Autogenous Brachial—Brachial Fistula for Vein Access. Haemodynamic Factors Predicting Outcome and 1 Year Clinical Data

A systematic review of the brachial vein arteriovenous fistulas as a viable option for haemodialysis access

OBJECTIVES

International guidelines recommend the use of autogenous vascular access. Where suitable superficial veins are unavailable deeper veins may be used as an option. In most cases, basilic veins are used when cephalic veins are unavailable; arteriovenous fistulas using the brachial vein from the deep venous network are rare. Therefore, the purpose of the present study was to conduct a systematic review of the available literature evaluating the use of the brachial vein in arteriovenous fistulas.

METHODS

Systematic literature search of electronic databases in accordance with PRISMA was conducted. The primary outcomes of this study were primary and secondary patency rates for brachial vein arteriovenous fistulas; the secondary outcomes were the rates of access thrombosis, steal syndrome, pseudo-aneurysm and infection.

RESULTS

The 1-year primary, assisted, and secondary patency was recorded at (24%-77%), (45%-85%) and (45%-96%), respectively. The 2-year primary, assisted and secondary patency rate was recorded at (12%-46%), (19%-75%) and (19%-92%), respectively. However, the consistency regarding the reports and definitions used were highly variable. The incidence rate of infection, thrombosis and steal syndrome was 5% (0%-12%), 15.9% (9.5%-35%) and 3% (2%-6%), respectively.

CONCLUSION

Available studies support the use of brachial veins as a reliable access option in patients with non-accessible superficial veins where an autologous option is required.

Comparison between autogenous brachial-brachial upper-arm elevated direct arteriovenous fistulas and prosthetic brachial-antecubital indirect forearm arteriovenous grafts

OBJECTIVES

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines recommend forearm arteriovenous grafts (AVGs) as an alternative procedure to transposed basilic vein fistulas for providing secondary access during hemodialysis. Recently, autogenous elevated brachial-brachial vein fistulas (BVE) have become increasingly popular. The aim of this study was to compare the outcomes of BVE and forearm loop AVG (AVG) for secondary access in hemodialysis.

METHODS

We retrospectively reviewed the medical records of patients who had received a BVE or forearm AVG at a single center from January 2015 to April 2019. In total, 19 BVE were created via two-stage operations and two via a one-stage operation; 53 forearm AVG's were performed.

RESULTS

The AVG group was twice as likely to suffer loss of primary patency compared with the BVE group (odds ratio [OR], 2.666; 95% confidence interval [CI], 1.108-6.412; p = 0.029) per the multivariate analysis. The primary patency and primary assisted patency of the BVE group were superior those of the AVG group, except for secondary patency (p = 0.02, p = 0.07, p = 0.879, respectively). In subgroup analysis, there were no significant differences in primary, primary assisted, or secondary patency between AVG and BVE when brachial vein was used for AVG outflow. In addition, no significant differences were noted regarding the infection rate (12.5% vs 12.3%, p = 0.331, severity >0), postoperative bleeding rate (14.5% vs 3.5%, p = 0.191, severity >1), early thrombus rate (0.0% vs 10.5%, p = 0.122), and early failure rate (7% vs 4.8%, p = 0.591).

CONCLUSIONS

The primary patency and primary assisted patency rates of BVE were significantly better than those observed in AVGs, but the complication rates were similar. The appropriate procedure to provide vascular access should be determined by the individual patient's condition and the surgical skill of the operating surgeon.

Forearm brachial artery to brachial vein looped arteriovenous grafts: A single center, single surgeon observational study

BACKGROUND

Long-term hemodialysis (HD) treatment requires the establishment of a cannulatable vascular access (VA) point. While the arteriovenous fistula (AVF) is considered the gold standard, the arteriovenous graft (AVG) is a viable alternative especially in patients with poor superficial venous anatomy. Few studies have assessed the efficacy of the brachial-brachial arteriovenous graft (BB-AVG) for long-term HD access. By analyzing one surgeon's experience in creating, surveilling and maintaining BB-AVGs, this retrospective study aims to add to the body of literature in assessing patency outcomes of BB-AVGs.

METHODS

We identified 57 BB-AVGs that met inclusion criteria and were created between October 6, 2005 and May 1, 2019 by a single surgeon in 54 patients. We analyzed primary failures, patency, complications and interventions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and interventions were expressed as number of events per person-year.

RESULTS

A total of 54 patients (median age of 65 years) were analyzed. Primary patency rates at 12, 24, and 36 months were 20.4% 7.4%, and 5.0%. Primary assisted patency rates at 12, 24, and 36 months were 46.7%, 33.5%, and 15.1%. The secondary patency rates at 12, 24, and 36 months were 81.8%, 63.8%, and 60.1%, respectively. The incidence of complications and interventions was 2.164 per person-year. Most complications and interventions were due to stenosis (1.202 per person-year) or thrombosis (0.802 per person-year).

CONCLUSION

In patients with poor superficial veins, the brachial vein is a reasonable alternative to use as the venous outflow. However, in order to achieve acceptable patency rates, close monitoring of the VA, as well as aggressive treatment of complications within the brachial vein is necessary. Overall, the BB-AVG should be considered in patients who lack adequate superficial veins and require preservation of the more proximal veins.

Comparison of different techniques for the management of venous steno-occlusive lesions during placement of peripherally inserted central catheter

The purpose of this study is to investigate strategies for peripherally inserted central catheter (PICC) placement in patients with venous steno-occlusive lesion (VSOL). We performed a retrospective cohort study in adults with central or peripheral VSOL who underwent PICC placement procedures from January 2015 to December 2018. Four different strategies [selecting alternative pathway/over the wire (SAP/OTW), percutaneous transluminal angioplasty (PTA), re-puncture in ipsilateral arm (RIA), and catheter placement in the contralateral arm (CICA)] were analyzed and we compared the clinical outcomes by strategy and compared the strategy between central and peripheral VSOLs. During 4 years, 258 PICC procedures performed in patients with VSOLs, 100 PICC were included in the analysis. The overall technical success rate of initial attempt with SAP/OTW was 32.2%. As a second-line technique, PTA was most frequently used in both central (100%) and peripheral (68.2%) VSOL groups. The clinical success rates within 2 months of SAP/OTW, PTA, RIA, CICA were 55.2%, 43.2%, 14.3%, and 33.3%, respectively (P = 0.24). In conclusion, when the SAP/OTW failed, the PTA can be preferred as a second-line technique for both central and peripheral VSOLs. When guidewire passage fails, the operator could adopt the RIA or CICA technique as an alternative method.

Brachial vein transposition: an alternative to hemodialysis arteriovenous graft

Background

There is currently a worldwide effort to increase the options for autogenous hemodialysis access.

Objectives

To evaluate patency and complications of brachial vein transposition compared to other autogenous hemodialysis accesses.

Methods

A retrospective evaluation of 43 patients and 45 procedures. Patients who did not have adequate superficial veins according to duplex scanning were allocated to brachial vein transposition. The sample was thus divided in two groups, as follows: A: brachial vein transposition n=10 and B: other autogenous accesses n=35.

Results

There were no statistical differences between the two groups in terms of age diabetes, systemic arterial hypertension, dyslipidemias, arteriopathies, neoplasms, kidney disease stage, donor artery diameter, recipient vein diameter, systolic blood pressure in the operated limb, postoperative ischemia, hematoma, or infection. There were no statistical differences in terms of patency on day 7: A 80% vs. B 90% p=0.6, on day 30: A 80% vs. B 86% p=0.6, or on day 60: A 60% vs. B 80% p=0.22. There were statistical differences between the groups for number of previous fistulae A 1.0 ± 0.44 vs. B 0.6 ± 0.3 p = 0.04 and upper limb edema A: 20% x B 0% p = 0.04. A vein with diameter of less than 3 mm was associated with an increased risk of early occlusion (RR = 8 p = 0.0125). During the study period there were no procedures using grafts.

Conclusions

Transposition of brachial vein is an alternative to arteriovenous graft.

The forearm arteriovenous graft between the brachial artery and the brachial vein as a reliable dialysis vascular access for patients with inadequate superficial veins

OBJECTIVE

The arteriovenous fistula (AVF) is recommended as the preferred hemodialysis access. However, placing an AVF in all patients may result in poor access outcomes and increased central venous catheter (CVC) use because of increased comorbid conditions, age, and suboptimal vessels. In patients with inadequate superficial veins for AVFs, the use of the brachial veins for creation of forearm arteriovenous grafts (AVGs) has received limited attention. This retrospective study aimed to evaluate outcomes of forearm brachial-brachial AVGs (BB-AVGs) placed in patients with poor superficial veins.

METHODS

We identified 111 BB-AVGs created in 111 consecutive patients, using standard-walled polytetrafluoroethylene grafts, between January 2010 and December 2015. After excluding 6 patients (non-dialysis initiation, missing information, and death within 1 month), we included 105 patients from 21 dialysis centers. We analyzed primary failures, time to cannulation, patency, complications, and revisions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and revisions was expressed as number of events per person-year.

RESULTS

A total of 105 patients (median age, 69 years) were followed up for a median time of 21.2 months (interquartile range, 9.2-36.5 months). Of the patients, 72.4% were on chronic hemodialysis and had previously undergone one or more access procedures. At the time of BB-AVG placement, prior accesses were 39 AVFs, 20 tunneled CVCs, and 17 AVGs. BB-AVG rates of primary failure and revision before cannulation were 7.6% and 5.7%, respectively. BB-AVGs were cannulated after a median time of 3.4 weeks (interquartile range, 2.8-4.1 weeks). Primary patency rates at 12, 24, and 36 months were 49.5%, 29.5%, and 19.5%. Secondary patency rates at 12, 24, and 36 months were 76.3%, 62.7%, and 54.6%. After cannulation, the incidence of complications and revisions was 1.054 and 0.649 per person-year, respectively. Most complications and interventions were due to thrombosis (0.527 per person-year) or stenosis (0.381 per person-year) and related interventions (0.490 per person-year). A minority of patients experienced AVG infections (0.052 per person-year), with only two requiring access removal.

CONCLUSIONS

In patients with poor superficial veins, the forearm BB-AVG is a reliable access because of low access-related morbidity and considerable long-term access survival. BB-AVG placement has the advantage of preserving proximal vessels. In these patients, such an approach can delay both rapid exhaustion of vascular sites and early recourse to CVC permanent use.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Arteriovenous Access: Infection, Neuropathy, and Other Complications

Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.

Brachial Artery-Brachial Vein Fistula for Hemodialysis: One- or Two-Stage Procedure-A Review

Purpose The purpose of the study was to investigate the patency rate of the brachial vein transposition-arteriovenous fistula [BVT-AVF] and to review the available literature regarding the comparison of the one-stage with the two-stage procedure. Methods A multiple electronic health database search was performed, aiming to identify studies on brachial vein superficialization. Case reports and series with five or less patients were excluded from the study. End points of the study were the patency rates at 12, 24, and 36 months of follow-up. The patency of the one- or two-stage BVT-AVF procedure was investigated. Results Overall, 380 BVT-AVFs were analyzed. The primary patency rate at 12 months ranged between 24 and 77%. Rate of early fistula malfunction or failure of maturation of the fistula resulting in loss of functionality ranged from 0 to 53%. Forearm edema, hematomas, wound infection, and early thrombosis were among the most common complications. Limited data were available for the comparison of patency rates between the one- and the two-stage procedure because of the absence of sufficient comparative studies. However, series with one-stage procedure presented a lower patency rate at 12 months compared to series with two stages. Conclusion Patency rates after BVT-AVF, although not excellent, has encouraging results taking into account that patients undergoing these procedures do not have an accessible superficial vein network; failure of maturation and the increased rate of early postoperative complications remain a concern. The BVT-AVF is a valuable option for creating an autologous vascular access in patients lacking adequate superficial veins.

Axial splitting of the medial antebrachial cutaneous nerve facilitates second-stage elevation of basilic or brachial vein in patients with arteriovenous fistula

We describe a novel surgical technique to facilitate the second-stage elevation of the basilic or brachial vein in patients with first-stage brachial-basilic or autogenous brachial-brachial arteriovenous fistula by axial splitting of the medial antebrachial cutaneous nerve (MABCN). Filaments of the MABCN typically traverse the anterior aspect of the basilic and brachial veins. The second-stage elevation/shelf superficialization of the basilic or brachial vein, so as not to cause an injury to the MABCN, requires division of these veins with transposition over the nerve branches and subsequent reanastomosis. Our method of axial splitting of the MABCN enables elevation and shelf superficialization of the basilic or brachial vein without the division and reanastomosis of the vein. Twenty-eight patients underwent this simplified elevation. The nerve perineurium was incised longitudinally, nerve fibers were divided intrafascicularly, and cutaneous nerve branches were retracted aside. The vein was elevated between the divided nerves. On discharge and at 1-month follow-up, only one patient complained of localized patch hypoesthesia as reported in a simplified neurologic assessment questionnaire and neurologic examination.

Comparison among Transposed Brachiobasilic, Brachiobrachial Arteriovenous Fistulas and Flixene™ Vascular Graft

Objective

To compare the outcomes of 3 upper arm access types: transposed brachiobasilic arteriovenous fistula (BBAVF), autogenous brachial vein–brachial artery access (ABBA), and a new type of ePTFE graft (Flixene™ graft) (AVG), in a consecutive series of patients treated in a tertiary centre.

Methods

A prospective, computerized access database was analysed retrospectively to identify all patients undergoing BBAVF, ABBA, or AVG between January 1, 2008, and December 31, 2009.

Results

A total of 108 patients were identified; of whom 45 had BBAVF, 15 ABBA, and 48 ePTFE brachioaxillary AVG. Early failure was similar in all 3 groups. The 18–month functional patency rates for the ABBAs, BBAVFs, and grafts were 27%, 51%, and 55%, respectively. The median time to first use for AVGs was significantly shorter (p<0.0001). Complications were not more frequent in AVGs than ABBAs and BBAVFs (p=0.127). The total number of access interventions was similar between the AVG and ABBA groups (p=0.58), but it was significantly higher in the AVG group compared with the BBAVF group (p<0.0001).

Conclusions

This study supports the current recommendations of the NKF Kidney Disease Outcomes Quality Initiative for using BBAVFs as third choice after radiocephalic and brachiocephalic arteriovenous fistulas. We also showed good results with a new type of prosthetic graft (Flixene™ graft) that allows cannulation within days of implantation. We now favour the use of this graft instead of basilic vein transposition in elderly patients with short life expectancy and urgent need of renal access.