Matyja, Andrzej

Matyja, Maciej

Osuch, Czesław

Sułkowski, Leszek

Archives of Medical Science - Civilization Diseases

English

Jagiellonian Univeristy Repository

NephrologyResearch letterCorresponding author:Leszek SułkowskiDepartment  of General SurgeryRegional Specialist HospitalPhone: +48 792244177E-mail: leszeksulkowski@icloud.com1 Department of General Surgery, Regional Specialist Hospital, Częstochowa, Poland2 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, PolandReceived: 10 June 2020Accepted: 29 July 2020Arch Med Sci Civil Dis 2020; 5: e44–e47DOI: https://doi.org/10.5114/amscd.2020.100838Copyright © 2020 Termedia & BanachOne-stage basilic vein tunneled transposition for hemodialysis accessLeszek Sułkowski1, Czesław Osuch2, Maciej Matyja2, Andrzej Matyja2The autogenous arteriovenous fistula (AVF) is an access of choice for chronically hemodialyzed patients [1–4], preferred over central venous catheter placement [5]. The AVF’s access vein on the upper extremity can be either the cephalic or basilic vein (BV). The forearm AVF is the first choice. In the case of inadequate, narrow or thrombosed forearm veins, the arm veins can be used to create an AVF. When the favorably located cephalic vein is narrow or thrombosed, the BV remains an alternative [6]. The deep location of BV in the arm makes this vein unsuitable for puncture without superficialization [1, 2, 7]. There are several techniques enabling the use of the deeply located BV, including lipectomy, BV eleva-tion and BV tunnel transposition (BVTT) [1, 2, 7, 8]. Therefore, BV AVF remains an access option for difficult cases, along with central venous catheter placement or prosthetic graft AVF [2]. BVTT is technically more complex than catheter placement or prosthetic graft AVF [5, 9], but has all the advantages of autogenous AVF and forms a long and superficial vein segment suitable for cannulation [7]. Surgical technique. A 34-year-old man had been suffering from ESRD and required hemodialysis. Preoperative vein mapping revealed insuffi-cient and too narrow basilic and cephalic veins on the forearm as well as the cephalic vein on the left arm. The diameter of these veins did not exceed 2.5 mm and mainly was less than 2 mm. The only vein sufficient for AVF creation was the BV on the arm. Due to the deep location of the BV on the arm, the patient was offered a BVTT. The course of the BV on the medial surface of the arm was mapped with ultrasound and marked on the skin (Figure 1, arrows). Under local anesthesia (0.5% lignocaine) two longitudinal incisions over the BV were performed (Figure 2) and the BV was exposed (arrows) along with its collaterals (arrowheads) and medial antebrachial cutaneous nerve (yellow arrows). The collater-als were ligated to mobilize the BV. The BV was distally dissected at the elbow level and dilated with isotonic saline solution (Figure 3, arrows). The subcutaneous tunnel was formed on the anterior surface of the arm and the BV was transposed into it. Through the distal skin incision, the brachial artery was exposed (Figure 3, arrowheads). End-to-side anasto-mosis between the brachial artery and the BV was performed with 7-0 suture (Figure 4, arrow). The thrill was palpable on the BV. Finally, the wounds were closed over the suction drain (Figure 5). The drain was re-moved on the second postoperative day and the patient was discharged One-stage basilic vein tunneled transposition for hemodialysis accessArch Med Sci Civil Dis 2020 e45on the 3rd day. The AVF cannulation was attempt-ed 6 weeks later.Discussion. The cephalic vein compared with the BV is more favorable, superficially located on the anterior surface of the arm and is more fre-quently used for AVF creation. However, BV AVFs remain an important option for ESRD patients, when the cephalic vein is inadequate for AVF cre-ation, narrow or thrombosed [1, 8, 10]. BV AVFs allow these patients to avoid catheter placement and prosthetic graft AVFs along with complica-tions associated with implantation of catheters or PTFE grafts.The brachial segment of the BV is deeply and medially located (Figure 2) and therefore it is in-adequate for HD without rerouting into subcuta-neous tissue, i.e. during the BVTT procedure [1, 8]. The transposition of the BV subcutaneously may Figure 1. Left arm with basilic vein (arrows) mapped under ultrasound guidanceFigure 2. Exposed basilic vein (white arrows), with collaterals (arrowheads) and medial antebrachial cutaneous nerve (yellow arrows)Figure 3. Basilic vein (arrows) with ligated collaterals, dilated with 0.9% saline solution and exposed brachial artery (arrowheads) in the ulnar fossaLeszek Sułkowski, Czesław Osuch, Maciej Matyja, Andrzej Matyjae46 Arch Med Sci Civil Dis 2020be performed during AVF creation (one-stage pro-cedure) or may follow the AVF maturation (two-stage procedure, when the first stage is a bra-chiobasilic arteriovenous anastomosis) [11–14]. The definitive answer to the question of whether one-stage or two-stage technique is optimal is still uncertain and needs a large randomized prospec-tive study. Authors emphasize that maturation, patency, failure and complication rates may sug-gest equivalence of both techniques. However, it is also emphasized that the strength of the evidence is limited [13, 15–17]. Some authors report that the one-stage technique decreases the time of maturation and the time to the first cannulation. This technique also minimizes the risk of cathe-ter-related infections, since it shortens the time of catheter-based HD [13]. The two-stage procedure is recommended if the basilic vein is less than 4 mm in size [15]. We prefer a one-stage BVTT due to the above-mentioned advantages, out of which the short time to the first cannulation and low risk of catheter-related infection are the most import-ant in our opinion. BVTT requires mobilization of the BV (Figure 3, arrows) and its rerouting into a subcutaneous tun-nel on the anterior surface of the arm (Figure 4) to achieve a long, superficial vein segment suitable for cannulation [10]. Pre-operative vein mapping is obligatory. Ultrasound confirms the sufficient di-ameter of the BV and reveals the BV course, which should be marked on the skin (Figure 1, arrows). Mapping minimizes the intraoperative trauma to both the BV and surrounding tissues (Figure 2). The surgical approach to the BV may be achieved with a single long incision along the BV or two or more skip incisions [18]. The skip inci-Figure 4. Arteriovenous anastomosis (side of brachial artery – end of basilic vein) (arrow)Figure 5. Wounds closed over the suction drainageOne-stage basilic vein tunneled transposition for hemodialysis accessArch Med Sci Civil Dis 2020 e47sions (Figure 2) allow as wide a view of the BV as a single long incision, but the procedure is more complex and time-consuming and surgery is pro-longed. However, skip incisions reduce wound-re-lated complications, i.e. infection or dehiscence, and increase the overall patients’ satisfaction with the whole procedure [18, 19]. We use pre-dominantly two or sometimes three skin incisions along the BV course (Figure 2).Since the wounds along the arm are long and deep, suction drainage for about two postopera-tive days is in our opinion mandatory to prevent hematoma formation (Figure 5).BV transposition is reported to be reliable and durable access also in children, for whom access creation is always challenging due to the small caliber of vessels [6].Conclusions. Preoperative BV mapping is oblig-atory. Dividing the skin incision into two or three skip segments makes the BV exposure more dif-ficult, but decreases the rate of wound-related complications. The BV should be transposed to a subcutaneous tunnel. Suction drainage should be routinely used. One-stage BVTT is a complex procedure, but should be recommended for pa-tients with insufficient other veins. It forms a long vein segment suitable for cannulation.Conflict of interestThe authors declare no conflict of interest.R e f e r e n c e s 1. Sulkowski L, Matyja M, Pasternak A. Lipectomy tech-nique as a second-stage procedure for primarily ma-tured, deep outflow vein in obese individuals. Indian J Nephrol 2018; 28: 320-2. 2. Korkut AK, Kosem M. Superficialization of the basilic vein technique in brachiobasilic arteriovenous fistula: surgical experience of 350 cases during 4 years period. Ann Vasc Surg 2010; 24: 762-7. 3. Sulkowski L, Matyja M, Pasternak A. Management of vascular access steal syndrome after high flow ar-terio-venous fistula with revision using distal inflow (RUDI) technique. MGM J Med Sci 2018; 5: 129-31. 4. Sulkowski L, Matyja M, Walocha JA, Pasternak A. Man-agement of hemorrhage from dialysis access site: our experience. MGM J Med Sci 2018; 5: 109-11. 5. Sulkowski L, Matyja M, Pasternak A. Salvage technique for complicated hemodialysis patients with central venous occlusion. J Postgrad Med Edu Res 2018; 52: 152-4. 6. Kfoury E, Demaree CJ, Poi MJ, Matos JM, Bechara CF, Lin PH. Long-term outcomes of staged basilic vein trans-position for hemodialysis access in children. J Vasc Ac-cess 2017; 18: 366-70. 7. Gerrickens MWM, Vaes RHD, Govaert B, Teijink JAW, Scheltinga MR. Basilic vein transposition for unsuitable upper arm hemodialysis needle access segment may at-tenuate concurrent hand ischemia. Hemodial Int 2018; 22: 335-41. 8. Wang S, Wang MS, Jennings WC. Basilic elevation trans-position may improve the clinical outcomes for superfi-cialization of basilic arteriovenous fistula veins. J Vasc Surg 2017; 65: 1104-12. 9. Rego D, Nogueira C, Matos A, et al. Two-stage basilic vein transposition: second stage results. Ther Apher Dial 2018; 22: 73-8. 10. Bourquelot P, Karam L, Robert-Ebadi H, Pirozzi N. Trans-position, elevation, lipectomy and V-Wing for easy nee-dling. J Vasc Access 2015; 16 Suppl 9: S108-13. 11. Mauro R, Pini R, Bianchini Massoni C, et al. A compari-son of two surgical techniques for the second stage of brachiobasilic arteriovenous fistula creation. Artif Or-gans 2017; 41: 539-44. 12. Przywara S, Ilzecki M, Terlecki P, Zubilewicz T. Axial split-ting of the medial antebrachial cutaneous nerve facili-tates second-stage elevation of basilic or brachial vein in patients with arteriovenous fistula. J Vasc Surg 2015; 62: 1353-6. 13. Shevitz AJ, Kim AH, Morrow KL, et al. Comparison of patient-specific factors and outcomes for one- and two-stage basilic vein transposition fistulas. J Vasc Surg 2018; 68: 1482-90.14. Ghaffarian AA, Griffin CL, Kraiss LW, Sarfati MR, Brooke BS. Comparative effectiveness of one-stage ver-sus two-stage basilic vein transposition arteriovenous fistulas. J Vasc Surg 2018; 67: 529-35. 15. Cooper J, Power AH, DeRose G, Forbes TL, Dubois L. Sim-ilar failure and patency rates when comparing one- and two-stage basilic vein transposition. J Vasc Surg 2015; 61: 809-16.16. Tan TW, Siracuse JJ, Brooke BS, et al. Comparison of one-stage and two-stage upper arm brachiobasilic arterio-venous fistula in the Vascular Quality Initiative. J Vasc Surg 2019; 69: 1187-95.e2. 17. Sheta M, Hakmei J, London M, et al. One- versus two-stage transposed brachiobasilic arteriovenous fistulae: a review of the current state of the art. J Vasc Access 2020; 21: 281-6.18. Shaikh FA, Nazeer S, Sophie Z, Shahzad N, Siddiqui NA. Multiple skip incisions versus single long incision for single-stage basilic transposition arteriovenous fistula: a cohort study. Ann Vasc Surg 2018; 50: 135-9. 19. Sulkowski L, Matyja M, Walocha JA, Pasternak A. Satis-faction with life among dialyzed patients: a cantril lad-der survey. MGM J Med Sci 2018; 5: 6-11. 

One-stage basilic vein tunneled transposition for hemodialysis access

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One-stage basilic vein tunneled transposition for hemodialysis access

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