Brachial vein transposition is a promising ultimate upper limb autologous arteriovenous angioaccess despite its many pitfalls.

OBJECTIVE: The objective of this study was to retrospectively evaluate the possibility of using the brachial veins despite their deep location, small caliber, and thin wall. METHODS: There were 64 patients without superficial veins who were eligible for two-stage brachial vein transposition (BrVT); 54 patients were on hemodialysis, 9 patients had sickle cell disease, and 1 patient had long-term parenteral nutrition. Preoperative imaging was performed with color duplex ultrasound as well as venography for suspected central vein stenosis. A surgical microscope was used to create an end-to-side anastomosis between the brachial vein (medial, if possible) and artery. No minimum vein diameter was required. Postoperative color duplex ultrasound imaging was scheduled at 1 month. Second-stage superficialization was performed 2 to 3 months later with tunnelization and a new arteriovenous anastomosis. RESULTS: For the 64 patients, cumulative primary patency rates (± standard deviation [SD]) at 1 year, 2 years, 3 years, and 4 years were 50% (±7%), 42% (±7%), 37% (±8%), and 27% (±11%), respectively. Primary assisted patency rates (±SD) at 1 year, 2 years, 3 years, and 4 years were 60% (±6%), 51% (±7%), 45% (±7%), and 37% (±9%), respectively. Secondary patency rates (±SD) at 1 year, 2 years, 3 years, and 4 years were 60% (±6%), 53% (±7%), 53% (±7%), and 45% (±8%), respectively. Early complications included thrombosis, nonmaturation, and upper arm edema. At the second stage (n = 50), four patients presented with unexplained major fibrosis extending cephalad from the first surgical site and preventing any dissection of the vein. Four patients had more usual complications (one nonmaturation, two occlusions of the brachial vein at the previous arteriovenous graft-vein anastomosis), and two were lost to follow-up. Vein transposition in a subcutaneous tunnel was technically unfeasible in eight patients. Of the 64 patients, 40 (62%) had a functional BrVT that was cannulated for effective dialysis after a median interval of 72 days (15-420 days) from the first stage. Mean cumulative secondary patency rates (from first cannulation) at 1 year, 2 years, and 3 years were 91% ± 5%, 72% ± 8%, and 62% ± 10%, respectively. Overall, 13 patients were lost to follow-up. Secondary complications were low flow and central vein occlusion. Long-term complications were related to stenosis and thrombosis, aneurysms, and puncture site necrosis. Median follow-up from the first stage was 1.62 years (0.02-11.3 years). CONCLUSIONS: Despite many pitfalls for the surgeon, BrVT offers promising long-term patency.

Long-term results of femoral vein transposition for autogenous arteriovenous hemodialysis access.

INTRODUCTION: When all access options in the upper limbs have been exhausted, an autogenous access in lower limb is a valuable alternative to arteriovenous grafts. We report our experience of transposition of the femoral vein (tFV). METHODS: From June 1984 to June 2011, 70 patients underwent 72 tFV in two centers (Paris and Meknès) with the same technique. All patients had exhausted upper arm veins or had central vein obstructions. Patients were followed by serial duplex scanning. All complications were recorded and statistical analysis of patency was performed according to intention to treat using the life-table method. RESULTS: The mean interval between initiation of dialysis and creation of the tFV was 10 years. The sex ratio was even (one female/one male). Mean age was 48 years (range, 1-84 years), and there were no postoperative infections. Duplex measurements in 33 patients indicated high-flow: mean = 1529 ± 429 mL/min; range, 700-3000 mL/min. Two immediate failures were observed and four patients were lost to follow-up soon after the access creation. Ten patients (14%) experienced minor complications (hematoma, five; lymphocele, one; delayed wound healing, two; distal edema, two) and 30 patients (42%) experienced mild complications (femoral vein and outflow stenosis, 16 [treated by percutaneous transluminal angioplasty, 13, or polytetrafluoroethylene patch, three]; puncture site complications, three [ischemia, two; infection, one]; reversible thrombosis, three [two surgical and one percutaneous thrombectomy]; abandoned thrombosis, eight [11%] after a mean patency of 8.1 years). Thirteen patients (18%) experienced major complications necessitating fistula ligation (ischemic complications, five diabetic patients with peripheral arterial occlusive disease [one major amputation included]; lower leg compartment syndrome, one; acute venous hypertension, two; secondary major edema, two; high-output cardiac failure, one; bleeding, two). All the patent accesses (59/72) were utilized for dialysis after a mean interval of 2 ± 1 months (range, 1-7 months) resulting in an 82% success rate. According to life-table analysis, the primary patency rates at 1 and 9 years were 91% ± 4% and 45% ± 11%, respectively. The secondary patency rates at 1 and 9 years were 84% ± 5% and 56% ± 9%, respectively. CONCLUSIONS: Femoral vein transposition in the lower limb is a valuable alternative to arteriovenous grafts in terms of infection and long-term patency. Secondary venous percutaneous angioplasties may be necessary. High flow rates are frequently observed and patient selection is essential to avoid ischemic complications.