Historical Background

In 1976 Dagher and colleagues reported a series of 23 upper arm basilic vein transpositions for hemodialysis. The procedure did not achieve widespread acceptance until after the first National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines were published in 1997. The first large series of femoral vein transpositions was published by Gradman and associates in 2001. The procedures are analogous but differ in their indications, magnitude, technique, and complications.

Basilic Vein Transposition

Preoperative Preparation

• •
  

  Preserving veins. Antecubital venipuncture should be discouraged and the jugular vein should be used used whenever possible for intravenous lines or pacemaker wires to preserve axial vein integrity.

  
  
• •
  

  Preoperative imaging. Duplex ultrasound with a proximal tourniquet can be used to determine the size of the basilic and cephalic veins and identify common anatomic variations. Duplex ultrasound is best conducted when the patient is hydrated, in a warm environment, and free of anxiety. Veins should be marked and sized on a nondialysis day to limit venoconstriction associated with volume shifts. Patients with long-standing ipsilateral central venous catheters, pacemakers, or previous dialysis catheters should have an imaging study to rule out central venous occlusive disease.

Pitfalls and Danger Points

• •
  

  Venous variations. The basilic vein occasionally joins the brachial vein in the midarm, rather than in the axilla. Antecubital vein variations are common. The median cubital vein, which extends from the midantecubital fossa to join the basilic vein, may be diseased, atretic, or nonexistent.

  
  
• •
  

  Nerve injury. The medial antebrachial cutaneous nerve of the forearm, a sensory nerve originating directly from the medial cord of the brachial plexus, crosses directly in front of the basilic vein at or just central to the entry of the median cubital vein. Dividing this nerve can lead to medial forearm anesthesia. The median nerve lies medial to the brachial artery at the level of the elbow and must be protected from injury during dissection and retraction.

  
  
• •
  

  Steal syndrome

Operative Strategy

One- or Two-Stage Procedure

Surgeons may choose to construct a basilic vein transposition in one or two stages. The single-stage procedure is cost effective but results in a higher frequency of primary failures. The two-stage procedure is most beneficial when the upper arm veins are of borderline size (2.5-3.5 mm; Fig. 65-1 ). A one-stage basilic vein transposition usually matures if the basilic vein is larger than 3.5 mm, but a two-stage basilic vein transposition should be constructed if the vein is between 2.5 and 3.5 mm. If the basilic vein is smaller than 2.5 mm, failure is common.

The most common sites for anastomosing the basilic vein to the brachial artery. ( 1 ) The basilic vein is divided at the entry of the median cubital into the basilic vein and transposed to the brachial artery in one stage. ( 2 ) The basilic vein is divided in the antecubital fossa and anastomosed to the distal brachial artery. This may be part of either a one- or a two-stage transposition procedure. ( 3 ) A side-to-side anastomosis is created between the median antecubital, cephalic, or median cubital vein and the proximal radial artery. No second stage may be necessary if retrograde venous valve destruction results in maturation of forearm veins. If it does not, a second-stage cephalic or basilic vein transposition is needed.

Harvest of the Basilic Vein

Whether done in one or two stages, the basilic vein must be transected distally and care must be taken to avoid injury to the medial antebrachial cutaneous nerve, which crosses anterior to the basilic vein at or just before the entry of the median cubital vein ( Fig. 65-2 , A ). Surgeons often encounter a stout large branch between the basilic and the brachial veins in the midarm. They should ligate or, if necessary, suture this branch carefully to avoid narrowing the lumen of the basilic vein. The basilic vein also occasionally joins the brachial vein in the midarm. Experience shows that if extra length is needed, the brachial vein may be harvested in continuity to the axilla without resulting in disabling postoperative arm edema. The brachial vein may be the dominant arm vein and can be used when no other autogenous vein is available. However, it is more fragile and has more branches than the basilic vein. The basilic vein should be freed to the proximal arm, marked to maintain orientation and tunneled over the anterior arm before anastomosis of the vein onto the brachial artery. Mere elevation of the vein makes for awkward cannulation and uncomfortable dialysis ( Fig. 65-2 , B ). The basilic vein can also be harvested endoscopically or via a “keyhole” technique. The benefit of decreased incisional pain has not been established.

A , The left basilic arm vein is exposed from the elbow to the axilla and marked for orientation before transection and tunneling. The medial antebrachial cutaneous nerve of the forearm, which crosses the basilic vein in the distal arm, should not be divided. Simple elevation of the vein, in contrast to transposition, results in medial forearm anesthesia and makes for uncomfortable and awkward cannulation for hemodialysis. B , The basilic vein has been tunneled anteriorly and anastomosed to the distal brachial artery. Twists and kinks must be avoided.

Operative Technique

Preoperative duplex vessel mapping is essential and may be assisted by placing a tourniquet on the proximal arm with gentle massage of the venous column centrally to distend the vein. Prophylactic antibiotics should be administered. Supraclavicular brachial plexus block can be used for anesthesia, along with 0.5% to 1.0% lidocaine to infiltrate the line of incision. Additional lidocaine can be administered into the fascial compartment. General anesthesia may be an alternative. The harvest incision extends the full length of the upper arm to the axilla. Exposure of the vein may begin anywhere along its length, but the venous anatomy is most reliably defined either in the axilla or at the median cubital vein. The basilic vein distal from its junction with the median cubital vein is occasionally harvested to gain additional length.