BRACHIOBASILIC FISTULA WITH ANTERIOR TRANSPOSITION, A WORKABLE SOLUTION IN DIFFICULT CLINICAL SITUATIONS.
Objective: This study was undertaken to assess the role of brachio-basilic fistulae with anterior transposition in patients with unsuitable veins for formation of conventional AV fistulae or after failure of multiple fistulae.
Study Design: Descriptive study.
Place and duration of Study: Armed Forces Institute of Urology and Military Hospital Rawalpindi, from November 2007 to October 2009
Material and Methods: Patients of CKD with unsuitable veins for the formation of conventional AV fistula and those with failed Radiocephalic and Brachiocephalic fistulae in whom Brachio-basilic fistula was formed, were included in the study. Patients unfit for general anesthesia and those with upper arm Prosthetic grafts were excluded. The patients were interviewed, examined with particular attention to vascular access and a complete data about their hemodialysis and previous vascular access was collected.
Results: Transposed Brachio-basilic fistulae were created in 38 patients of End Stage Renal Disease (ESRD) during study period; out of which 1 patient was lost during followup and the rest 37 were followed prospectively. The median duration of follow-up was 13.56 months (SD +6.03) with a range of 3 to 23 months. In 92% of cases transposed Brachio-basilic fistula was created after failure of one or more conventional fistulae. Complications were noted in 16.2% cases which included primary failure, wound infection, arm swelling and distal ischemia as a result of steal phenomena (Table). Three patients died during this period. Life of fistulae ranged from primary failure to as long as 23 months.
Conclusion: Transposed brachio-basilic fistula is a viable option for patients who do not have suitable vasculature for formation of conventional fistula but especially for those after failure of fistulae at other sites.
The diagnosis of end stage renal disease (ESRD) used to be a death warrant for patients suffering from it, but with the advent of renal replacement therapy, the situation has changed. At present renal transplantation is regarded as treatment of choice for patients of ESRD but due to increasing gap in demand and supply of cadaveric donors, there is an ever increasing waiting list1-3. Even in transplant recipients dialysis is required before and after rejection of transplant. So hemodialysis is the primary mode of renal replacement therapy, with some of the load being shared by peritoneal dialysis. Hemodialysis became possible after establishment of access to the circulation. It was in 1966 when Brescia et al explored the possibility of creating Arterio-venous fistula (AV fistula) on the wrist (Brescia-Cimino fistula)4. Even now Radio-cephalic fistula is the preferred site for AV fistula followed by Brachio-cephalic elbow fistula5,6.
In case of unsuitable veins or failure of previous AV fistulas, the choice of access is between transposed Brachio-basilic fistulae and prosthetic grafts. Greater cost, high infection rate and inferior long term patency makes prosthetic graft a less suitable option7-9. Both one stage and two stage basilic vein transposition procedures have been reported with generally good results10-11.
In Pakistan, only live donor transplantation is carried out and peritoneal dialysis is not in use except for emergency situations. So hemodialysis shares maximum load of patients with ESRD. The situation with AV fistulae is even more alarming. Due to lack of awareness, late referrals to nephrologists and dialysis phobia in the patients, AV fistulae are usually formed after starting hemodialysis12,13. This study was undertaken to assess the role of Brachio-basilic fistulae with anterior transposition in patients with unsuitable veins for formation of conventional AV fistulae or after failure of multiple fistulae.
PATIENTS AND METHOD
This descriptive study was carried out from November 2007 to October 2009. Inclusion criteria were (1) CKD patients with unsuitable veins for the formation of conventional AV fistula. (2) CKD patients with failed Radiocephalic and Brachiocephlic fistulae. Patients unfit for general anesthesia and those with upper arm Prosthetic grafts on ipsilateral side were excluded. The patients were interviewed, examined with particular attention to vascular access and a complete data about their hemodialysis and previous vascular access was collected.
After consent and fitness of the patient, one stage transposed Brachio-basilic fistula was formed under general anesthesia by consultant urologist or vascular surgeon. Transposed Brachio-basilic fistulae were formed by giving a hockey stick incision from antecubital fossa to axilla [Figure 1].
The Basilic vein was identified and dissected, then side tributaries were ligated, and it was mobilized from its bed. It was flushed with heparinized saline and occluded with a vascular clamp. A subcutaneous tunnel was created, such that the basilic vein could be pulled through in a semicircular fashion. The brachial artery was then dissected free above the elbow, the patient was heparinized, and the vein was spatulated to facilitate better inflow. The artery was incised after clamping, and an end-to-side anastomosis between the basilic vein and the brachial artery was completed with Prolene 6/0. Once done, clamps were removed and bleeding was controlled. The patency of fistula was checked clinically by thrill. Fistula was allowed to mature for 6 to 8 weeks before use.
Primary outcome was primary failure rate and secondary outcome was incidence of complications. A fistula was deemed to have had a primary failure when it never matured adequately to be used successfully for dialysis.
The statistical analyses were carried out using the SPSS-16 package for windows. Descriptive statistics were used to describe the results.
Thirty eight patients with CKD in whom transposed Brachio-basilic fistulae were created as vascular access, were included in this study. Out of these one patient was lost during followup and the rest 37 were followed prospectively. The mean duration of follow-up was 13.56 months (SD +6.03) with a range of 3 to 23 months. No operative death occurred while three patients died during followup due to ischemic heart disease.
The mean age of the patients was 48.17 years (SD+14.5) and males (73.5%) outnumbered females (26.5%). In 19% of these transposed Brachio-basilic fistulae were created after failure of 3 or more conventional fistulae, in 73% of cases transposed Brachio-basilic fistulae were formed after failure of 1 or 2 conventional fistulae and in rest 8% these were created as primary fistula due to unsuitable vessels for other type of fistulae, after confirmation by Doppler ultrasound Of the total 37 cases, complications were noted in 16.2% cases (n=6). Out of these in 2.7% (n=1) fistula had a primary failure and second transposed Brachio-basilic fistula had to be created on other side, as on all other sites the fistulae had failed (Table). In 5.4% cases (n=2) we had wound infection which recovered with antibiotics. In another 5.4% cases (n=2) there was swelling of the arm which slowly settled with arm elevation only.
Distal arm ischemia as a result of steal phenomena developed in 2.7% (n=1) leading to the pain and numbness in the arm and loss of Radial pulse. This fistula had to be closed electively. Apart from 2 cases rest of the transposed Brachio-basilic fistulae are functioning well. Life of fistulae ranged from primary failure to as long as 23 months.
Vascular access is life line for patients on hemodialysis. This should be prepared as early as possible, preferably 4 months before starting hemodialysis as it is associated with a lower risk of sepsis and death, primarily by reducing the use of hemodialysis catheters14. In our setup Radiocephalic fistula is the preferred site followed by Brachiocephalic fistula; this is in accordance with Canadian and American guidelines5,6.
For long term hemodialysis patients lacking adequate superficial veins, the choices are generally between Brachio-basilic fistula and a prosthetic graft. Lesser cost, decreased risk of infections and longer patency rate favors Brachio-basilic fistula. Oliver MJ et al evaluated the clinical outcomes of the three major types of upper arm vascular access transposed Brachio-basilic fistulae, Brachio-cephalic fistulae and prosthetic grafts7. Primary access failures for transposed Brachio-basilic fistulae was 21% which was more than prosthetic grafts (15%) but much less than that of Brachio-cephalic fistulae (32%). Apart from primary failure other complications included access infection, distal steal, arm swelling, poor maturation and hemorrhage. In our study primary access failure rate is much lower as compared to Brachio-basilic fistulae rate of this study but rest of the complications are comparable (Table-1).
TabLe: Comparison with other studies
###Maya etal8###Oliveratal7###Lee etal15###Our study
No of patients###n=67###n=59###n = 16###n = 37
Age (years)###56 +- 15###53###63.4###47.17 +- 14.5
Gender % male###52 % (35)###59 %###37.5 % (6)###73.5 %
Previous access###46 % (31)###63 %###92 %
Primary failure###18 %###21 %###0 %###2.7 % (1)
Infection###0 %###2 %###0 %###5.4 % (2)
Steal###-###2 %###6.25 % (1)###2.7 % (1)
Arm swelling###-###3 %###6.25 % (1)###5.4 % (2)
Poor maturation###-###6 %###-###-
Haermorrhage###-###3 %###0 %###0 %
Maya et al8 carried out a similar study with identical results i.e. primary failure rates of 18%, 15%, and 38% for transposed Brachio-basilic fistulae, prosthetic grafts and Brachio-cephalic fistulae, respectively. In comparison to our study this study also had a very high primary failure rate for transposed Brachio-basilic fistulae.
In our study 92% of patients had a previous vascular access before transposed Brachio-basilic fistula which is higher than the studies discussed. So an explanation of low rate of primary access failure could be an increased basilica vein diameter due to failed previous ipsilateral forearm vascular access. Furthermore apart from veins diameter primary access failure is also due to technical or judgmental error likely due to kinking of vein over anastomosis, inadequate anastomotic technique and undetected venous outflow occlusion, in our study all the operations were performed by experienced surgeons.
Lee et al15 compared Brachio-basilic fistulae with upper arm prosthetic grafts. In this study, complications of Brachio-basilic fistulae requiring additional procedures developed in 5 out of total 20 patients including balloon angioplasty, surgical thrombectomy, banding and reexploration. There was no incidence of primary failure. This study has a comparable complication to our study.
Coburn et al9 compared the patency rate and complications of transposed Brachio-basilic fistulae with prosthetic grafts. Transposed Brachio-basilic fistulae had a superior patency with low complication rate in comparison to prosthetic graft group. Bashir EA carried out a study in CMH Kharian16. According to this study; the transposed Brachio-basilic fistulae were used in preference to prosthetic grafts on 26 occasions.
In case of failure of transposed Brachio-basilic we are left with option of prosthetic graft on the same side or transposed Brachio-basilic on the contralateral side. Milburn JA et al17 concluded that transposed Brachio-basilic fistula offers an autogenous fistula in the upper arm which has superior patency rates to an arm AV graft. Once a transposed Brachio-basilic fistula has failed, an ipsilateral prosthetic graft is technically feasible and may offer better patency than a primary prosthetic graft.
Vascular access is the Achilles heel for all involved in the care of hemodialysis patients. The early planning, better operative technique and long term care of vascular access are all important factors in the management of patient with ESRD. Transposed Brachio-basilic fistula is a viable option for patients who do not have suitable vasculature or after failure of conventional fistulae.
1. Cohen DJ, St Martin L, Christensen LL, Bloom RD, Sung RS. Kidney and pancreas transplantation in the United States, 1995-2004. Am J Transplant. 2006; 6:1153-69.
2. Gaston RS, Danovitch GM, Adams PL, Wynn JJ, Merion RM, Deierhoi MH. The report of a national conference on the wait list for kidney transplantation. Am J Transplant 2003; 3:775-85.
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7. Oliver MJ, McCann RL, Indridason OS, Butterly DW, Schwab SJ: Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas. Kidney Int: 2001; 60:1532 -39.
8. Maya ID, O'Neal JC, Young CJ, Finkel JB, and Allon M. Outcomes of Brachiocephalic Fistulas, Transposed Brachiobasilic Fistulas, and Upper Arm Grafts. Clin J Am Soc Nephrol: 2009; 4: 86-92.
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12. Fan PY, Schwab SJ. Vascular access: Concepts for the 1990s. J Am Soc Nephrol: 1992; 3: 1-11.
13. Anees M, Mumtaz A, Nazir M, Ibrahim M, Rizwan SM, Kausar T. Referral pattern of hemodialysis patients to nephrologists. J Coll Phys Surg Pak: 2007; 17: 671-74.
14. Oliver M, Rothwell D, Fung K, Hux J, Lok C. Late creation of vascular access for hemodialysis and increased risk of sepsis. J Am Soc Nephrol: 2004; 15:1936-42.
15. Lee ch, Ko PJ, Liu YH, Hsieh HC, Liu HP. Brachiobasilic fistula as a secondary access procedure: An alternative to dialysis prosthetic graft. Chang Gung Med J. 2004; 27(11): 816-23.
16.Bashir EA. Brachiobasilic Fistula for Vascular Access. J Surg. 2001; 23-24:28-30.
17. Milburn JA, Lo ST, Szucs ZJ, Humphrey A, Macaulay EM. Transposed brachiobasilic fistula or PTFE arm graft - alternative or complementary? J Vasc Access: 2008; 9: 117-21.
Text Box: Correspondence: Maj Zahid Farooq Baig, Street No. 14, House No. 163, Jinnahabad, Abbottabad
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|Author:||Farooq, Zahid; Mehmood, Arshad; Saeed, Shahzad; Raja, Khalid Mehmood; Khan, Malik Nadeem Azam; Murt,|
|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Dec 31, 2010|
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