Basilic Vein Superficialization Is an Effective Alternative to Transposition in Patients Requiring Brachiobasilic Arteriovenous Fistula

The goal of this study was to compare outcomes for techniques in the creation of brachiobasilic arteriovenous fistulas, namely in the second stage basilic vein transposition or the second stage basilic vein superficialization. We performed a retrospective review of patients undergoing two-stage brachiobasilic arteriovenous fistula construction at an urban academic medical center between 2012 and 2017. The second stage consisted of either tunneling the basilic vein and reanastomosis to the brachial artery, that is, “transposition,” or “superficialization,” which mobilized the basilic vein into the anterolateral subcutaneous plane through creation of a flap. Operative time, postoperative morbidity, access maturation, primary patency, and need for subsequent interventions were compared. In all 58 patients (29 male; mean age, 58 years) underwent a two-stage brachiobasilic arteriovenous fistula construction, 19 of which had a second stage superficialization (Table). The mean follow-up was 30 months. The second stage required significantly less time for superficialization compared with transposition (113 minutes vs 188 minutes, respectively; P < .001). The mean estimated blood loss was lower for superficialization at 45 mL compared with transposition at 84 mL (P = .18). The postoperative incidence of thrombosis, hematoma, and wound infection with superficialization (10.5%, 5.3%, and 10.5%, respectively) was lower than with transposition (17.9% [P = .46], 12.8% [P = .38], and 15.4% [P = .62], respectively); however, this difference failed to reach statistical significance. Access maturity was achieved in 94.7% of superficialization patients compared with 84.6% of transpositions (P = .27). Primary patency for superficialization was 89%, 79%, 63%, and 57.9% at 3, 6, 12, and 18 months, respectively, whereas for transposition it was 74%, 62%, 49%, and 41% at 3, 6, 12, and 18 months, respectively. The incidence of high-grade stenosis requiring intervention was significantly lower with superficialization than transposition (10.5% vs 58.9%; P < .001), leading to fewer percutaneous interventions after fistula creation. The reanastomosis site in transpositions was the location of 74% of high-grade stenoses requiring intervention, whereas none of the superficializations had problems with the AV anastomosis. Second-stage superficialization of the brachiobasilic arteriovenous fistula is an effective alternative to transposition given its shorter operative time, improved primary patency, and a lower need for percutaneous interventions after construction.TableResultsSuperficialization (n = 19)Transposition (n = 39)P valueGender11 M, 8 F18 M, 21 FAge, years6056.16Used left arm16/19 (84%)32/39 (82%)Interval between creation and second stages, days7883.79Operative time, minutes Creation109111.88 Second stage113188