Two-stage Basilic Vein Transposition Research Articles

Comparison of patient-specific factors and outcomes for one- and two-stage basilic vein transposition fistulas

ObjectiveThe decision to perform a one- or two-stage basilic vein transposition (BVT) arteriovenous fistula often depends on factors such as the vessel's diameter, the patient's disposition, and the surgeon's preference. This study's aim was to analyze patency by BVT staging technique and to identify patient-specific characteristics associated with outcomes. MethodsA retrospective review of all patients who underwent one- or two-stage BVT at our institution between 2008 and 2013 was performed. Comparisons of age, sex, race, and associated comorbidities were made. Clinical course was followed for 2 years after fistula construction, comparing maturation rate, thrombosis, stenosis, steal, and catheter infections. Continuous variables were expressed as means or medians and compared across stage and maturation groups by t-test; differences between categorical variables were assessed using Fisher exact test. A Kaplan-Meier survival analysis was performed to calculate patency rates and compared by log-rank test. ResultsThere were 49 one-stage and 169 two-stage BVTs examined. The mean age of the patients at time of construction was 58 years and 61 years for one-stage and two-stage patients, respectively. There was no difference in mean proximal, mid, or distal basilic vein diameters between the groups. Fistula maturation was similar between stage groups, with primary failure affecting 26.5% of one-stage and 24.3% of two-stage BVTs (P = .78). Across one- and two-stage BVTs, 2-year primary patency rates were 51% and 52%, respectively (P = .68); primary assisted patency, 66% and 85% (P = .05); and secondary patency, 64% and 78% (P = .26). Multivariate logistic regression showed a trend toward diabetics at higher risk for primary failure (odds ratio, 1.60; 95% confidence interval, 0.95-2.55; P = .07). For two-stage BVT, the median interstage period between operations lasted 105.00 (interquartile range, 77.00-174.50) days and was associated with a large proportion of the overall primary failures (19/41 [46%]) and catheter-related infections (12/20 [60%]). ConclusionsThis study demonstrates similar maturation, primary patency, primary assisted patency, secondary patency, and complication rates in a large series of BVTs constructed using a one- or two-stage transposition technique regardless of vein diameter. Diabetes was associated with primary failure by either technique. High proportions of overall primary failures and catheter-related infections observed in two-stage BVT occurred during the interstage, suggesting that a one-stage technique should be considered over a two-stage approach to minimize the risk of catheter infection and to decrease time to maturity.

Comparative effectiveness of one-stage versus two-stage basilic vein transposition arteriovenous fistulas

ObjectiveBasilic vein transposition (BVT) fistulas may be performed as either a one-stage or two-stage operation, although there is debate as to which technique is superior. This study was designed to evaluate the comparative clinical efficacy and cost-effectiveness of one-stage vs two-stage BVT. MethodsWe identified all patients at a single large academic hospital who had undergone creation of either a one-stage or two-stage BVT between January 2007 and January 2015. Data evaluated included patient demographics, comorbidities, medication use, reasons for abandonment, and interventions performed to maintain patency. Costs were derived from the literature, and effectiveness was expressed in quality-adjusted life-years (QALYs). We analyzed primary and secondary functional patency outcomes as well as survival during follow-up between one-stage and two-stage BVT procedures using multivariate Cox proportional hazards models and Kaplan-Meier analysis with log-rank tests. The incremental cost-effectiveness ratio was used to determine cost savings. ResultsWe identified 131 patients in whom 57 (44%) one-stage BVT and 74 (56%) two-stage BVT fistulas were created among 8 different vascular surgeons during the study period that each performed both procedures. There was no significant difference in the mean age, male gender, white race, diabetes, coronary disease, or medication profile among patients undergoing one- vs two-stage BVT. After fistula transposition, the median follow-up time was 8.3 months (interquartile range, 3-21 months). Primary patency rates of one-stage BVT were 56% at 12-month follow-up, whereas primary patency rates of two-stage BVT were 72% at 12-month follow-up. Patients undergoing two-stage BVT also had significantly higher rates of secondary functional patency at 12 months (57% for one-stage BVT vs 80% for two-stage BVT) and 24 months (44% for one-stage BVT vs 73% for two-stage BVT) of follow-up (P < .001 using log-rank test). However, there was no significant difference between groups in use of interventions (58% for one-stage BVT vs 51% for two-stage BVT; P = .5) to maintain patency. These findings were confirmed in multivariate analysis, in which two-stage BVTs were associated with a significantly lower rate of failure (hazard ratio, 0.39; 95% confidence interval, 0.2-0.8; P < .05) than one-stage BVTs after controlling for confounding variables. Finally, the two-stage BVT was more cost-effective (3.74 QALYs for two-stage BVT vs 3.32 QALYs for one-stage BVT) during 5 years, with an incremental cost-effectiveness ratio of $4681 per QALY. ConclusionsOur data show that two-stage BVTs are more durable and cost-effective than one-stage procedures, with significantly higher patency and lower rates of failure among comparable risk-stratified patients. These findings suggest that additional upfront costs and resources associated with creating two-stage BVTs are justified by their long-term outcomes.

RS07. Comparative Effectiveness of One-Stage vs Two-Stage Basilic Vein Transposition Arteriovenous Fistula

Basilic vein transposition (BVT) fistula may be performed as either one- or two-stage operations, although there is debate within the vascular surgery community as to which technique is superior. This study was designed to evaluate the comparative effectiveness of one-stage vs two-stage BVT. We identified all patients at a single large academic hospital who had undergone creation of either a one-stage or two-stage BVT between January 2007 and December 2014. Data evaluated included patient demographics, comorbidities, medication usage, reasons for abandonment, and all secondary interventions performed to maintain patency. Outcomes were failure or abandonment of the fistula and survival during follow-up. Statistical comparisons between one-stage and two-stage BVT procedures were performed using multivariate Cox proportional hazards models and Kaplan-Meier analysis with log-rank tests. We identified 128 patients, in whom 57 (44%) one-stage BVT and 74 (56%) two-stage BVT fistulas were created among 8 different vascular surgeons during the study time period. There was no significant difference in the mean age (54 vs 53 years; P = .9), male gender (46% vs 53%; P = .4), Caucasian race (63% vs 62%; P = .9), diabetes (72% vs 74%; P = .8), or coronary artery disease (54% vs 57%; P = .8) among patients undergoing one-stage vs two-stage BVT. Similarly, medication adherence for antiplatelet therapy (44% vs 49%; P = .6) and statin therapy (46% vs 50%; P = .6) was comparable between patients undergoing one and two-stage BVT. Following fistula transposition, the median follow-up time was 8.3 months (interquartile range, 3-21 months). Patency rates of one-stage BVT were 56% at 12 months and 43% at 24 months of follow-up, whereas patency rates of two-stage BVT were 79% at 12 months and 70% at 24 months of follow-up. However, there was no difference between groups in use of secondary interventions (58% one-stage vs 51% two-stage; P = .5) to maintain patency. Using Kaplan-Meier estimates (Fig), two-stage BVT had a significant higher patency after 24 months of follow-up (P < .001 by log-rank test). These findings were confirmed in multivariate analysis, where two-stage BVT were associated with significant lower rate of failure (hazard ratio, 0.39; 95% confidence interval, 0.2-0.8; P < .05) than one-stage BVT after controlling for patient and procedure-level factors. Finally, there was no significant difference in 1-year survival between one and two-stage BVT. Our data show that two-stage BVT are more durable than one-stage procedures, with significant lower rates of failure among comparable risk-stratified patients. These findings suggest that additional resources associated with creating two-stage BVT are justified by their long-term benefits.

8:16 AM Abstract No. 72 - Outcomes of single-stage compared to two-stage basilic vein transposition fistulae

Purpose Basilic vein transposition (BVT) fistulae are increasing in prevalence in the U.S. as more patients undergo dialysis through an autologous access. We examined whether BVT fistulae created in a single operation (1-stage) differ in outcomes compared to those requiring two stages due to small caliber ( Materials and Methods Surgical access records and IR QA databases were used to identify a consecutive cohort of 144 patients with BVT fistulae (66 M: 78F). Of these, 61 (42%) underwent BVT fistula creation in a single operation; 83 (58%) underwent BVT fistula creation in two stages. Fistula maturation rates and mean time to initiation of fistula use were compared. Intensity of percutaneous interventions (including angioplasty, stenting and thrombectomy) was compared as interventions/patient-year of dialysis (PYD); secondary patency rates were compared from time of first intervention with the Kaplan Meier method. Results More women than men required BVT creation in 2 stages (62% vs 32%). Maturation rates (inclusive of fistulae needing percutaneous angioplasty to assist maturation) were 55/61 (90%) among 1-stage BVT, and 62/83 (75%) among 2-stage BVT (p = 0.02). Mean time to initiation of fistula use was 142 days among 1-stage BVT and 146 days among 2-stage BVT (p = 0.92). Intensity of percutaneous interventions was 1.84/PYD among 1-stage BVT and 2.15/PYD among 2-stage BVT. Secondary patency at 1, 2, 3 and 4 years for 1-stage BVT was 86±5.6, 75±9.1, 69±10.2 and 57±13%; secondary patency at 1, 2, 3 and 4 years for 2-stage BVT was 76±7.4, 71 ± 8.5, 49 ±14 and 25 ± 19 %, respectively (p=0.12). Conclusion Both forms of BVT were associated with high maturation rates, low intensity of interventions, and high secondary patency rates. When a basilic vein is small, BVT creation in two stages confers only a modest reduction in maturation and secondary patency outcomes; this access strategy should therefore be considered over a synthetic graft in patients not otherwise deemed suited to fistula creation.

Modified two-stage basilic vein transposition for hemodialysis access

BackgroundVarious techniques for basilic vein transposition have been described, including endovascular, 1-stage, and 2-stage transposition. However, none of these 2-stage techniques include a new arteriovenous anastomosis during the second stage. This study adds to the current literature as well as introducing a new and innovative technique for hemodialysis access. MethodsForty-nine basilic vein transpositions were performed. Data were collected retrospectively. Primary and secondary patency was calculated using life table methods. Complications and interventions were recorded. ResultsPrimary patency was 72% at 1 year, 54% at 2 years, and 54% at 3 years. Secondary patency was 95%, 80% and 65% at 1, 2, and 3 years, respectively. Twenty-nine patients experienced complications related to the fistula, and 15 required intervention to maintain patency. Patency was achieved in 100% of the procedures using percutaneous techniques. ConclusionsThis 2-stage procedure should be strongly considered when planning brachial basilic fistulas for hemodialysis access.

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

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.

Basilic Vein Transposition: What is the Optimal Technique?

Objectives To compare the outcome of the one-stage basilic vein transposition (BVT) fistula with a modified, two-stage technique. Design Retrospective case-controlled study, performed in an academic centre. Material A total of 173 candidates for BVT fistula (87 males, mean age 61 years). Methods In one-stage BVT, the basilic vein is mobilised through a single incision, placed inside an anterolateral arm tunnel and anastomosed with the brachial artery. In two-stage procedures, the fistula–arterial anastomosis is created first, followed by the second stage, after fistula maturation several weeks later, when the basilic vein is mobilised through two skip incisions, transected near the anastomosis, placed inside an anterolateral arm tunnel and reanastomosed. Morbidity and fistula maturation rate were the main outcome measures. Results In one-stage BVT ( n = 76), the incidence of venous hypertension, wound haematomas and all complications (17%, 13% and 43%, respectively) was significantly higher than in two-stage procedures ( n = 98) (4%, p = 0.004, 3%, p = 0.012 and 11%, p < 0.001, respectively). Time (68 days) to fistula use was significantly decreased in one-stage BVT than in two-stage procedures (132 days, p < 0.001) but failure to mature rate was equivalent (15% vs. 18%, p = 0.49). Conclusions Our results indicate that the two-stage BVT fistula through two skip-arm incisions is superior to the established one-stage procedure in terms of less morbidity but at the cost of a second operation and longer time to access use. Further research comparing these two techniques is necessary. Until this issue is resolved, an individualised approach is suggested.

Two-stage basilic vein transposition––a new approach for pediatric dialysis access

Two-stage basilic vein transposition––a new approach for pediatric dialysis access

Two-stage basilic vein transposition—a new approach for pediatric dialysis access

Purpose The fistula first initiative has led to increased efforts to create arteriovenous fistulas (AVFs) as primary dialysis access. Two-stage basilic vein transposition (BVT) allows maturation of smaller veins, often a limiting factor in the pediatric population, before elevation and use. We sought to determine whether using 2-stage BVT improves maturation, use, and patency compared with other AVFs, including arteriovenous (AV) grafts. Methods Thirty-one patients underwent AV access creation between 1997 and 2008. Data were collected on types of access, maturation, complications, and patency. Results Forty-two AV access procedures were performed: 15 (36%) 2-stage BVT, 13 (31%) 1-stage BVT, 6 (14%) radiocephalic, 3 (7%) brachiocephalic, 1 (2%) brachiobrachial, and 4 (10%) AV grafts. Follow-up averaged 20.4 ± 3.2 months for 2-stage BVT and 47.9±4.1 months for other AVFs ( P < .001). All 2-stage BVT matured compared with 52% (14/27) of other AVFs ( P = .001). More 2-stage BVTs (87%) were used for dialysis than other AVFs (48%, P = .024). Fistula failure occurred in 7% 2-stage BVT compared with 59% other AVFs ( P = .001). One-year patency rates were 91% for 2-stage BVT vs 47% for other AVFs ( P = .003). Conclusions Rates of fistula maturation, use, and patency are higher for 2-stage BVT with lower rates of failure. Two-stage BVT shows great promise as the preferred approach to creation of AVF in pediatric patients, especially those with smaller veins.

Selective two-stage basilic and cephalic vein transpositions can significantly improve the rate of fistula construction

Modified proximal radial artery arteriovenous fistula (MPRAVF) can be used to improve the success and patency of basilic vein transposition (BVT) and cephalic vein transposition (CVT). In the present study, surgical experience with patients requiring a two-stage BVT or CVT using MPRAVF as the first stage was reviewed. All two-stage BVTs and CVTs performed between September 2004 and October 2006 were retrospectively reviewed. The median follow-up for this cohort was 23.7 months. One-year secondary patency of all transpositions was assessed. Two hundred nineteen MPRAVFs were constructed. Twelve MPRAVFs failed and underwent a second procedure. Ninety-eight patients required no further procedures and their upper arm cephalic vein was matured and used for dialysis. Of 121 patients whose MPRAVFs were functioning but unusable due to their depth, 87 underwent BVT and 34 underwent CVT. The Kaplan-Meier one-year secondary patencies (± standard error) for BVTs and CVTs were 0.90±0.03 and 0.82±0.06, respectively. At one year, 87% of all transpositions remained patent. Use of MPRAVF as the first stage of a two-stage BVT or CVT can significantly improve the patency rate of autogenous hemodialysis access placement beyond the 66% set forth by the Fistula First guidelines.

SUCCESSFUL CAMPAIGN TO REDUCE RELIANCE ON ARTERIOVENOUS GRAFTS (AVG) IN FAVOR OF ARTERIOVENOUS FISTULAE (AVF) FOR HEMODIALYSIS

Bovinecarotid heterografts or Dacron polyester AVG are less satisfactory than native arteriovenous fistulae (AVF) for hemodialysis access. AVG carry a high risk of thrombosis, infection, and leakage limiting their life and compromising rehabilitation in dialysis patients. Introduction of a two-stage basilic vein transposition to create a brachio-brachial arteriovenous fistula sharply increased the proportion of dialysis patients able to avoid AVG. To assess the impact of this surgical innovation, we surveyed the type of hemodialysis access presently employed in an ambulatory hemodialysis unit serving an inner city population comprised primarily of Hispanic and Black patients. In December, 2002, a total of 127 patients were receiving thrice weekly hemodialyses (mean serum albumin of 3.8 g/dl, mean hematocrit 36%, urea reduction rate of 75% for 85%). Annual mortality has been less than 10% for the past three years. A total of 87 patients (68.5%) had a functioning AVF. Of these 87 patients, 62 (48.8%) had traditional one-stage Cimino-Breccia fistulae while 25 (19.7%) had the newer two-stage AVF. Only 25 (19.7%) patients were undergoing dialysis via an AVG. Of these, no new AVG had been created prior to 1999. An additional 15 patients (11.8%) were dialyzed via a “permanent” jugular catheter. Conversion to AVF from AVG by a concerted effort when linked to surgeons skilled in brachio-brachial arteriovenous fistulae is both practical and likely to be associated with low mortality and reduction in use of frequently complicated AVG.

Creation of Native Arteriovenous Fistulas with Interrupted Anastomoses Using a Self-Closing Clip Device - One Clinic's Experience

The nitinol U-CLIPTM Anastomotic Device (Coalescent Surgical, Inc., Sunnyvale, CA) is a self-closing penetrating vascular clip that reduces suture management and eliminates knot tying, thus enabling rapid and precise interrupted suture placement and facilitating creation of an optimal vascular anastomosis. This report describes the use of U-CLIP devices in the surgical creation of native arteriovenous fistulas in 68 chronic hemodialysis patients. Overall, 61 of the 65 fistulas created matured successfully within 8-9 weeks. Radial cephalic fistulas: 93% were mature at 8 weeks. Brachiocephalic fistulas: 69% were mature at 8 weeks. One-stage basilic vein transposition: 100% were mature at 9 weeks. Two-stage basilic vein transposition: 100% were mature at 8 weeks after second stage. The results in this report show the excellent performance of U-CLIP vascular clips in the creation of several types of native arteriovenous fistulas in chronic hemodialysis patients. The fistulas created using the U-CLIP devices had a high maturation rate within a relatively short time period, and provided uniformly high flow rates. The patients in this study were a challenging population, with a high incidence of diabetes mellitus (81% of the patients) and vein sizes that were smaller than typically used for fistula creation. The U-CLIPTM Anastomotic Device offers the opportunity to create superior interrupted anastomoses for AV fistulas, even in patients who would otherwise be considered poor candidates for fistula creation.