A Large-Scale Study of the Upper Arm Basilic Transposition for Hemodialysis

Abstract

Conclusion: Basilic vein transposition fistulas have excellent maturation rates and good functional patency at 1 year. Major limitations to long-term durability are the need for frequent revisions and central venous stenosis. Summary: The fistula-first initiative set a goal of >65% prevalence of autogenous fistulas for hemodialysis access to be achieved in the United States by 2009. Multiple studies in the recent past (10 during 2007-2009 alone) have examined maturation and patency rates of basilic vein transposition. The authors used basilic vein transposition as their third choice in the construction of dialysis access, with radiocephalic the first choice and brachiocephalic fistula the second choice. In this article they reviewed the results of basilic vein transposition from April 2001 to June 2008. This retrospective study included information on demographics, volume flow creation, maturation and patency rates, postoperative complications, and the need for secondary interventions as well as overall mortality. There were 217 upper arm basilic vein transposition fistulas in the study. Fifty-three percent of the patients were men and there were 215 patients with a mean of 2.9 previous surgical access attempts before basilic vein transposition. Only 14% of the time was basilic vein transposition the initial fistula. Mean flow at time of fistula creation was 347 mL/min (range, 10-880 mL/min). The maturation rate was 87%. Mortality related to the procedure was 0.5%. At 6, 12, and 24 months, primary patency rates were 63%, 40%, and 26%, and primary assisted patency rates were 74%, 56%, and 38%, respectively. Secondary patency rates at 6, 12, and 24 months were 85%, 72%, and 65%, respectively. The most common complication before maturation was fistula thrombosis (16%), and the most frequent cause of fistula failure was central venous stenosis (22%). Comment: What makes this article stand out among the numerous reports on basilic vein transposition have been published in the recent past is the very high initial maturation rate. The authors attribute this to a technical modification of the procedure. They noted previously that an area of the vein in the upper part of the wound as it passes centrally was a frequent site of intimal hyperplasia. They hypothesize this was caused by tethering of the vein by a large profunda branch in the upper arm. The authors now routinely divide this branch and all entering veins as high as they can reach in the axilla and postulate that the smoother course of the transposition that this allows results in improved maturation. The division of the profunda vein appears to cause no significant complications, and therefore, it seems reasonable to incorporate this technical modification of basilic vein transposition into the operation.