Two-Stage Basilic Vein Transposition—A New Approach for Pediatric Dialysis Access

Abstract

Conclusion: Rates of arteriovenous fistula (AVF) maturation and patency in pediatric patients are higher for two-stage basilic vein transposition (BVT) than for BVT performed in one stage. Summary: BVT can be performed as a one-stage or a two-stage procedure. Advantages of a two-stage procedure are potential maturation of smaller veins before the actual transposition, thereby potentially improving ultimate success of the transposition. The two-stage procedure is technically easier than a one-stage transposition but does involve two separate procedures. The authors sought to determine whether using two-stage BVTs in children improves fistula maturation rates, fistula use, and overall patency compared with one-stage BVTs, other types of AVFs, and AV grafts. The study took place at two tertiary care children's hospitals. Between 1997 and 2008, 31 patients underwent AV access creation. Forty-two access procedures were performed: 15 two-stage BVTs (36%), 13 one-stage BVTs (31%), 6 radiocephalic fistulas (14%), 3 brachiocephalic fistulas (7%), 1 brachiobrachial fistula (2%), and 4 AV grafts (10%). Average follow-up was 20.4 ± 3.2 months for two-stage BVT and 47.9 ± 4.1 months for other AVFs. All two-stage BVTs matured, but only 14 of 27 (52%) other AVFs matured (P = .001). More two-stage BVTs (87%) were used for dialysis than other AVFs (48%; P = .024). The fistula failure rate in the two-stage BVT was 7% compared with 59% for other AVFs (P = .001). The patency at 1-year was 91% for two-stage BVT vs 47% for other AVFs (P = .003). The size of the basilic vein increased from 0.3 ± 0.027 cm before the performance of the first stage of the BVT to 0.79 ± 0.08 cm after the first stage of the two-stage BVT. Of the 16 failures in the other AVF group, 11 were primary failures occurring before attempted access. One case of steal syndrome occurred in the two-stage BVT group. Comment: Establishing durable hemodialysis access is difficult in all patients and is particularly difficult in the pediatric population because of the overall small caliber of the vessels. Most of the patients in this study, however, were not small children but adolescents with reasonable size vessels to work with. It is therefore a bit unclear whether the apparent advantage of the two-stage BVT in these patients was due to converting a more difficult procedure to a less difficult procedure for performance by surgeons who do not perform large volumes of dialysis access surgery. Two-stage BVT requires two operations, but the first is a relatively small procedure. Given the big picture, there appears to be no great disadvantage to the two-stage procedure and there may be a significant advantage in pediatric patients. The authors' contention that two-stage BVT should be preferred hemodialysis access in the pediatric population deserves consideration.