Primary and staged transposition arteriovenous fistulas

BACKGROUND: The use of catheters or prosthetic grafts for vascular access has significantly higher mortality and morbidity risks, in addition to higher costs, than arteriovenous fistulas (AVF). Many patients have a difficult access extremity due to complex medical illnesses, previous vascular access procedures, intravenous catheters, diabetes, vascular disease, female sex, age, and other complicating factors. Transposition AVFs (AVF-T) have been used for these individuals to avoid catheters and grafts. We report our experience with primary and staged basilic vein AVF-Ts and staged brachial vein AVF-Ts. METHODS: From our database of consecutive vascular access operations, we reviewed patients from May 2003 to September 2006 for all upper extremity AVF-Ts. A primary AVF-T was used when the basilic vein was continuous with a minimum diameter of 4 mm and of adequate length. When the basilic vein was 2.5 to 4 mm, the procedure was staged. The proximal radial artery was used for inflow, if possible. When the basilic vein was not suitable, a radial vein or brachial vein anastomosis was performed as the first stage of a planned brachial vein AVF-T. The second stage operations of staged AVF-Ts were generally done 4 to 6 weeks after the primary AVF construction. All patients were evaluated with preoperative ultrasound imaging by the operating surgeon. RESULTS: From a database of 412 consecutive vascular access patients, 78 upper extremity transposition procedures were identified. Of these, 57 patients (73.1%) were women, 44 (56.4%) were diabetic, and 46 (59.0%) had previous access surgery. Fifty-eight operations were staged procedures. The basilic vein was used in 68 AVF-T, the brachial vein in six, and cephalic vein in four. The anastomosis was based on the proximal radial artery in 60 patients. Mean follow-up was 18 months (range, 3-48 months). Primary patency, primary assisted patency, and cumulative patency were 45.7%, 93.5%, and 96.0% at 12 months and 27.6%, 86.5%, and 88.9% at 24 months, respectively. No prosthetic grafts were used in the study period. CONCLUSION: Both primary and staged AVF-T procedures were successfully used in patients with difficult access extremities. AVF-Ts were durable, although many required an interventional procedure for maturation or maintenance. Cumulative (secondary) patency was 96.0% at 12 months and 88.9% at 24 months. The absence of an adequate basilic vein does not preclude the use of a staged AVF-T because the brachial vein offers a suitable alternative.