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.
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.
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.
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.
Steal syndrome occurs less frequently with a basilic vein transposition (<4%) than with a prosthetic bridge graft. Upper arm fistulas may be originated from the proximal radial artery to reduce the incidence of steal syndrome.
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.
An incision is made over the median cubital vein, which is dissected for a short distance. The adjacent brachial artery is exposed, a 4- to 5-mm-long arteriotomy is made, and an end-to-side, vein-to-artery anastomosis is created with 6-0 or 7-0 polypropylene.
After 4 weeks, ultrasound confirms that the basilic vein is suitable, as indicated by slight thickening and enlargement of the vein. At the second stage, the basilic vein is exposed to the axilla. A tunnel is created about 2 to 3 cm anterior to the basilic vein with a sheathed tunneler. The basilic vein is marked along its anterior surface, transected distally, gently dilated with heparinized saline, and drawn through the tunnel, with care taken to avoid rotation or kinking. The transposed basilic vein is reanastomosed to the distal vein. Subcutaneous tissue is reapproximated with a running 3-0 absorbable suture. A drain is usually unnecessary. Skin is closed with 5-0 subcuticular suture, and a sterile adhesive dressing is applied.
Superficialization of the Fistula
An additional popular variation involves performing an initial end-to-side basilic vein to brachial artery anastomosis. After a 4- to 6-week maturation period, the basilic vein is exposed, branches are divided and ligated, and the vein is superficialized by approximating the subcutaneous tissue below the vein. The fistula can be accessed after healing of the skin incision.
Use of the Radial Artery
Variations at the second stage include creating an anastomosis to the brachial artery at a more proximal site or transecting the vein close to the original arteriovenous anastomosis. Jennings has described a variation in which the radial artery is exposed in the proximal forearm and a side-to-side anastomosis is created to the adjacent median antebrachial, median cubital, or cephalic vein. Before creating the anastomosis, the valves in the distal vein are disrupted with a valvulotome to allow both antegrade and retrograde flow. The upper arm cephalic vein, cubital veins, and forearm veins may dilate and mature sufficiently for dialysis. If not, the upper arm cephalic or basilic vein can be transposed.
Most basilic veins are 4 mm in diameter or greater, and a one-stage procedure is usually possible if the vein is of sufficient size and free of intimal disease. The vein is exposed to the axilla, and a tunnel is created 2 to 3 cm anterior to the main harvest incision. The vein is marked on its anterior surface, transected distally at the level of the median cubital vein, and drawn through the tunnel, avoiding vein rotation or kinking. The vein is anastomosed end to side to the brachial artery. In most patients the brachial artery is exposed through the main incision about 2 to 3 cm proximal to the basilic vein transection. In the obese patient a second incision may be necessary to expose the artery.
An important variation of this procedure is to begin the basilic vein harvest starting at the confluence of basilic and median cubital veins. The advantage of transecting the basilic vein at this more proximal site is that the vein is usually 4 mm or larger and is unaffected by previous venipuncture, catheters, or revision of forearm prosthetic grafts. The obvious drawback is that there is less basilic vein for the transposition, but this has not proved detrimental in practice. If the basilic vein ends in the midarm, the surgeon needs to harvest the brachial vein in the upper arm to achieve adequate length. Subcutaneous tissue is reapproximated with a running 3-0 absorbable suture. A drain is usually unnecessary. Skin is closed with 5-0 subcuticular suture, and a sterile adhesive dressing is applied.