Keyhole technique for autologous brachiobasilic transposition arteriovenous fistula

Abstract

Autologous brachiobasilic transposition arteriovenous fistulas (AVFs) are desirable but require long incisions and extensive surgical dissection. To minimize the extent of surgery, we developed a catheter-based technique that requires only keyhole incisions and local anesthesia. The technique involves exposure and division of the basilic vein at the elbow. A guidewire is introduced into the vein, and a 6F "push catheter" is advanced over the guidewire and attached to the vein with sutures. Gently pushing the catheter proximally inverts, or intussuscepts, the vein. Side branches that are felt as resistances when pushing the catheter forward are localized, clipped, and divided under direct vision. Throughout the procedure, the endothelium always remains intraluminal. The basilic vein is externalized at the axilla without dividing it proximally and is tunneled subcutaneously, where it is anastomosed to the brachial artery. Thirty-two patients underwent the procedure--31 as outpatients. The mean duration of operation was less than 90 minutes. All patients tolerated the procedure well, and 31 required only intravenous sedation and local anesthesia. At a mean follow-up of 8 months, the primary patency rate of AVFs in patients with basilic vein diameters of 4 mm or more on preoperative duplex ultrasonography was 80%, vs 50% for those with vein diameters less than 4 mm. Overall, 78% of patent AVFs were being successfully accessed and 22% were still maturing at last follow-up. Autologous brachiobasilic transposition AVFs can be created by using catheter-mediated techniques that facilitate the mobilization and tunneling of the basilic vein through small incisions. Medium-term data suggest that the inversion method results in acceptable maturation and functionality of AVFs created with this technique.