Radial-cephalic Arteriovenous Fistula Research Articles

Preoperative mapping and multidisciplinary team are the key to success of arteriovenous access for hemodialysis

Introduction and objectivesFunctional and durable vascular access is needed for adequate hemodialysis. Arteriovenous fistula is preferred over prosthetic grafts or central venous catheters, but it is associated with high rates of primary failure and maturation failure.Preoperative mapping of arm vessels with color Doppler ultrasound (CDU) has been shown to be helpful in achieving better short and long-term outcomes. Unfortunately, is more time-consuming than a physical examination and requires an experienced examiner and special equipment; some authors defend that CDU should not be part of the routine preoperative assessment.We reported our experience in preoperative vessel mapping using color Doppler ultrasound to purpose a vascular access to the surgical team, surveillance of vascular access, and evaluation of main outcomes (primary failure, maturation failure, and patency). MethodsThis is a single-center retrospective study that includes patients who attended a specific appointment for vascular access planning consultation between January 2019 and December 2021. A nephrologist performed the physical exam and vascular mapping and proposed to the vascular surgeon team a specific type and location of vascular access. Patients were followed until one month after the first hemodialysis through functioning vascular access. ResultsIn this study, 167 patients were evaluated (114 incident patients – chronic kidney disease stage 4 or 5 – and 53 prevalent patients – under hemodialysis through central venous catheter). The vascular accesses proposed by nephrologist were radial-cephalic arteriovenous fistula in 70 patients (41.9%), brachio-cephalic arteriovenous fistula in 50 patients (29.9%), brachio-basilic arteriovenous fistula in 34 patients (20.4%), arteriovenous graft in 8 patients (4.8%) and central venous catheter in 2 patients (1.2%).Vascular access was constructed in 141 patients: distal arteriovenous fistula in 57 patients (40.4%), brachio-cephalic arteriovenous fistula in 54 patients (38.3%), brachio-basilic AVF in 27 patients (19.1%), and arteriovenous graft in 3 patients (2.1%). The created access corresponds to the proposed access in 129 patients (91.5%).Twenty-two (15.6%) primary failures were registered. Distal arteriovenous fistulas and diabetes mellitus were associated with a higher risk of primary failure (OR=3.929 (1.485–10.392), p=0.004; OR=3.867 (1.235–12.113), p=0.014, respectively).The incidence of maturation failure at eight weeks was 4.8%.The primary patency at 6, 12 and 24 months was 76.3%, 70.4% and 49.2%. Primary assisted patency was 84.8% at 6 and 12 months and 81.3% at 24 months. ConclusionsThis study demonstrates that the study of the entire vascular territory performed with color Doppler ultrasound, within a multidisciplinary team of nephrologists and vascular surgeons, is associated with high rates of autologous access and very low rates of primary failure and maturation failure (almost unprecedented in the literature).

Long-term efficacy and risk factors of balloon-assisted maturation for radial-cephalic arteriovenous fistula with small-caliber veins.

Balloon angioplasty maturation (BAM) is a salvage method for autologous arteriovenous fistula (AVF) maturation failure. AVF creation using small-diameter veins is considered to have poor outcomes. Therefore, this study aimed to explore the long-term patency of small-diameter veins (≤3 mm) using BAM. BAM was performed if the fistula failed to mature and function adequately to provide prescribed dialysis. Out of 61 AVFs, 22 AVFs successfully matured without further intervention (AVF group) and 39 AVFs failed to mature. Except for 1 patient who required peritoneal dialysis, the remaining 38 patients received salvage BAM, and 36 of those successful matured (BAM group). Kaplan-Meier analysis revealed no significant differences between the AVF and BAM groups in terms of primary functional patency (p = 0.503) and assisted functional patency (p = 0.499). Compared with the AVF group, the BAM group had similar assisted primary functional patency (1-year: 94.7% vs. 93.1%; 3-year: 88.0% vs. 93.1%; 5-year: 79.2% vs. 88.3%). In addition, there were no significant difference between groups in the duration of primary functional patency and assisted primary functional patency (p > 0.05). Multivariate analyses showed that vein diameter and number of BAM procedures were independent predictors of primary functional patency in the AVF group and BAM group, respectively. Patient with 1 mm increase in vein size had 0.13-fold probability of having decreased duration of patency (HR = 0.13, 95% CI: 0.02-0.99, p = 0.049), while patients who received two times of BAM procedures were 2.885 as likely to have decreased duration of primary functional patency (HR = 2.885, 95% CI: 1.09-7.63, p = 0.033) than patients who received one BAM procedure. BAM is a relatively effective salvage management option with an acceptable long-term patency rate, even for small cephalic veins.

Methods for reducing the incidence of complications in distal arteriovenous fistula formation

The OBJECTIVE was to improve the results of surgical treatment and to reduce the incidence of postoperative vascular complications in patients after distal radial-cephalic arteriovenous fistula formation using a new method of vascular anastomosis application and cilostazol medication.MATERIALS AND METHODS. We studied 69 patients. The comparison group included 32 patients who underwent standard treatment with distal radiocephalic fistula formation according to the generally accepted method without additional conservative treatment. The main group consisted of 37 patients in whom the fistula formation was carried out according to the proposed method, and in the postoperative period, cilostazol medication was used at a dosage of 100 mg mg twice a day for more than 2 months.RESULTS. The main group showed smaller number of vascular complications: 12 (32.4 %) patients versus 15 (46.8 %) patients in the comparison group.CONCLUSION. The use of the proposed surgical method for arteriovenous fistula formation in combination with the use of cilostazol in the postoperative period leads to a decrease in the incidence of vascular complications, in particular, to a decrease in the frequency of thrombosis and disorders of the arteriovenous fistula formation.

Achieving high maturation and cannulation rates of radial-cephalic arteriovenous fistulas with VasQ™ device.

Hemodialysis is the predominant treatment modality for chronic kidney disease, with arteriovenous fistula (AVF) being considered to be the preferred type of long-term vascular access. Implantation of the external anastomotic VasQ™ support device during AVF creation has been suggested to improve the functional outcomes of AVFs. In the current study, we report the clinical outcomes when using the device with radial-cephalic AVF (RCAVF) creation in a large cohort over 3years. One hundred fifty RCAVFs were created between June 2018 and August 2021 with implantation of VasQ™. Time to maturation, cannulation characteristics, and assisted (AP) and secondary patency (SP) rates were analyzed. In this predominantly male (68%), median 64 years old cohort, 150 VasQ™ devices were implanted. Physiological maturation was achieved in 142/150 (95%) and was unassisted in 133/150 (89%). Of those, 129 matured within 1month and four additional AVFs within 165 days. Eight AVFs achieved maturation following percutaneous transluminal angioplasty, and one required surgical patch angioplasty. The median time from creation to first successful cannulation in dialysis patients was 41 days. AP at 6, 12, 18, 24, and 30 months was 89%, 81%, 78%, 73%, and 73%, and SP was 94%, 87%, 86%, 84%, and 84%, respectively. Consistent use of the VasQ™ device in RCAVF creation demonstrates excellent AVF maturation and patency rates with very low frequency of assisted maturation and interventions for maintenance. The VasQ™ device appears a suitable aid in increasing the creation of functional RCAVFs.

Better Efficacy of Balloon Assisted Maturation in Radial-Cephalic Arteriovenous Fistula for Hemodialysis.

PurposeNative arteriovenous fistula (AVF) is the first choice for hemodialysis access; however, the maturation failure rate remains high. Hence, balloon-assisted maturation (BAM) is increasingly being used to overcome maturation failure. This study evaluated the outcomes of BAM and compared the differences between radial-cephalic (RC) and brachial-cephalic (BC) AVF.MethodsMaterials and Between January 2013 and December 2017, 1,622 new AVFs were created. BAM was considered if the AVF did not satisfy the criteria for hemodynamic maturation (6-mm diameter and 500-mL/min flow rate within 8 weeks after the operation).ResultsOf the 1,622 AVFs, BAM was performed in 142 patients (8.75%). There were 92 RC and 50 BC AVFs. Multivariate analyses revealed that ipsilateral central vein catheter history was the sole risk factor for maturation failure after BAM. One-year functional primary patency (FPP) and functional secondary patency (FSP) in RC AVFs were higher than those in BC AVFs without statistical significance (FPP, RC vs. BC: 70.9% vs. 50.9%, P=0.099; FSP, 95.5% vs. 81.1%, P=0.146). Further, based on the multivariate analysis, the independent risk factors for FPP in the RC and BC AVFs were the number of BAMs (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.11-8.37; P=0.03) and age (OR, 1.04; 95% CI, 1.00-1.07; P=0.04), respectively.ConclusionBAM is a relatively good salvage method with tolerable patency. However, the risk factors for patency and the outcomes of BAM differ between RC and BC AVFs.

Optimizing arteriovenous fistula patency

The authors have examined the impact of vessel diameter (both artery and vein) on patients (N = 356) undergoing their first autogenous hemodialysis arteriovenous fistula (AVF) in the upper extremity.1 They reported that vein diameter (<3 mm) and artery diameter (<2.1 mm) were associated with both maturation and secondary patency for radial-cephalic AVFs, whereas vein diameter (<3.4 mm) was associated with secondary patency for brachial-cephalic AVFs. These findings are not particularly surprising and are largely consistent with earlier reports and our own published algorithm.

Baseline characteristics of arm vessels by preoperative duplex ultrasonography in Korean patients for hemodialysis vascular access.

Preoperative mapping with duplex ultrasonography is crucial for successful vascular access creation for hemodialysis. The aims of this study are to assess the baseline characteristics of arm vessels by preoperative duplex ultrasonography in Korean patients, to find out a preoperative duplex ultrasonography parameter precluding distal arteriovenous fistula creation, to assess the maturation failure rate of arteriovenous fistulas, and to identify associated risk factors. Preoperative duplex ultrasonography mapping for vascular access creation was done in all patients with end-stage renal diseases during the year 2015. The baseline data of duplex ultrasonography were retrospectively analyzed with follow-up clinical data. A total of 299 end-stage renal disease patients (mean age = 62 years, 62% male) were included. On preoperative duplex ultrasonography, mean diameters of radial artery and cephalic vein at wrist were 2.03 and 2.40 mm in the non-dominant arm and 2.10 and 2.26 mm in the dominant arm, respectively. The most common reason for precluding radial-cephalic arteriovenous fistula at wrist was small-sized cephalic vein. Multivariate logistic regression analysis revealed that the risk factors for inadequate vessels were warfarin treatment, old age (⩾75 years), and peripheral arterial occlusive disease. The rate of arteriovenous fistula maturation failure was 21% and vein diameter <2.5 mm was the only risk factor for arteriovenous fistula maturation failure by multivariate logistic regression analysis. Preoperative duplex ultrasonography evaluation is important to find out inadequate vessels for native arteriovenous fistula and to determine the location of vascular access.

Effect of first cannulation time and dialysis machine blood flows on survival of arteriovenous fistulas.

To study the effect of cannulation time on arteriovenous fistula (AVF) survival. Methods. Analysis of two prospective databases of access operations and dialysis sessions from 12 January 2002 through 4 January 2015 with follow-up until 4 January 2016. First cannulation time (FCT), defined from operation to first cannulation, was categorized as <2 weeks, 2-4 weeks, 4-8 weeks, 8-16 weeks and ≥16 weeks. Early cannulation was defined as FCT within 4 weeks. AVF survival was defined as the date until the AVF was abandoned. Maximum machine blood flow rate (BFR) for the first 29 dialysis sessions on AVF was analysed. Altogether, 1167 AVF with functional dialysis use were analysed: 667 (57%) radial cephalic AVF, 383 (33%) brachiocephalic AVF and 117 (10%) brachiobasilic AVF. The 631 (54%) AVF created in on-dialysis patients were analysed separately from 536 (46%) AVF created in pre-dialysis patients. AVF survival was similar between cannulation categories for both pre-dialysis patients (P = 0.19) and on-dialysis patients (P = 0.83). Early cannulation was associated with similar AVF survival in both pre-dialysis patients (P = 0.82) and on-dialysis patients (P = 0.17). Six consecutive successful cannulations from the start were associated with improved AVF survival (P = 0.0002). A below-median BFR at the start of dialysis was associated with better AVF survival (P < 0.0001). A below-median increase in BFR in the first 2 months was associated with worse AVF survival (P = 0.007). The type of AVF, diabetes, pre-dialysis state at operation and six successful cannulations from the start were independent predictors for AVF survival. FCT is not associated with AVF survival. Failures to achieve six successful cannulations from the start of dialysis and higher machine BFR in the first week of dialysis are associated with decreased AVF survival.

Radial artery deviation and reimplantation inhibits venous juxta-anastomotic stenosis and increases primary patency of radial-cephalic fistulas for hemodialysis

Although the end cephalic vein-to-side radial artery arteriovenous fistula is the "gold standard" procedure for primary hemodialysis access, it is associated with high rates of primary failure because of the development of neointimal hyperplasia and juxta-anastomotic stenosis. We report initial results of a new approach to perform radial-cephalic fistulas, radial artery deviation and reimplantation (RADAR), designed to avoid juxta-anastomotic stenosis. RADAR patients' data were prospectively maintained and retrospectively reviewed and compared with a historical control group of traditional radial-cephalic fistulas created in the same center. Duplex ultrasound was used to monitor maturation (flow ≥500mL/min and venous diameter ≥5mm) and to diagnose juxta-anastomotic stenosis. Study end points were rates of maturation, juxta-anastomotic stenosis, reintervention, and primary and secondary patency. There were 53 RADAR fistulas performed (follow-up, 10.5± 2.6months) and compared with 73 control fistulas (follow-up, 12.0± 6.6months). RADAR fistulas had increased rates of maturation compared with control fistulas (75% vs 45% at 6weeks, P= .001; 92% vs 71% at 3months, P= .003) and decreased incidence of juxta-anastomotic venous stenoses (2% vs 41%; P= .001). At 6months, RADAR fistulas had increased primary patency (93% vs 53%; P< .0001) and secondary patency (100% vs 89%; P= .0003) and decreased incidence of reinterventions (10% vs 74%; P= .001) compared with control fistulas. No RADAR fistulas caused ischemic symptoms. The RADAR technique is associated with less juxta-anastomotic stenosis, increased maturation and patency, and fewer secondary interventions. These improved outcomes suggest that RADAR may be the preferred surgical technique to perform radial-cephalic arteriovenous fistula.

Preemptive open surgical vs. endovascular repair for juxta-anastomotic stenoses of autogenous AV fistulae: a meta-analysis.

There is controversy about the best mode of preemptive repair of juxta-anastomotic stenoses in radial-cephalic arteriovenous fistula (AVFs). The aim of the present review was to compare the outcome of surgical vs. endovascular repair of those AVF stenoses. A systematic review and meta-analysis was performed for studies comparing the outcome of open surgical vs. endovascular preemptive repair of AVF stenoses located in the juxta-anastomotic region. A search was carried out in April 2015. The analyzed outcome measures were the primary patency at 12 and 18 months and the assisted primary patency at 24 months. In addition, assessment of the methodological quality of the included studies was carried out. Four non-randomized cohort studies (297 patients) were analyzed. A random effects model was used to pool the data. The pooled odds ratio (OR and 95% confidence intervals) for the primary patency at 12 and at 18 months was 0.42 (0.25-0.72) and 0.33 (0.2-0.56), respectively, showing statistically significant higher patency of the surgically repaired group. The pooled OR for the assisted primary patency at 24 months was 0.53 (0.28-0.98) also in favor of the surgically repaired group (p&lt;0.04). The available evidence, based on non-randomized cohort studies, suggests that surgery is the best way to treat 'juxta-anastomotic' stenotic lesions in distal radial-cephalic AVFs, although angioplasty remains a valuable but less durable option in this location of the stenosis.

Use of the subcutaneous venous network of the forearm to create an arteriovenous fistula

The reconstruction of vascular access in patients with kidney allograft failure is a challenging problem. A case of a 62-year-old man with transplanted kidney insufficiency is described. The patient was initially dialyzed with a wrist radial-cephalic arteriovenous fistula. In the post-transplantation period, the enormously dilated venous part of the anastomosis was ligated and the part of the vein suspected of being the source of bacteremia was excised. The man was referred to our department due to kidney allograft failure for vascular access creation. During preoperative assessment, we unexpectedly found a soft thrill on the forearm. Doppler ultrasound confirmed fistula patency, although the blood supply was not sufficient to perform dialysis. Angiography showed the blood flow from the radial artery to the cephalic vein, through a complicated vessel system consisting of inter alia a dilated vein of the subcutaneous venous network. We successfully used this vein as the vascular access outflow for fistula recreation. In conclusion, making use of veins of the subcutaneous venous network of the forearm for creation of a native fistula should be considered in selected cases.

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.

Risk factors associated with inadequate veins for placement of arteriovenous fistulas for hemodialysis

An arteriovenous fistula (AVF) between the radial artery and cephalic vein at the wrist is the preferred type of hemodialysis vascular access. However, in the practice of access placement, we are aware that some patients fail to form the standard forearm radial-cephalic AVF, owing to naturally small veins or acquired abnormal lesions of the veins. To identify the risk factors for failure to form the standard AVF, we examined 305 consecutive patients who underwent first-time access surgery at our hospital from January 2006 to December 2010. We compared the patients' characteristics between those having normal vessels and successfully forming the standard AVF, and those having apparently abnormal vessels and thus forming alternative types of access instead. Histories of major and minor surgery were specifically evaluated, assuming that surgical procedures in the past could potentially damage the superficial veins. We created 207 standard and 98 alternative accesses during the period and found that significantly more patients with alternative accesses (31%) had undergone major surgery of a variety of specialties, in comparison with those with the standard AVF (15.0%). Multivariate logistic analysis revealed that a history of major surgery (OR=2.39, 95%CI 1.29-4.47, p=0.006) and female gender (OR=1.87, 95%CI 1.10-3.20, p=0.02) were independent risk factors associated with failure to construct the standard AVF. Our results indicate that previous surgery can damage the superficial veins and cause venous abnormality, which makes construction of the standard AVF difficult. We propose that care should be taken to preserve the superficial veins when patients for whom dialysis therapy is a future possibility undergo surgical procedures, especially invasive ones.

Effect of anastomosis angle on the localization of disturbed flow in ‘side-to-end’ fistulae for haemodialysis access

Early failure of the vascular access for haemodialysis (HD) after the surgical creation of a radial-cephalic arteriovenous fistula (AVF) occurs mainly due to a juxta-anastomotic stenosis. Even if elevated blood flow induces high wall shear stress, we have recently shown that disturbed flow, characterized by low and reciprocating flow, may develop in zones of the AVF where it can provide a good indication of the sites of future stenoses. The present study was aimed at investigating whether the anastomosis angle influences disturbed flow in radial-cephalic 'side-to-end' AVF. By means of a parametric AVF model we created four equivalent meshes with anastomosis angles of 30°, 45°, 60° and 90°, respectively. We then performed transient, non-Newtonian computational fluid dynamics simulations using, as boundary conditions, previously measured blood volume flow and division ratio in subjects requiring primary access. The relative residence time (RRT), a robust indicator of disturbed flow, was calculated for the overall wall surface and disturbed flow was localized as areas having RRT > 1. Quantitative characterization and statistical tests were employed to assess the difference in RRT medians between the four anastomosis angle cases. Disturbed flow was located in all AVF models in the same areas where flow recirculation and stagnation occurred, on the inner wall of the swing segment (SS) and on the arterial wall at the anastomosis floor (AF). A smaller angle AVF had smaller disturbed flow areas with lower RRT peak values, either on the venous or the arterial limb. There were significant differences in the RRT medians on the SS and on the AF between sharper (30° and 45°) and wider (60° or 90°) angles. We have found that in 'side-to-end' radial-cephalic AVFs for HD, the anastomosis angle does impact on the local disturbed flow patterns. Among the four geometries we considered in this study, the smaller angle (30°) would be the preferred choice that minimizes the development of neointima. Clinicians should consider this at the time of AVF creation because the anastomosis angle is in part amenable to surgical manipulation.

Arterial Angioplasty to Treat Hand Ischemia in a Radial‐Cephalic Fistula

A chronic hemodialysis patient was referred to interventional nephrology for evaluation of left hand pain. The patient had been receiving hemodialysis through a left radial-cephalic arteriovenous fistula and reporting hand pain during dialysis. Physical examination demonstrated cold hand and reduced capillary refill compared with the right hand. Clinical features, differential diagnosis, and physical examination findings were consistent with the diagnosis of hand ischemia due to dialysis access. Arteriography revealed >80% stenosis of the distal ulnar artery. Percutaneous balloon angioplasty successfully dilated the lesion with resolution of symptoms. Although uncommon, patients with forearm fistula can also experience symptoms of hand ischemia. This case demonstrates that in addition to the history, clinical features, differential diagnosis, and physical examination, arteriography is a vital step in the management of patients presenting with signs and symptoms of hand ischemia. Further, employment of a basic procedure (percutaneous balloon angioplasty) can successfully resolve the condition and maintain the dialysis access.

Fistula Salvage by Endovascular Therapy

Fistulas are considered superior to synthetic grafts as a hemodialysis vascular access; however, fistulas are not without problems. To maximize the number of fistulas being used in prevalent patients, it is important to have a program designed to salvage early failures or fistulas that fail to mature and those that become dysfunctional during the course of usage. Endovascular techniques have proven to be very effective in the management of both of these problems. These fistulas should be aggressively evaluated and treated because treatment carries with it a high expectation of successful salvage of what would have otherwise been an abandoned access.

Accessory Veins and Radial-Cephalic Arteriovenous Fistula Non-Maturation: A Prospective Analysis Using Contrast-Enhanced Magnetic Resonance Angiography

Purpose To determine if large caliber accessory veins are associated with radial-cephalic arteriovenous fistula (RC-AVF) non-maturation. Methods RC-AVFs were created in 15 consecutive patients (radial artery and cephalic vein diameter &gt;2 mm, in the absence of arterial inflow or venous outflow stenoses or occlusions). Contrast-enhanced magnetic resonance angiography (CE-MRA) was performed preoperatively for the determination of vessel diameters, stenoses and occlusions. The location and caliber of accessory veins was determined. Vascular access (VA) function was monitored and all interventions required to obtain a functioning VA were recorded. Non-maturation was defined as a nonfunctional VA at 2 months after creation. The predictive value of accessory vein caliber for prediction of RC-AVF non-maturation was evaluated using receiver operating characteristic (ROC) analysis. Results Non-maturation occurred in 10 (67%) out of 15 RC-AVFs. Large caliber accessory veins (n=4), venous stenosis (n=3) or both (n=2) were associated with RC-AVF non-maturation. The presence of large caliber accessory veins was the only significant predictor for RC-AVF non-maturation (p=0.01). Preoperatively detected accessory veins with a diameter &gt;70% of the cephalic vein diameter, had a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 80, 100, 100 and 91% for prediction of RC-AVF non-maturation on patient level. Accessory vein ligation and dilatation of venous stenosis resulted in an overall salvage success rate of 89% (8/9). Conclusion Large caliber accessory veins are associated with RC-AVF non-maturation. Ligation of large caliber accessory veins is a successful salvage procedure in a substantial group of patients. Furthermore, ligation of these accessory veins during initial RC-AVF creation can potentially reduce non-maturation rates; and therefore, preoperative assessment of accessory veins is recommended.

Transposed basilic vein-brachial arteriovenous fistula. A reliable secondary-access procedure.

Over a two-year period, 25 transposed basilic vein-brachial arteriovenous fistulas were created as secondary vascular access procedures in patients undergoing chronic hemodialysis. The operative technique is described in detail. One-year patency rate by life-table analysis was 85%. There were two minor complications. The procedure is advocated as a reliable secondary-access procedure when a radial-cephalic arteriovenous fistula cannot be constructed or has failed.