Ulnar-Basilic Arteriovenous Fistula for Hemodialysis Access: Utility as the "Second Procedure" after Radio Cephalic Fistula

Objectives: As per standard guidelines, the recommended order of arteriovenous fistula (AVF) creation for hemodialysis (HD) access is radiocephalic (RC), followed by proximal elbow fistulas and arteriovenous graft. Although ulnar-basilic (UB) fistula has been an alternative to RC-AVF, still this procedure searches clear recommendations. We present here our experience on UB-AVF as the preferred “second procedure” instead of proximal fistula after the RC-AVF.

Methods: Forty-two UB-AVF were created in nonfeasible and failed RC-AVF cases between 2016 and 2018. They were reviewed retrospectively and outcomes were compared with 480 RC-AVF constructed within the same period.

Results: The primary patency at 18 months was 73.8%, 69.6% and mean maturation time was 33.7±6.6 days, 32.1±4.7 days for UB-AVF and RC-AVF respectively (p>0.05).

Conclusion: Our altered order of preference enabled us to create all the first-time fistula in the distal forearm, providing all the advantages of distal fistula like RC-AVF and avoiding proximal fistula, improved patient convenience and short-term benefit. In an inference that may be used for references and needs support from a larger sample and longer duration study from other centers, UB-AVF may be considered as the second option after RC-AVF depending on the clinical scenario.

Radiocephalic Fistula Recovery Using the Brachial Vein and Forearm Basilic Vein: A Case Series and Literature Review

Vascular access dysfunction is a serious problem in dialysis units. Some patients have complex dysfunctions that are difficult to resolve. In this article, we report the case a of two patients with radiocephalic arteriovenous fistulae (RC-AVF) who had stenosis/occlusion of the forearm median vein and where we used the basilic vein of the forearm as a solution. We reviewed the use of this surgical solution in RC-AVF. Two male patients on hemodialysis exhibited stenosis/occlusion of the forearm median vein. The forearm basilic vein was isolated and rotated toward the forearm median vein in order to solve RC-AVF problems. One patient had fistula thrombosis 5 months after the procedure, while for the other patient, the fistula continues to work without problems. Literature describes only a few cases using the forearm basilic vein or the brachial vein for fistula recovery. This procedure increased the patency of fistulas. This approach has been proven to be a good solution for solving outflow problems using the superficial or deep veins, increasing fistula patency and avoiding the need to place a central venous catheter and all the related complications.

Long-Term Results of Ulnar-Basilic Fistula Versus Radiocephalic Fistula for Maintenance Hemodialysis Access

OBJECTIVE

The aim of this study is to compare the rate of primary patency and secondary patency achieved by ulnar-basilic arteriovenous fistula (UBAVF) and radiocephalic arteriovenous fistula (RCAVF) in the maintenance of hemodialysis access.

METHODS

This retrospective analysis consists of 365 patients who had a forearm UBAVF or RCAVF between January 2012 and December 2015. Of these patients, 44 patients were treated with UBAVF, while 321 patients were treated with RCAVF. Demographics, primary patency, and secondary patency were documented and compared.

RESULTS

Primary patency rates at 1 and 2 years were 77.2% and 63.9% in group UBAVF and 88.1% and 71.3% in group RCAVF, respectively. Secondary patency rates at 1 and 2 years were 93.0% and 78.8% in group UBAVF and 98.7% and 80.9% in group RCAVF, respectively. The Kaplan-Meier analysis showed that the primary and secondary patency rates were all without statistical difference between the 2 groups.

CONCLUSION

Given the similar patency rate between UBAVF and RCAVF, the UBAVF could be considered as a reliable alternative when an RCAVF is not possible.

Radio-cephalic fistula recovered with drainage to forearm basilic vein

Dysfunction problems with vascular access are a concern to patients and dialysis units. The vascular surgeon should analyse such dysfunction and perform a careful assessment of the vascular network in order to find new fistula layouts. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the forearm basilic vein through rotation of the forearm basilic vein toward the cephalic vein in the forearm of an 88-year-old hemodialysis male patient. This technique enables extending fistula patency and improves cost efficiency.

Efficacy of the Ulnar-Basilic Arteriovenous Fistula for Hemodialysis: A Systematic Review

BACKGROUND

The fistula first initiative has promoted arteriovenous fistulas (AVFs) as the vascular access of choice. To preserve as many future access options as possible, multiple guidelines advocate that the most distal AVF possible should be created in the first place. Generally, snuff box and radiocephalic (RC) are accepted and well-described sites for AVFs; however, the forearm ulnar-basilic (UB) AVF is seldom used or recommended. The aim of this study is to assess and systematically review the evidence base for the creation of the UB fistula and to critically appraise whether more attention should be given to this site.

METHODS

Electronic databases were searched for studies involving the creation of UB fistulas for dialysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes for this study were 1-year primary and secondary patency rates. Secondary outcomes were rates of hemodialysis access-induced distal ischemia (HAIDI) and infection.

RESULTS

After strict inclusion and/or exclusion criteria by 2 reviewers, 8 studies were included in our review. Weighted-pooled data reveal 1-year primary patency rate for UB AVFs of 53.0% (95% confidence interval [CI]: 40.1-65.8%) with a secondary patency rate of 72.0% (95% CI: 59.2-83.3). HAIDI and infection rates were low.

CONCLUSIONS

Our review has shown that the UB AVF may be a viable alternative when a RC AVF is not possible, and dialysis is not required urgently. It has adequate 1-year primary and secondary patency rates and extremely low risk of HAIDI. While it may be more challenging for both surgeons and dialysis nurses to make it a successful vascular access it offers a further option of distal access which may be overlooked.

Distal ulnar-basilic fistula as the first hemodialysis access

PURPOSE

A distal forearm ulnar-basilic (UB) arteriovenous fistula (AVF) can be chosen if a radial-cephalic (RC)-AVF is not suitable for a primary AVF. However, limited data are available on the feasibility of using a distal forearm UB-AVF as an option for primary AVF.

METHODS

This retrospective analysis included 446 patients for whom AVFs (417 RC and 29 UB) had been newly created from January 2003 to December 2009, at our hospital. Patients in whom the arterial or venous anatomy precluded RC-AVF creation, UB-AVF was established as distally as possible on the forearm. Patency, defined as access survival after creation, was calculated using Kaplan-Meier analysis. The difference in patency between the two groups was examined using log-rank test.

RESULTS

The primary patency of UB-AVFs was significantly lower than that of RC-AVFs (p=0.037, log-rank test). The primary patency rate at 1 year was 25.0% versus 44.7%, respectively. However, there was no significant difference in secondary patency between the two groups. The secondary patency rate at 1 year was 85.5% for UB-AVFs versus 82.9% for RC-AVFs. The incidence rate of percutaneous angioplasty until access abandonment per patient-years was 1.100 for UB-AVFs versus 0.671 for RC-AVFs. There was no difference in the time to maturation between the two groups.

CONCLUSIONS

The secondary patency rate of UB-AVF is similar to that of RC-AVF. We recommend the creation of an UB-AVF when an RC-AVF is not a suitable option for the primary AVF.

Outcomes after ulnar-basilic arteriovenous fistula formation

BACKGROUND

The ulnar-basilic arteriovenous fistula (UBAVF) is rarely used owing to perceived problems with poor patency and prolonged maturation times. We report outcomes after UBAVF formation.

METHODS

Patients who had a forearm UBAVF formed between October 1, 2002 and September 31, 2010 were identified from a prospectively maintained database.

RESULTS

Fifty-two UBAVFs were formed in 48 patients. The majority were male (77.1%), with a median (range) age of 69.5 (18-86) years. Primary and secondary patencies at 1, 3, and 5 years were 43%, 13%, 13%, and 54%, 18%, and 13%, respectively. Primary patencies were higher in those with previously functioning radiocephalic arteriovenous fistulas on the same arm (P = 0.03). Thirty-six percent of UBAVFs became functional, with a median (range) time to maturation of 100 (32-471) days. Nine UBAVFs (17.3%) required revision surgery. Complications were rare (7.7%), with only one case of steal syndrome.

CONCLUSIONS

Although UBAVF patency and functionality rates are low, we believe that these are acceptable, given the low risk of complications and preservation of precious upper-arm venous capital. Maturation can be prolonged, but when the forearm cephalic vein is unusable, UBAVFs can provide an alternative to upper-arm fistulas, and should be utilized more widely, especially in those with previously functioning ipsilateral radiocephalic arteriovenous fistulas.