Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysis-related complications.

OBJECTIVE

Easy access to the vascular system is vital in patients with chronic renal failure undergoing long-term hemodialysis. Such patients often require multiple operations, and options for secondary or tertiary access procedures become increasingly limited. Brachiobasilic arteriovenous fistula offers excellent access in such difficult cases and is increasingly preferred over prosthetic grafts. Many surgical techniques have been described to create such fistulas. The purpose of this study was to determine the difference in long-term patency and dialysis-related complications among various techniques.

METHODS

Seventy brachiobasilic arteriovenous fistulas were constructed in 70 patients. This was the secondary or tertiary access in 88.6% of patients. The basilic vein was transposed in 30 patients and elevated in 40 patients; twenty veins were elevated with a one-stage technique, and 20 were elevated with a two-stage (delayed elevation) technique.

RESULTS

The early failure rate was 5.7% in the entire group. Sixty-six fistulas (94.3%) were successfully used for dialysis. Mean follow-up was 25.8 months (range, 4-36 months). Four fistulas (5.7%) required additional procedures during follow-up, 2 in the transposed vein group and 2 in the elevated vein group. Cumulative secondary patency rate, measured with the Kaplan-Meier survival method, was 86.7%, 90%, and 84.2% at 1 year for the transposed, one-stage, and two-stage elevation procedures, respectively, compared with 82.8%, 70%, and 68.4% at 2 years. The difference was statistically nonsignificant. Forty-two complications developed in 29 (43.9%) fistulas. Thirteen fistulas (19.7%) had more than one complication. Twelve complications in 10 fistulas (35.7%) were recorded in the transposition group, 15 complications in 9 fistulas (47.4%) in the one-stage elevation group, and 15 complications in 10 fistulas (52.6%) in the two-stage elevation group. The total complication rate was higher in the elevated fistulas (71.4% vs 28.6%); the difference was statistically highly significant (P <.001). The most common complication was arm edema (21.2%; n = 14), followed by puncture site-related hematoma (16.7%; n = 11) and thrombosis (16.7%; n = 11). Hematoma was statistically more common (P <.05) in the elevated vein group (26.3% vs 3.6%). The difference in thrombosis between the transposition and elevation groups (23.7% vs 7.1%) was not significant. Hematoma preceded thrombosis in 63.7% (7 of 11) of the fistulas, and it was the major predisposing factor for fistula failure. Transposed vein was easier to manage by dialysis staff. All nurses were satisfied with the transposed veins, but only 53.3% were satisfied with the elevated veins; the difference was statistically highly significant (P <.001).

CONCLUSION

Available techniques for creating brachiobasilic arteriovenous fistula are associated with good patency rate, and most related complications can be treated conservatively without loss of the fistula. Among the various procedures, transposition has a lower complication rate and is favored by the dialysis staff dealing with such fistulas.