B and Crespectively. While cumulative secondary patencyrates at 12 months were 57, 79 and 65% in groupA, B and C respectively.

Reviewing the literature 9,10,16,17,18,19 for BVT(one stage) our patency rates were less thanexpected. This may be related to the low efficacyof preoperative imaging study with higherincidence for failure of the fistulae to mature.

Group A patency rates (primary and secondary)were statistically significant lower than groupB. This may be due to (1) Exclusion of cases withsteel or venous hypertension from the study ingroup B and C but not in group A as the procedurewas done in one stage (2) The damage that can becaused by extensive dissection of this thinwalled vein and or (3) Higher rates of woundinfection after starting the dialysis.

Although patency rates of group A were thelowest, this group of fistulae had the shortestmean period of time to use the fistula (45 days)compared with the other two groups.

Group B had the highest patency rates in ourstudy and this may due to: (1) it is a stagedprocedure, (2) opportunity to perform accessrevision in the second stage if the thrill wasweak (3) less tissue destruction (no skin flaps).

It was noted in the present study that, theshorter time to the fistula to be used indialysis in comparison with kokkos et al study inwhich the median time to hemodialysis for one andtwo stage procedures was 68 (49-103 days) and 132(102-166 days) days, respectively, with lesspatency rates (still the highest in our study).That may indicate the rush of the patient and usto use the fistula to avoid complications ofcentral venous catheter which may affect thepatency rates.

Early and late hemodialysis-related morbidityof BVT has been reported to be as high as 44-55%20.

Postoperative wound hematomas have beenreported to occur in 3.6-11%,16,21,22,23,24

necessitating wound exploration in 2.5-6.5%cases.21,23,24,25,26. A low rate of hematomas, 3%, was

noted after two-stage procedures in Kakkosseries, significantly lower than thecorresponding 7.9% rate in group B of our study.

In group C (staged superficialization) despitethere was no statistical significant increase inpostoperative complications in comparison togroup A and B, it was noted that there wasincrease in total number of complications; thismay be owing to single long skin incision withflap elevation.

The main limitation of our study is its nonrandomized design and lack of longer term followup. Although failure to estimate total operativeduration precisely was one of the limitations ofthis study it was obvious that BVT group has theshorter operative duration owing to single stagetechnique also group B (staged BVT) had longestoperative duration due to extra anastomosis.ConclusionIn conclusion one stage BVT has less operationtime and can be cannulated earlier but with lowerpatency rates. Although staged BVsuperficialization has better patency rates, ithad longer operative duration and morepostoperative complications. Staged BVT has goodpatency rates with early use of the fistula andfewer postoperative complications thansuperficialization but still with more effort inperforming extra anastomosis.

Recommendations:1-Further reporting of precise total operativetime, postoperative pain and the need foranalgesia as the wound of eithersuperficialization or elevation procedures arelonger than transposition.

2- We must increase the awareness amongnephrologists for early referral of patients withrenal insufficiency to avoid central cathetercomplications and allow us enough time for thefistula to mature.

Refferrences1. Kolff WJ, Berk HT. The artificial kidney: A

dialyser with a great area. Acta Med Scand 1944;117:121–131.

2. Conlon PJ, Nicholson ML, Scwab S. In: Conlon PJ, Nicholson ML, Scwab S, eds. Hemodialysis vascular access: Practice and problems. NY, USA: Oxford University Press: 2000[preface].

3. Foundation NK. KDOQI clinical practice guidelines for vascular access, 2000. Am J Kidney Dis 2001;37(Suppl. 1):S137-S181.

4. Dagher F, Gelber R, Ramos E, Sadler J. The useof basilic vein and brachial artery as an A–V fistula for long term haemodialysis. J Surg Res 1976;20:373–376.

5. Dagher FJ, Gelber RL, Ramos EJ, Sadler JH. Basilic vein to brachial artery fistula: A newaccess for chronic hemodialysis. South Med J 1976;69(11):1438–1440.

6. Davis Jr JB, Howell CG, Humphries Jr AL. Hemodialysis access: Elevated basilic vein arteriovenous fistula. J Pediatr Surg 1986; 21(12):1182–1183.

7. Davis AD. Brachiobasilic fistula with autogenous basilic vein: Surgical technique and pilot study. Aust N Z J Surg 1991;61:631–635.

8. El Mallah S. Staged basilic vein transpositionfor dialysis angioaccess. Int Angiol 1998;17:65-8.

9. Kakkos SK, Haddad GK, Weaver MR, Haddad RK, Scully MM. Basilic Vein Transposition: What isthe Optimal Technique?. Eur J Vasc Endovasc Surg (2010) 39, 612-619

10.Arroyo MR, Sideman MJ, Spergel L and Jennings WC. Primary and staged transposition arteriovenous fistulas. J Vasc Surg 2008;47:1279-83.

11.Rooijens PPGM, Tordoir JHM, Stijnen T, Burgmans JPJ, Smet de AAEA, Yo TI. Radiocephalic wrist arteriovenous fistula for hemodialysis: Meta-analysis indicates a high primary failure rate. Eur J Vasc Endovasc Surg2004;28:583–589.

12.Foran R. Saphenous vein and bovine arterial grafts—a comparative study. Dial Transplant 1975;4:34.

13.Kinnaert P, Vereerstraeten P, Toussaint C, vanGeertruyden J. Nine years’ experience with internal arteriovenous fistulas for hemodialysis. Br J Surg 1977;64:242.

14.Gonzalez E, Kashuk JL, Moore EE, Linas S and Sauaia A. Two stage brachial-basilic transposition fistula provides superior patency rates for dialysis access in a safety-net population. Surgery 2010;148:687-94.

15.Coburn MC, Carney WI. Comparison of basilic vein and polytetrafluoroethylene for brachial arteriovenous fistula. J Vasc Surg 1994;20:896–904.

16.Hossny A. Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysisrelated complications. J Vasc Surg 2003;37:821-6.

17.Murphy GJ, Saunders R, Metcalfe M, Nicholson ML. Elbow fistulas using autogenous vein: Patency rates and results of revision. Postgrad Med J 2002;78(922):483–486.

18.Tsai YT, Lin SH, Lee GC, Huen GG, Lin YF, TsaiCS. Arteriovenous fistula using transposed basilic vein in chronic hypotensive hemodialysis patients. Clin Nephrol 2002;57(5):376–380.

19.Humphries AL, Colborn GL, Wynn JJ. Elevated basilic vein arteriovenous fistula. Am J Surg 1999;177:489–491.

20.Taghizadeh A, Dasgupta P, Khan MS, Taylor J, Koffman G. Long term outcomes of brachiobasilic transposition fistula for hemodialysis. Eur J Vasc Endovasc Surg 2003;26:670-2.

21.Rao RK, Azin GD, Hood DB, Rowe VL, Kohl RD, Katz SG. Basilic vein transposition fistula: agood option for maintaining hemodialysis access site options? J Vasc Surg 2004;39:1043-7.

22.Francis DM, Lu Y, Robertson AJ, Millar RJ, AmyJ. Two-stage brachiobasilic arteriovenous fistula for chronic haemodialysis access. ANZ J Surg 2007;77:150-5.

23.Wolford HY, Hsu J, Rhodes JM, Shortell CK, Davies MG, Bakhru A. Outcome after autogenous brachial-basilic upper arm transpositions in the post-National Kidney Foundation Dialysis Outcomes Quality Initiative era. J Vasc Surg 2005; 42:951-6.

24.Harper SJF, Goncalves I, Doughman T, NicholsonML. Arteriovenous fistula formation using transposed basilic vein: extensive single

centre experience. Eur J Vasc Endovasc Surg 2008;36:237-41.

25.Woo K, Farber A, Doros G, Killeen K, Kohanzadeh S. Evaluation of the efficacy of the transposed upper arm arteriovenous fistula: a single institutional review of 190 basilic and cephalic vein transposition procedures. J Vasc Surg 2007; 46:94-100.

26.Keuter XH, van der Sande FM, Kessels AG, de Haan MW, Hoeks AP, Tordoir JH. Excellent performance of one-stage brachial-basilic arteriovenous fistula. Nephrol Dial Transplant 2005; 20:2168-71.