Reply

Abstract

We thank Shemesh and Olsha for their comments and appreciate the points raised because they further underscore many of the issues we feel are essential to amplify the use of autogenous veins for the creation of arteriovenous fistulas. Regarding the use of skip incisions, we do not think that their use in the dissection of the brachial vein is a good idea. This vein is very thin and has multiple small branches, and to free it safely for transposition and prevent injury, a long incision that provides better exposure is superior. With regard to flap necrosis from long incisions, as we mentioned in our note, care has to be taken not to undermine the incision. As long as flaps are avoided, the chance of skin necrosis is minimized. As a matter of fact, we have not seen this complication in either basilic or brachial vein transposition arteriovenous fistulas. We agree that one should be selective in choosing the correct patient for this type of arteriovenous fistula creation. In patients with small veins, a synthetic arteriovenous graft may be the more optimal choice. Shemesh and Olsha are to be commended for such a high secondary patency rates in their arteriovenous grafts. In our institutions, however, the secondary patency rate has been in the 60% to 70% at 1 year, similar to that reported in the literature. We believe, therefore, that increasing the prevalence of autogenous fistula creation, as stated in the guidelines set forth by The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines, should lead to an overall increased arteriovenous access patency, decreased costs, and decreased morbidity. The brachial vein is simply another conduit to consider in those without suitable superficial venous anatomy, such as cephalic or basilic veins, in the creation of native arteriovenous fistulas. Regarding “Transposition of the brachial vein: A new source for autologous arteriovenous fistulas”Journal of Vascular SurgeryVol. 41Issue 6PreviewBazan and Schanzer (J Vasc Surg 2004;40:184-6) are to be commended for their timely article that encourages the use of brachial vein transposition in the absence of other suitable autogenous veins. They teach us a lesson in the uncompromising creation of autogenous arteriovenous access (AVA) from veins that we may be unaware of. However, we believe that other factors need to be taken into consideration in the construction of transposed brachial vein AVAs. Full-Text PDF Open Archive