Outcome after autogenous brachial-basilic upper arm transpositions in the post-National Kidney Foundation Dialysis Outcomes Quality Initiative era

Abstract

The Dialysis Outcomes Quality Initiative (DOQI)-inspired push to create autogenous fistulas has led to a resurgence of interest in basilic vein transposition as an autogenous access conduit. We reviewed our experience with autogenous brachial-basilic upper arm transpositions (BTX) to clarify current maturation and patency rates and provide realistic expectations for a tertiary referral vascular practice. We follow an aggressive "all-autogenous" policy with regard to dialysis access and recommend BTX when all cephalic options are exhausted. Prosthetic grafts are not attempted unless all upper extremity veins are unusable. The records of all patients undergoing autogenous basilic and brachial vein upper arm transpositions for hemodialysis access between April 2001 and December 2004 were retrospectively evaluated. Mean follow-up was 10 months (range, 0 to 38 months). Eighty-seven patients underwent 100 basilic and 3 brachial vein transpositions. Most of the patients were already receiving hemodialysis (83%), with a mean of 1.1 (range, 0 to 4) previous access attempts. Perioperative complications included 1 death secondary to a myocardial infarction, 7 hematomas (4 requiring reoperation), and 6 infections (2 requiring reoperation). Steal syndrome developed in five patients. Maturation rate was 79%. Functional primary and secondary patency rates were 23% +/- 5% and 47% +/- 6% at 1 year and 11% +/- 5% and 40% +/- 10% at 2 years, respectively (mean +/- SE). The most common causes of failure for a matured fistula were stenosis within the body of the basilic vein (44%) followed by central venous outflow stenosis (20%). No preoperative variable, including gender, age, diabetes mellitus, presence of ipsilateral hemodialysis catheter, number of previous access attempts, maximal or minimal vein diameter, or obesity, had a significant impact on rate of maturation or long term patency. In our experience, autogenous brachial-basilic upper arm transposition fistulas have initial maturation rates that exceed DOQI guidelines, but disappointing short- to medium-term patency rates. Although these outcomes were obtained within the context of an aggressive all-autogenous policy, the poor durability of these transpositions should prompt further investigation of current access algorithms.