Results.

Huber et al reported a series of 30 patients who underwent translocated femoral vein–to–upper arm brachial-axillary access.¹¹ They reported primary and secondary patency rates of 79% and 100% at 12 months and 67% and 100% at 18 months. Clinically significant access-related ischemia of the upper extremity occurred in 27% of patients in that series. Each patient underwent a distal revascularization–interval ligation (DRIL) procedure to treat severe ischemia and thereby salvage the access. Huber’s group stressed the importance of using the contralateral rather than the ipsilateral saphenous vein for the DRIL procedure to reduce the risk of limb swelling and compartment syndrome after the initial femoral vein harvest. Two patients (7%) developed compartment syndrome necessitating fasciotomy. Wound hematomas developed at the vein harvest site in 23% of patients and in the arm in 17% of patients. Although this procedure has potential advantages because it is an autogenous access, those advantages must be balanced against a high incidence of wound complications and access-related upper extremity ischemia.

A longitudinal skin incision is made over the brachial artery proximal to the antecubital fossa, and a 3-cm segment of the artery is exposed. The axillary vein is exposed through a single longitudinal incision in the axilla and proximal upper arm. To expose the femoral vein, an incision is made in the groin and extended distally along the medial border of the sartorius muscle. The sartorius muscle is retracted laterally in the proximal thigh and medially in the distal thigh to facilitate exposure of the femoral and popliteal vein. The vein is mobilized from the mid–popliteal fossa to the common femoral vein. Tributaries off the vein are ligated and divided. The femoral vein is harvested flush with the profunda vein. It is important to preserve the profunda vein to minimize the occurrence of compartment syndrome. A tunnel is created between the brachial artery and axillary vein over the ventral aspect of the upper arm. The vein is reversed and passed from the brachial artery to the axillary vein. An end-to-side anastomosis is performed between the femoral vein and the axillary artery with a 5-0 or 6-0 polypropylene suture (Fig. 75-3). A closed suction drain is placed in the thigh wound, and the incisions are closed in layers. Because of the significant size mismatch between the femoral vein and the brachial artery, there may not be enough turbulence in the vein to feel a thrill initially.

In 2004, Bazan and Schanzer reported two cases of autogenous brachial vein transposition in patients with inadequate superficial upper extremity veins for autogenous AV access creation.¹² No manifestations of venous hypertension occurred in either patient. After 1 year, both accesses were functional. Subsequently, Elwakeel et al reported a series of 21 patients who underwent brachial vein transposition.¹³ In contrast to Bazan and Schanzer’s technique, they used a two-stage procedure. During the first stage, the brachial artery–brachial vein anastomosis was performed at the antecubital fossa. If the brachial vein at the antecubital fossa measured less than 3 mm, the procedure was abandoned and a prosthetic graft was placed. Approximately 1 month after the first-stage procedure, the patients underwent a second step “superficialization” procedure. This procedure involved the mobilization of the arterialized brachial vein from the antecubital fossa to the axilla. The mobilized access was then transposed to a subcutaneous pocket lateral to the incision. All but one patient in this series had undergone previous upper extremity AV access procedures. The functional patency rate was 76% at 1 year and 55% at 2 years. Three accesses failed to mature. Although four patients experienced arm edema postoperatively, it resolved spontaneously in all cases. Angle and Chandra reported a series of 20 patients who underwent a two-stage procedure similar to that reported by Elwakeel, except that all the procedures were first-time accesses.¹⁴ Of the 20 AV accesses, 19 (95%) matured and were functional; patency rates were not reported. One patient with pacemaker wires in the subclavian vein ipsilateral to the access developed venous hypertension secondary to central vein stenosis. Casey et al reported a series of 17 brachial vein transpositions.¹⁵ Only patients with brachial vein diameters greater than 4 mm on preoperative vein mapping were considered candidates for the procedure. All were performed as single-stage procedures. Fifty-three percent of the brachial vein transpositions in this series failed to mature. The functional primary and secondary patency rates were 40% at 12 months. In 2009, Jennings reported outcomes of a series of 58 brachial vein transpositions.¹⁶ The majority were performed as two-stage procedures. Single-stage procedures were performed only in cases in which the brachial vein initially measured more than 6 mm in diameter on preoperative vein mapping. The primary and secondary patency rates were 52% and 92% at 12 months.

In addition to the studies cited previously, several other brachial vein transposition series have recently been reported. However, those reports failed to use standard methods for reporting vascular access outcome and thus were not included in this review. None of the published series on brachial vein transposition report follow-up long enough to obtain reliable patency estimates beyond 1 year.

Technique.

Upper extremity vein mapping is performed to determine the diameter and quality of the brachial, cephalic, and basilic veins. Brachial vein transposition should be considered as an option for vascular access only if the brachial vein diameter is greater than 2.5 mm and in cases in which vein quality precludes the creation of a brachial-cephalic autogenous access or basilic vein transposition. Most reports recommend that brachial vein transposition be performed as a two-stage procedure whereby the AV anastomosis is created at the first stage, followed 6 weeks later by vein transposition. One-stage procedures are considered only in cases in which the brachial vein exceeds 4 mm in diameter. The first stage (creation of the AV anastomosis) is performed using local anesthesia. For the second stage (mobilization and transposition of the vein), local sedation can be used in selected cases; however, the preferred anesthetic technique is either a regional (interscalene) block with sedation or general anesthesia. The first stage of the procedure involves making a longitudinal incision over the brachial pulse in the antecubital fossa in order to expose both the brachial artery and vein. When multiple brachial veins are present, the largest vein is used for the AV anastomosis. Use of the proximal radial artery, rather than the brachial artery, as the site for the AV anastomosis may reduce the risk of access-related limb ischemia. An end-to-side vein-to-artery anastomosis is performed using a running 6-0 polypropylene suture. The second stage is performed 4 to 6 weeks after the first to allow the vein wall to arterialize, thereby facilitating its mobilization. A longitudinal incision is made over the course of the brachial artery and vein in the distal upper arm. This incision is extended proximally several centimeters at a time while sequentially freeing up the anterior surface of the vein in order to expose the entire brachial vein length from the antecubital fossa to the axilla.

Mobilization of the vein can be challenging and thus requires considerable patience. The medial antebrachial cutaneous and median nerves are adjacent to the vein and must be protected from injury. Also, because the vein may be adherent to the adjacent brachial artery, it can easily be torn during mobilization. Venous tributaries are individually ligated with 4-0 silk sutures. Short, broad tributaries are oversewn with 7-0 polypropylene. After mobilization, the anterior surface of the vein is marked to prevent twisting during transposition. A number of techniques for transposing the vein have been described. If the length of mobilized vein is adequate, the preferred technique is to tunnel it through a separate subcutaneous tunnel over the ventral aspect of the upper arm. For this, a tunneling device is passed lateral to the upper arm incision from antecubital fossa to axilla. The vein is divided near the AV anastomosis and passed through this subcutaneous tunnel, taking care to prevent twisting or kinking. An end-to-end anastomosis of the vein is performed using a 6-0 polypropylene. If the vein is too short to be transposed through a separate subcutaneous tunnel, it can be simply elevated by closing the fascia and subcutaneous tissue of the wound beneath it with interrupted 3-0 absorbable suture. A running 4-0 absorbable suture is used to close the skin over the vein containing the access. Postoperatively, dialysis personnel are instructed to cannulate the AV access directly through the overlying scar. Alternatively, a subcutaneous flap (approximately 3 mm below the skin) can be developed anterior to the skin incision. Placement of the access in this pocket positions it away from the skin incision. The access can be cannulated once the skin incision has completely healed, usually in about 3 weeks after the second-stage procedure.

Results.

The common femoral artery–saphenous vein loop transposition was first described in a single patient by May et al in 1969.¹⁷ Pierre-Paul et al recently reported a series of seven patients who underwent the procedure.¹⁸ Two of the seven accesses (29%) did not achieve functional maturation. Local wound complications from the vein harvest incision occurred in more than half the patients. Secondary interventions to maintain access patency were necessary in all cases (mean of three angioplasties per access). The mean time to secondary failure was 16 months. Gorski et al reported a series of five saphenous vein transpositions in patients with acquired immunodeficiency syndrome.¹⁹ The primary and secondary patency rates were 80% at 1 year. The only failure occurred as a result of bleeding from early cannulation of the access. In 2002, Illig et al reported a series of four patients who underwent the procedure.²⁰ In an effort to minimize the wound complications reported in other series, an endoscopic technique was used to harvest the greater saphenous vein. One access failed early; functional patency in the remaining accesses was achieved for 6 months, 12 months, and 13 months. No major wound complications or infections occurred.

Based on the limited number of series reporting the outcome of saphenous vein translocation, the following conclusions can be made: (1) The use of skip incision or endoscopic techniques to harvest the saphenous vein may decrease the wound complications associated with this procedure. (2) Because the great saphenous vein does not readily dilatate after access creation, only veins greater than 3 mm in diameter should be used, and the vein must be tunneled just beneath the dermis to allow reliable cannulation of the access. (3) Cannulation of the access must be delayed at least 6 weeks postoperatively to prevent puncture site bleeding and hematoma. (4) The procedure may not be practical for patients who are morbidly obese or those with a large, redundant pannus, because access cannulation may require the patient to lie in the supine position and retract the pannus to expose the access.

The largest experience with autogenous femoral artery–femoral vein transpositions was reported by Gradman et al in two separate series.^21,22 The initial series reported the outcome for 25 patients who underwent the procedure. Ten of the accesses were narrowed or “banded” (i.e., flow limited) at the time of the initial procedure to prevent postoperative access-related limb ischemia. Even with banding, limb ischemia necessitating additional surgery was common, occurring in 32% of patients. The primary and secondary patency rates at 12 months were 78% and 87%, respectively. The ankle-brachial index decreased an average of 0.21. Major wound complications occurred in 28% of cases. One patient developed compartment syndrome requiring fasciotomy and ultimately required an above-knee amputation.²¹

In an effort to decrease the incidence of access-related limb ischemia associated with this procedure, Gradman modified the technique and patient selection criteria, reporting the outcome in a separate series of 22 patients.²² To prevent access-related limb ischemia, the size of the arterial anastomosis was limited to 4.5 to 5 mm. This was accomplished by inserting a 5-mm mandrel in the beveled vein and closing the excess vein with suture. The tapered vein was then anastomosed end to side to the distal superficial femoral artery. Patients with an ankle-brachial index less than 0.85 or absent pedal pulses were excluded. Prophylactic fasciotomies were performed in patients with weak or absent pedal pulses after access creation. The secondary patency rate in this second series was 94% at 2 years. With the modification in technique and patient selection criteria, the occurrence of limb ischemia necessitating revascularization was reduced from 32% to 0%. Bourquelot recently reported outcomes from a series of 72 femoral vein transpositions.²³ Patients with diabetes mellitus or peripheral artery disease were not considered candidates for the procedure. The primary patency was 91% at 1 year. The secondary patency was 84% at 2 years. Major complications requiring access ligation was required in 13 (18%) of patients. These complications included five cases of distal limb ischemia, two cases of venous hypertension, two cases of bleeding, and one case of high-output heart failure. In a case report, Jackson reported flow rates for femoral vein transposition exceeding 2000 mL/min.²⁴ Therefore caution is necessary when creating this access in patients with congestive heart failure.

Technique.

A preoperative assessment of the lower extremity arterial and venous anatomy with duplex ultrasonography is necessary. Complication rates for this operation may be reduced through careful patient selection and modification of the procedure for patients who are at high risk for complications.

The femoral vein is exposed and mobilized as described previously. In obese patients it is often necessary to mobilize the vein to the popliteal vein at the knee to gain adequate length. The profunda femoral vein is an important collateral vessel; therefore it is important to preserve its continuity to prevent venous hypertension and compartment syndrome. The femoral vein is ligated distally and transected. The vein is brought through a subcutaneous tunnel lateral to the vein harvest incision to the superficial femoral artery in the distal thigh. The distal end of the femoral vein should be tapered to 4.5 to 5 mm as described by Gradman and outlined earlier (Fig. 75-4A). An end-to-side anastomosis is performed to the distal superficial femoral artery with a 6-0 polypropylene suture.