Brachial-basilic Arteriovenous Fistula Research Articles

#2515 Optimizing brachial-basilic arteriovenous fistula outcomes: insights from a mapping and pre-transposition review

Abstract Background and Aims Brachial- Basilic arteriovenous fistulas (BBAVF) are an option for our patients when superficial vascular patrimony is lacking, but they pose technical and time challenges due to the necessity of a second-stage surgical transposition. The literature reports a 47% primary patency rate within the first year. BBAVFs are associated with higher incidences of steal syndrome and increased stenosis rates, commonly requiring interventions. This study aims to provide insights about optimizing BBAVF outcomes through a comprehensive mapping and pre-transposition evaluation. Method We developed a retrospective single-centre study from 2016 to 2022 that included 101 patients with BBAVFs mapped and constructed at Centro Hospitalar Universitário de Santo António. Mapping and pre-transposition evaluations data were collected from our digital records and the dialysis centre's provided insights about the BBAVFs outcomes through telephonic contact. A comparative analysis between patients achieving one-year primary patency (1Y-P) and those who did not (No 1Y-P) was performed, considering mapping variables (brachial artery and basilic vein diameters) and pre-transposition variables (brachial artery flow and basilic vein diameter). Results At 12 months our primary patency rate was 72.27%. The 1Y-P and No 1Y-P groups showed no significant differences concerning to baseline characteristics such as sex (p = 0.536), age (p = 0.489), and major comorbidities like diabetes (p = 0.929), ischemic heart disease (p = 0.741), peripheral arterial disease (p = 0.174), kidney transplantation (p = 0.384), and previous haemodialysis (p = 0.384). When the BBAVFs were constructed as the first access, they were significantly associated with less primary patency at 12 months (1Y-P n = 32 (43.84%) vs No 1Y-P n = 23 (82.14%); p < 0.001). In the vascular mapping the brachial artery (1Y-P 4.32 ± 0.86 mm vs No 1Y-P 4.11 ± 0.78 mm; p = 0.454) and basilic vein (1Y-P 3.90 ± 1.11 mm vs No 1Y-P 3.59 ± 0.88 mm; p = 0.249) diameters were larger in the 1Y-P group, although without statistically significance. It is important to emphasise that only 12 BBAVFs were constructed with less than 3 mm basilic veins and we only had 50% 12-month primary patency in those patients. Pre-transposition flow was significantly higher in patients with primary patency at 12 months (1Y-P 1069,77 ± 311,89 ml/min vs No 1Y-P 985,00 ± 500,83 ml/min; p = 0.018) and basilic vein diameter was higher in the same group, but without statistical significance (1Y-P 6.50 ± 1.19 mm vs No 1Y-P 6.14 ± 1.53 mm; p = 0.123). Conclusion Our primary patency rate was higher than the described in the literature, which could be a reflection of the organized mapping process in our centre that excludes limit size veins from the BBAVF construction. Patients with BBAVF as their initial access face worse outcomes with decreased primary patency time, probably due to lack of intrinsic vascular patrimony. Stringent construction criteria are warranted in those cases. Contrary to expectations, vessel diameters did not show significant relevance, prompting consideration of factors like distensibility or vessels calcifications as potentially influential. However, we have to underline that the average mapping basilic vein diameter was greater than 3 mm in both groups, which suggests a pre-selection is already carried out in our centre, and, even though there was not statistical significance, the 1Y-P group had bigger basilic veins in the vascular mapping. Our results were worst in the 12 BBAVFs constructed with less than 3 mm basilic veins. BBAVFs pre-transposition evaluation importance is emphasized by the association of higher pre-transposition brachial artery flow rates with improved outcomes. This research highlights the importance of mapping and pre transposition evaluation for optimal BBAVF outcomes, but further studies need to be done with longer follow up times and including more vascular access mapping criteria.

Midterm outcomes of endoscopic-assisted brachial-basilic arteriovenous fistula creation

Endoscopic vein harvest remains underused in single-stage brachial-basilic arteriovenous fistula creation. We analyzed our results with the use of this technique in a cohort of predominantly obese (body mass index ≥30 kg/m2) patients. Demographics, intraoperative details, and outcomes for all consecutive patients who underwent single-stage endoscopic-assisted brachial-basilic arteriovenous fistula creation between 2020 and 2022 at a single institute were analyzed retrospectively. The primary outcomes were technical success, fistula maturation, and primary assisted and secondary patency rates. Of the 11 patients (7 men; mean age, 62 ± 11.6 years), 7 (64%) already required dialysis at referral. The mean body mass index was 34 ± 7 kg/m2, 64% were obese, and an additional 27% were overweight. The medical comorbidities included hypertension in 11 patients (100%), diabetes in 7 (64%), and smoking in 8 (73%). Technical success was 100%, with no intraoperative complications. The median procedural length was 231 minutes (range, 183-302 minutes). Early complications in two patients (18%) included bleeding of the venous side branch requiring ligation and the loss of thrill requiring division of a tethering bridge of a large tributary. The maturation rate was 100%, and the brachial-basilic arteriovenous fistula was successfully accessed in all patients who required dialysis. At 12 months, the primary assisted and secondary patency rates were 90% ± 10% and 100%, respectively. Reintervention in seven patients (64%) included successful angioplasty in four, thrombectomy in two, and aneurysm resection with an interposition graft in one patient. Endoscopic vein harvest can be used for single-stage brachial-basilic arteriovenous fistula creation with good technical success and favorable maturation and patency rates, even for obese patients.

Reliability of preoperative venous mapping ultrasonography in predicting for autogenous arteriovenous fistula maturation

BackgroundAutogenous arteriovenous fistula creation is the preferred route for vascular access for hemodialysis. Although preoperative venous mapping ultrasonography has been advocated as an operative planning adjunct and recently incorporated into the Society for Vascular Surgery clinical guidelines, controversy remains regarding its usefulness for predicting access success. The purpose of the present retrospective clinical study was to test the hypothesis that vein size measured on routine preoperative venous mapping is a poor predictor of primary fistula maturation. MethodsConsecutive upper extremity autogenous arteriovenous fistulas created by three dedicated vascular surgeons were retrospectively reviewed. The demographic characteristics, preoperative venous mapping, functional maturation, and patency were analyzed. The clinically relevant variables were tested for predictive significance using a logistic regression model. ResultsA total of 199 upper extremity autogenous arteriovenous fistulas had been created during a 5-year period. Patients were aged 70 ± 16 years (range, 20-96 years), and 62% were men. Most had already been undergoing dialysis before fistula creation (83%), usually via a tunneled central venous catheter (62%). Radial-cephalic, brachial-cephalic, and brachial-basilic arteriovenous fistulas had been created in 82 patients (41%), 76 patients (38%), and 10 patients (5%), respectively. Fistula maturation, defined as a palpable thrill and/or successful cannulation of the fistula with the ability to deliver a flow rate of 400 mL/min, was achieved in 67% of the patients. A higher body mass index was associated with nonmaturation on both univariate and multivariate analyses (success, 28.6 ± 7.7 kg/m2; vs failed, 31.6 ± 9.4 kg/m2; P = .029; odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10; P < .01). On univariate analysis, the maximum target vein diameter assessed by preoperative venous mapping was slightly larger in the group achieving successful maturation (2.9 ± 1.1 mm vs 2.6 ± 0.9 mm; P = .014). However, neither the maximum target vein diameter nor a target vein size >3 mm was significantly predictive of maturation on multivariate analysis (maximum vein diameter: OR, 0.65; 95% CI, 0.35-1.22; P = .176; vein size >3 mm: OR, 0.91; 95% CI, 0.32-2.60; P = .857). After a median follow-up of 15 months (interquartile range, 26 months), the primary functional patency, primary-assisted patency, and secondary patency rates were 39.1% ± 0.6%, 94.5% ± 0.6%, and 97.9% ± 0.5%. No association of vein diameter with long-term patency was found. ConclusionsDespite the national fistula-first initiatives, most patients still undergo access via catheter at the initiation of hemodialysis. The use of routine preoperative venous mapping does not predict successful primary maturation. Also, no clinically useful predictor of fistula maturation was identified in the present study.

An original technique to create a brachial-basilic arteriovenous fistula

Several techniques were developed to create brachial-basilic arteriovenous fistulas (BBAVF). The objective was to present a novel method of superficialisation of the BBAVF and to compare this method to the other techniques described in the literature.

Double Plication of Basilic Vein of Brachial-Basilic Arteriovenous Fistula as Effective Treatment for Dialysis Related Steal Syndrome (DRESS) : A Case Report

Introduction Overall incidence of steal syndrome in AVF is 1% to 9%, but can produce devastating complication hand ischemia (1), this frequency increases depending on the type of AVF (2, 3), and were predominantly (83%) brachial based (4). There were several different term for hand ischemia re

Transposed Brachial-Basilic Arteriovenous Fistula for Vascular Access in Japan.

As more than 320,000 patients are currently receiving hemodialysis treatment in Japan, the creation and maintenance of hemodialysis access is a major concern. The national guidelines recommend autogenous arteriovenous hemodialysis, and the brachial–basilic arteriovenous fistula has been the focus of attention, because the need for secondary, tertiary, or even more vascular access is growing. Although favorable results have been reported in terms of patency and access-related complication, this fistula involves various unsolved or controversial issues, with limitations including complex procedures, which might contribute to the lower prevalence at this point in Japan. This review addresses those issues and discusses the role of fistula in Japan.

One-Stage Upper Arm Brachial-Basilic Arteriovenous Fistulas Have Superior Patency to Two-Stage Procedure

One-Stage Upper Arm Brachial-Basilic Arteriovenous Fistulas Have Superior Patency to Two-Stage Procedure

Open Repair and Venous Inflow Plication of the Arteriovenous Fistula Is Effective in Treating Vascular Steal Syndrome

Vascular steal syndrome related to a dialysis arteriovenous fistula (AVF) can lead to symptoms of distal ischemia, limb loss, digit ulceration, and gangrene. Several complex procedures have been used to augment and restore distal limb perfusion while maintaining a functional AVF. We reviewed our experience in treating AVF-related vascular steal syndrome by simple plication of the initial AVF inflow segment. Clinical data of 26 patients (15 men; mean age, 58 years; range, 26-80) with vascular steal syndrome related to their AVF underwent plication during a 36-month period. There were 18 brachial-cephalic AVFs and 8 brachial-basilic AVFs with vein transposition. Relevant clinical variables, imaging studies, and treatment variables were analyzed. Eighty-four percent of patients had hypertension, 62% were diabetics, and 15% had a previous limb or digit amputated. Hand pain, skin ulceration, or gangrene was present in 96%, 15%, and 12% of patients, respectively; 19% of patients had more than one symptom. Twelve (46%) patients had an aortic arch and upper extremity arteriogram, of which 67% showed evidence of arterial disease. One patient required percutaneous balloon-expandable stent treatment of a proximal left subclavian artery stenosis to improve flow. Duplex-derived volume flow measurements of the AVF were obtained with an average flow of 1.95 ± 0.83 L/min. Open repair and venous inflow plication was performed in all 26 patients. Average flow reduction in patients with preoperative and postoperative flow measurements was 0.6 ± 0.5 L/min (P < 0.05). There was a 12% revision rate within 3 months. Symptom resolution was achieved in 92% of patients while maintaining a functioning access out to 1 year. Two remaining patients who did not improve and proceeded to ligation of the AVF. Surgical plication of the initial AVF inflow segment offers a simple solution to preserve the dialysis access and resolve symptoms related to vascular steal associated with high volume flow through the AVF.

Transposition, elevation, lipectomy and V-Wing for easy needling.

The purpose of this study is to report surgical techniques to facilitate cannulation of deep matured veins. 1) Basilic vein tunnel superficialization with rerouting in an anterior tunnel is mandatory for brachial-basilic arteriovenous fistula (AVF), mostly performed in a second surgical stage. The elevation technique, which could necessitate cannulation of the vein through the overlying scar, is not advisable. 2) Femoral vein superficialization is a one-stage surgical operation. Complications of this high-flow AVF are distal ischemia (diabetes and occlusive arterial disease are contraindications), iliac vein stenosis due to intimal hypertrophy and cardiac issues. Nevertheless, we have achieved high long-term patency rates (N = 70). Primary patency rates at 1 and 9 years were 91% ± 4% and 45% ± 11%, respectively. Secondary patency rates at 1 and 9 years were 84% ± 5% and 56% ± 9%, respectively. 3) Lipectomy for superficialization of the forearm radial-cephalic AVF is described for obese patients. Subcutaneous tissues are resected using two transverse incisions. Mobilization of the vein is avoided. At 3 years (N = 49), we recorded 63% ± 8% and 88% ± 7% primary and secondary patency rates, respectively. Anterior transposition of the forearm basilic vein is not necessary when using microsurgery for creation of distal ulno-basilic AVF. 4) VWING is a novel surgically implanted device to help buttonhole technique cannulation. It is too early to draw any conclusion from the preliminary published reports. Tunnel-transposition and lipectomy are efficient techniques to allow easy needling of deeply situated upper-arm basilic vein, and cephalic vein in obese patients, respectively.

Percutaneous thrombectomy of AVF: immediate success and long-term patency rates.

The purpose of this study was to report the results obtained in a cohort of 520 cases of thrombosed arteriovenous fistulas (AVF) treated by percutaneous intervention over a period of 8 years. The methods used varied according to the individual characteristics of the case. A clinical success rate of 91.1% was obtained with no significant difference being noted among radial-cephalic, brachial-cephalic, and brachial-basilic AVFs. The mean primary patency for this group was 227.3 ± 14.6 days, and the mean assisted primary patency was 677.2 ± 44.6 days. The lower arm AVFs had both a primary patency and an assisted primary patency that were significantly better than the upper arm cases (p = 0.006 and 0.002, respectively). The primary patency for radial-cephalic AVFs was significantly better than that for brachial-cephalic AVFs (p = 0.021), but not for brachial-basilic cases (p = 0.122). Assisted primary patency for radial-cephalic cases was significantly superior to the values for either patients with a brachial cephalic (p = 0.046) or a brachial-basilic (p = 0.004). Complications occurred in seven cases (1.3%), all of which were venous ruptures. Blood flow was affected in four cases. Only one of these was salvaged with angioplasty balloon tamponade. In the remaining three cases, the AVF was lost.

Clinical Experience With Office-Based Duplex-Guided Balloon-Assisted Maturation of Arteriovenous Fistulas for Hemodialysis

To examine the effect of office-based duplex-guided balloon-assisted maturation (DG-BAM) on arteriovenous fistula (AVF), we retrospectively analyzed our experience. Over the past 10 months, we performed 185 DG-BAMs (range, 1-8 procedures; mean, 3.7) in 45 patients (29 male, 16 female; mean age, 68.2 ± 12.8 years) with 31 radial-cephalic, 7 brachial-cephalic, and 7 brachial-basilic AVFs. Balloon sizes (3-10 mm) were chosen based on duplex measurements (1-2 mm larger than minimal vein diameter). Forearm AVFs were dilated to 8 mm, and arm AVFs were dilated to 10 mm. All cases but one (99.5%) were successfully dilated. This exception was a large AVF rupture that required surgical repair. AVFs failed to mature in seven of the remaining 44 patients (16%) despite DG-BAM because of proximal vein stenoses (PVS). Four patients had cephalic arch stenoses, and three had proximal subclavian vein stenoses. Arm AVFs were more commonly associated with PVS (6 of 14 patients, 43%) as compared with the ones placed in the forearm (1 of 30 patients, 3.3%), with a P value of 0.0024. All these seven AVFs subsequently matured after successful balloon angioplasty of the venous outflow. These data suggest that office-based DG-BAM of AVFs is feasible, safe, and averts nephrotoxic contrast and radiation. PVS appear to be the most common cause of failure for AVFs subjected to BAM. Because arm AVFs are at increased risk of PVS, we suggest that a careful duplex evaluation of the outflow be performed in these cases and in all AVFs that fail to mature.

Basilic vein transposition versus biosynthetic prosthesis as vascular access for hemodialysis

Vascular access (VA) complications account for a significant number of hospital admissions in dialysis and have substantial costs. A native arteriovenous fistula (AVF) cannot be successfully obtained in all patients. At our center, we established an autogenous brachial-basilic AVF (BBAVF) in the upper arm in patients with a failed forearm fistula or with superficial vessels that were unsuitable for preparing a good site for VA. In most of these patients, we resort to prosthetic materials for creating a functioning VA as the last strategy. The present study compared the outcomes of BBAVF and AV graft (AVG) in patients undergoing long-term hemodialysis in whom there was no other possibility of creating a VA. We analyzed 57 complex patients, 27 randomized to receive AVG and 30 randomized to BBAVF, between 2002 and 2008. The Omniflow II Vascular Prosthesis (Bio Nova International Pty Ltd, North Melbourne, VIC, Australia), the latest-generation collagen-polyester composite, was used to create the prosthetic VA. Primary patency (PP) and secondary patency (SP) rates were calculated using the Kaplan-Meier test. The log-rank test was used to compare PP and SP rates of the single VA. Length of hospital admission time, total intervention time, and mean interval to the first venipuncture for dialysis were longer for BBAVF. In the early postoperative period, patients who received BBAVF had a complication rate similar to those who received AVG; however, patients who received AVG showed a higher rate of long-term adverse events. PP and SP rates were higher for BBAVF than for AVG, although this was not statistically significant for SP. Our results show that BBAVF should be the first choice in patients with a good life expectancy and who can rely on an available temporary VA. However, given the shorter time to use, AVG could be an alternative in patients with compromised clinical conditions and in whom a temporary VA is not reliable, considering that the long-term outcome may be considered beneficial regardless.

The Natural History of Vascular Access For Hemodialysis: A Single Center Study of 2,422 Patients

Conclusion: With the possible exception of older patients with diabetes, autogenous conduits are preferable for dialysis access. Summary: The Clinical Guidelines for Vascular Access from the National Kidney Foundation Disease Outcomes Quality Initiative recommend radial-cephalic arteriovenous fistulas (AVFs) and brachial-cephalic AVFs as the first and second choices for dialysis access, followed by prosthetic grafts, brachial-basilic AVFs, and venous catheters as secondary choices. These recommendations have been verified by review articles and small prospective trials and small clinical series. The article represents a retrospective review of a very large dialysis access experience in which 2422 consecutive patients underwent 3685 vascular access procedures in a tertiary care hospital. Radial-cephalic, brachial-cephalic, brachial-basilic, and prosthetic graft fistulas were all performed. Maximum follow-up was 20 years, and patency rates were determined by Kaplan-Meier analysis. Median primary patency for radial-cephalic AVFs was 712 days (95% confidence interval [CI], 606-818 days). Median primary patency for brachial-cephalic AVFs was 1009 days (95% CI, 823-1195 days). Median primary patency for PTFE reconstructions was 384 days (95% CI, 273-945 days). Median secondary patency for radial-cephalic fistulas was 1809 days (95% CI, 1692-1582 days). Median primary patency of brachial-basilic AVFs (second or third choice for vascular access) was 1582 days (95% CI, 415-2749 days). The cumulative incidence of clinically important complications in patients receiving radial-cephalic, brachial-cephalic, brachial-basilic, and PTFE dialysis access was 0.25, 0.57, 0.33, and 0.61 per patient-year, respectively. After 2000 days, radial-cephalic AVF patency was superior to brachial-cephalic AVF patency. Ten years after construction, 18% of radial-cephalic AVFs and 12% of brachial-cephalic AVFs were still functional. More than 50% of brachial-basilic arteriovenous fistulas were still patent after 4 years. Comment: The value of this study lies in the large number of patients and the long period of follow-up. Otherwise, the conclusions are really not substantially different from those derived previously. There has, however, been some controversy about the use of prosthetic vs brachial-basilic fistulas as secondary or tertiary access procedures. This study would suggest that a brachial-basilic fistula is far superior to prosthetic access and that brachial-basilic AVF, although more technically demanding, should be the preferred secondary or tertiary access over a prosthetic graft.

ASDIN: Autogenous Side‐to‐Side Brachial‐Basilic Fistulas Without Vein Transposition: A Valuable Option?

An autogenous brachial-basilic arteriovenous fistula (BBAVF) in the upper arm must be considered before placing prosthetic grafts in hemodialysis patients with multiple failures of forearm AVFs. The aim of this observational study was to compare technical and clinical outcomes of a new construction technique for BBAVF (n-BBAVF) with that of the standard one-stage side-artery to end-vein transposed BBAVF (t-BBAVF). A n-BBAVF is constructed in the following way: basilic vein and brachial artery are isolated. Patency of the proximal and distal vein is verified by injecting warmed (37 degrees C) saline solution. A venotomy and an arterotomy of 4-5 mm are performed. The two vessels are prepared for a side-to-side anastomosis without transposition of the vein. The latter allows both an antegrade and retrograde flow along the basilic vein, both proximally and distally to the anastomosis with more sites available for the venipunctures of the dialysis. Thirty BBAVFs were constructed as the secondary or tertiary vascular access in 30 patients over a 4-year period: 17 patients with adequate forearm basilic vein underwent the construction of a n-BBAVF; 13 underwent the construction of a t-BBAVF. The construction of a n-BBAVF requires a significantly lesser surgical time (55.0 +/- 9.0 minutes vs. 115.0 +/- 18.0, p < 0.0001), has fewer surgical complications (5.9% vs. 46.2%, p < 0.0001), and a reduced time to first use (24.5 +/- 6.3 vs. 37.7 +/- 9.1 days, p < 0.0001) than that of a t-BBAVF. n-BBAVFs showed a relatively low rate of thrombosis per patient-year at risk (0.067 at 1 year and 0.099 at 2 years). The latter was significantly lower at 1 year when compared with t-BBAVFs (0.067 vs. 0.285; p < 0.004). Our policy of "all AVFs should be autogenous" led us to the construction of a vascular access which is based on a side-to-side anastomosis between the brachial artery and the basilic vein without transposition of the vein allowing both antegrade and retrograde flow into the basilic vein. The results of this surgical technique appear satisfactory.

A randomized multicenter study of the outcome of brachial-basilic arteriovenous fistula and prosthetic brachial-antecubital forearm loop as vascular access for hemodialysis

A randomized multicenter study of the outcome of brachial-basilic arteriovenous fistula and prosthetic brachial-antecubital forearm loop as vascular access for hemodialysis

Transposed brachial-basilic arteriovenous fistulas versus prosthetic upper limb grafts: A meta-analysis

Background Controversy exists regarding the best type of arteriovenous (AV) fistula to be formed in secondary and tertiary access procedures when primary fistulas have failed. This meta-analysis aimed to compare transposed brachial-basilic AV fistulas (BBAVFs) with upper limb AV prosthetic grafts. Methods A literature search of the MEDLINE and SCOPUS databases was performed to identify comparative studies reporting outcomes for both BBAVFs with upper limb AV prosthetic grafts. Meta-analysis techniques were applied to identify differences in outcomes between the two groups regarding primary and secondary 1-year failure rates. Results Eleven relevant studies, involving 1509 patients, met the inclusion criteria and were incorporated in the final analysis; however, only one was randomised controlled trial. The pooled odds' ratio (OR) estimate for the primary and secondary failure rates at 1 year was 0.67 (CI 0.41–1.09) and 0.88 (CI 0.69–1.12), respectively, showing no difference in the outcome between the two groups. The re-intervention rate was higher for prosthetic grafts (0.54 per BBAVF versus 1.32 per graft). In a small subgroup of two studies comparing BBAVFs with forearm grafts the pooled estimate for 1-year primary failure rate was in favour of the BBAVF group (OR 0.3, CI 0.15–0.58, p = 0.0004) suggesting that forearm grafts were inferior having a 3-fold risk of failure at 1 year. Conclusion This analysis supports the use of BBAVF early in difficult access cases prior to the use of prosthetic grafts. However, the latter conclusion is debatable due to heterogeneity, small size and non-randomised design of the included studies.

A randomized multicenter study of the outcome of brachial-basilic arteriovenous fistula and prosthetic brachial-antecubital forearm loop as vascular access for hemodialysis

Vascular access is a necessity for patients with end-stage renal disease who need chronic intermittent hemodialysis. According to Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, radial-cephalic (RC) and brachial-cephalic (BC) arteriovenous fistulas (AVF) are the first and second choice for vascular access, respectively. If these options are not possible, an autogenous brachial-basilic fistula in the upper arm (BBAVF) or a prosthetic brachial-antecubital forearm loop (PTFE loop) may be considered. Until now, it was not clear which access type was preferable. We have performed a randomized study comparing BBAVF and prosthetic implantation in patients without the possibility for RCAVF or BCAVF. Patients with failed primary/secondary access or inadequate arterial and/or venous vessels were randomized for either BBAVF or PTFE loop creation. The numbers of complications and interventions were recorded. Kaplan-Meier method was used to calculate primary, assisted-primary and secondary patency rates. The patency rates were compared with the log-rank test. Complication and intervention rates were compared with the Mann-Whitney test. A total of 105 patients were randomized for a BBAVF or PTFE loop (52 vs 53, respectively). Primary and assisted-primary 1-year patency rates were significantly higher in the BBAVF group: 46% +/- 7.4% vs 22% +/- 6.1% (P = .005) and 87% +/- 5.0% vs 71% +/- 6.7% (P = .045) for the BBAVF and PTFE group, respectively. Secondary patencies were comparable for both groups; 89% +/- 4.6% vs 85% +/- 5.2% for the BBAVF and PTFE group, respectively. The incidence rate of complications was 1.6 per patient-year in the BBAVF group vs 2.7 per patient-year in the PTFE group. Patients in the BBAVF group needed a total of 1.7 interventions per patient-year vs 2.7 per patient-year for the PTFE group. These data show a significantly better primary and assisted-primary patency in the BBAVF group compared with the PTFE group. Furthermore, in the BBAVF group, fewer interventions were needed. Therefore, we conclude that BBAVF is the preferred choice for vascular access if RCAVF or BCAVF creation is impossible, or when these types of access have already failed.

Effect of Upper arm Brachial Basilic and Prosthetic Forearm Arteriovenous Fistula on Left Ventricular Hypertrophy

Creation of an arteriovenous fistula (AVF) may increase left ventricular hypertrophy in the hemodialysis population. Aim of this study was to compare the effects of a brachial-basilic (BB) AVF and the prosthetic brachial-antecubital forearm loop access (PTFE) on cardiac performance. Patients were randomized to receive BB-AVF or prosthetic brachial-antecubital forearm loop access. Before and three months after AVF creation patients underwent an echocardiographic examination. Mann-Whitney U-test was used to compare relative increase between the measured cardiac parameters for the two groups. Twenty-seven patients participated in the study. The relative increase in left ventricular parameters was not significantly different between the two groups. Only left ventricular end-diastolic diameter tended to be of significance. Mean blood flow through the brachial artery was 1680+/-156 and 1450+/-221 mL/min three months after surgery for the PTFE and the BB-AVF group, respectively. After three months of follow-up, changes in cardiac structure were comparable between patients with BB and PTFE AVFs. Also access flow was comparable at this time. In general, the effects of creation of a fistula on LV structure were limited. Longer follow up time may be needed to explore the long term effects of different vascular accesses on cardiac function.

Elevated basilic vein arteriovenous fistula

Background: Many surgeons continue to use prosthetic arteriovenous grafts for dialysis access despite the clear superiority of native arteriovenous fistulas. This study was undertaken to review our experience with elevated brachial-basilic fistulas as an alternative to prosthetic grafts in patients lacking veins suitable for more conventional arteriovenous fistulas.Methods: We retrospectively reviewed the outcomes of 67 patients receiving elevated brachial-basilic arteriovenous fistulas over a 10-year period. Operative complications and causes of failure were identified and actuarial fistula patency determined.Results: No patients suffered wound infections, and only 1 developed a steal syndrome in the late postoperative period. Actuarial fistula patency was 84% at 1 year, 73% at 3 and 5 years, and 52% at 10 years.Conclusions: The elevated brachial-basilic arteriovenous fistula is a superb alternative to prosthetic arteriovenous grafts in patients lacking suitable cephalic veins for native arteriovenous fistulas. Operative complications are uncommon, vascular steal is rare, and long-term patency is excellent.

Transposed basilic vein-brachial arteriovenous fistula: an alternative vascular access for hemodialysis.

Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated one-year patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachial-basilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels.