Surgical Treatment of Cephalic Arch Stenosis by Central Transposition of the Cephalic Vein

Abstract

After creation of a brachiocephalic (BC) arteriovenous fistula (AVF), stenosis of the cephalic vein close to its junction with the axillary vein (cephalic arch stenosis, CAS) can develop. Flow impairment and access thrombosis are the consequences, sometimes complicated by prestenotic aneurysm of the cephalic vein. We here report our experience with cephalic vein transposition (CVT) for CAS. From March 2007 through February 2012, symptomatic CAS was detected in 25 patients (13 female) with either dysfunction (n=14) or thrombosis (n=11) of their BC AVF. All were treated by CVT: the vein was ligated and cut distally to the stenotic segment, then tunneled subcutaneously to the medial aspect of the upper arm and anastomosed to the proximal brachial or basilic vein in an end-to-side fashion. Simultaneous thrombectomy of the cephalic vein was performed in 11 patients and aneurysmorrhaphy in 9. In addition, one patient had a proximal new AV anastomosis, another angioplasty of an in-stent restenosis of the access-draining subclavian vein. After CVT, two acute complications (8%) occurred: access thrombosis (one) and bleeding (one). During follow-up (1 to 54 months, median 13 months, 34.5 patient-years), six patients died with functioning AVF, three were successfully transplanted. Primary (secondary) 1-year patency was 79% (90%), with a reintervention rate of 0.1/patient/year. Primary 1-year access patency rates after CVT compare favorably with those after interventional treatment, and reintervention rates are lower. Frequently occurring prestenotic aneurysms could be repaired simultaneously. CVT should therefore be regarded as the treatment of choice for CAS.