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Hemodialysis access: Elevated basilic vein arteriovenous fistula
Hemodialysis
Access:
Elevated
Basilic
Vein Arteriovenous
Fistula
BY J.B. Davis, Jr, C.G. Howell, and A.L. Humphries, Jr Augusta, 6 Vascular access in the pediatric patient with endstage renal disease (ESRD) can be a surgical challenge to perform as well as maintain. We have recently developed a new technique of elevating the basilic vein in the upper arm for the arteriovenous LAVAfistula instead of using a polytetrefluoroethylene (PTFE) graft. During the past 2 years, 66 patients with ESRD and unsuitable superficial veins have had basilic vein elevation. Of these 66 patients, four have been in children, aged 11 to 1g years. The technique of mobilization of the vein from the elbow to the axilla was similar to that described by Dagher et al except that we used one long incision. The new feature of this technique is that the vein is not rerouted laterally through a subdermal tunnel. Instead, after the AV fistula to the side of the brachial artery is created, the vein is elevated within the incision by closing the subcutaneous fascia beneath, and the skin over, the vein. Most veins could be used in 2 to 4 weeks. Of the entire group, the patency rate has been 55 of 66 (63.3%). with no infections or long-term morbidity. Of the four pediatric patients, there have been no thromboses or infections. We believe the operation to be easier to perform than the standard PTFE bridge graft. The subsequent AV fistula is easy to access, less likely to cause a “steal syndrome,” less likely to become infected, and if it does become infected, more likely to respond to treatment with antibiotics. c 1986 by Grune & Stratton, Inc. INDEX WORDS: hemodialysis.
Vascular access; arteriovenous fistula;
H
EMODIALYSIS ACCESS in the pediatric patient with chronic renal failure can be difficult to perform as well as maintain. Use of external appliances (Scribner type shunts) are limited for longterm hemodialysis because of the small size of peripheral blood vessels, which predisposes to thrombosis.’ Subsequent experience with bovine carotid heterografts revealed a high rate of complications including thrombosis, pseudoaneurysm formation, and infection.’ A current popular technique for chronic hemodialysis is the polytetrafluoroethylene (PTFE) graft fistula.3 Recently, we have developed a new technique of
From the Section of Pediatric Surgery, Department of Surgery, Medical College of Georgia Hospital and Clinics, Augusta. Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto, Ontario. May 14-I 7. 1986. Address reprint requests to C.G. Howell, MD Section of Pediatric Surgery. Medical College of Georgia Hospital and Clinics, Augusta, GA 30912-2843. 0 1986 by Grune & Stratton, Inc. 0022-3468/86/21 I2-0034$03.00/0
1182
Georgia
elevating the basilic vein in the upper arm for an arteriovenous (AV) fistula4 and even more recently have applied this new technique to children. After using this technique for 1% years we discovered that Barnett et al’ had described a similar technique for 16 adult patients in 1979. The elevated basilic vein operation is easier to perform and less likely to cause a steal syndrome or become infected. MATERIALS AND METHODS During the period January 1984 to January 1986,66 patients with FSRD and unsuitable superficial veins have had basilic vein elevation. Four of the 66 patients were children aged 11 to 19 years.
Operative
Technique
The technique of mobilization of the vein from the elbow to axilla is similar to that described by Dagher et al6 except that we use one long incision (Fig 1). The new feature of this procedure is that the vein is not rerouted laterally through a subcutaneous tunnel but instead the vein is elevated within the incision by closing the subcutaneous fascia beneath, and the skin over, the vein after anastomosing the brachial artery to the basilic vein. All four children were given general anesthesia. A 6 to 8 cm vertical incision is made over the brachial artery in the middle third of the upper arm. Meticulous dissection is required in order to ensure primary healing of the skin edges over the vein. Hemostasis is obtained with minimal use of the electrocautery. The basilic vein is found medial to the brachial artery and after extending the skin incision, is mobilized from the axilla to the elbow. Connecting veins are ligated with 4-O or 5-O silk and divided. Rarely, a vein is oversewn with 7-O polypropylene suture. An attempt is made to dissect the vein en bloc with its surrounding areolar tissue and vasa vasorum. Care is taken to preserve the medial antebrachial cutaneous nerve, which may accompany or cross the basilic vein. A 3-cm segment of the brachial artery is skeletonized just proximal to the biceps tendon, then bathed with papaverine solution. The basilic vein is transected at elbow level just below the confluence of the cubital and forearm basilic veins. Probing, irrigation with heparinized saline, and distention of the vein is avoided to minimize damage to the endothelium. The confluence is then spatulated and the edges everted. A 6-mm longitudinal arteriotomy is made and an endto-side anastomosis is performed with a continuous or interrupted 7-O polypropylene suture depending on the size of the artery. After creation of the AV fistula, the vein is compressed between the thumb and forefinger of each hand and the intervening segment is ballooned out gently to dilate it. The deep fascia is not closed; the vein is elevated into the wound by approximating the subcutaneous fascia with interrrupted 4-O polyglycolic acid sutures. The skin is closed directly over the vein with staples at l-cm intervals widely spaced to allow for adequate drainage. The wound is covered with a large bulky dressing from axilla to fingertips to ensure immobilization for three days after the operation. Most veins can be used in 2 to 4 weeks. A 9- to 18-cm segment of vein is available for needle puncture. The dialysis unit nurses are urged to use the portion of vein closest to the axilla because of the larger diameter of vein at that site.
JournalofPediatricSurgery,
Vol21,
No 12 (December), 1986: pp 1182-l
183
1183
HEMODIALYSIS ACCESS
Fig 1. Elevated basilic vein AV fistula. The basilic vein is anastomosed to the brachial artery, then elevated within the incision by closing the subcutaneous fascia beneath. and the skin over the vein.
RESULTS
A total of 66 patients were found to have a suitable vein with which an elevated basilic vein AV fistula was created. In the four pediatric patients there were no thromboses. Of the entire group of patients the patency rate of 2 years was 83.3% (55/66). Attempts to declot the vein in four of the patients was unsuccessful, and other alternate forms of vascular access were used. There were no infections in any of the 66 patients or any long-term morbidity. Minor postoperative problems included mild swelling, which was temporary, and occasional coolness of the hand, particularly in diabetic patients. Four adult patients died several months postoperatively of causes unrelated to the surgical procedure. All pediatric patients are doing well and have a functional elevated basilic vein AV fistula. DISCUSSION
The elevated basilic vein AV fistula is easier to perform than the standard PTFE bridge graft and has a patency rate comparable to the PTFE graft fistula. A
second advantage of this technique is a decreased chance of producing a “steal syndrome.“’ Because the arteriotomy need not be as long for a vein as for a PTFE graft (flow need not be as great to maintain patency), there is a decreased chance of developing a vascular steal syndrome and producing ischemia of the nerves of the involved limb. For the same reason, high output cardiac failure is less likely to occur.’ Third, there is a lower risk of infection, and if infection should ever occur, response to antibiotics should be more likely. In our experience in the past 10 years, almost every patient with an infected PTFE-graft fistula has required surgical removal and Iigation of the artery. No patient with an elevated basilic AV fistula has developed an infection of the vein. For patients with an elevated vein who require dialysis before the vein is useable, dialysis can be performed by use of an external shunt or a double lumen central line dialysis catheter. The elevated basilic vein AV fistula has been readily accepted in our pediatric population and currently remains our procedure of choice for patients with inadequate superficial veins.
REFERENCES 1. Robinson
HM, Wenzl JE, Williams CR: Internal vascular access for hemodialysis in children weighing less than fifteen kilograms. Surgery 85525-529, 1979 2. Applebaum H, Shashikumar VL, Somers LA, et al: Improved hemodialysis access in children. J Pediatr Surg 15:764-769, 1980 3. Tellis VA, Kohlberg WI, Bhat DJ, et al: Expanded polytetrafluorethylene graft fistula for chronic hemodialysis. Ann Surg 189:101-1051979 4. Humphries AL, Hamilton WF, Rives DA, et al: Elevated basilic vein AV tistula instead of PTFE graft. American Society Nephrology, Kidney Int 27:164, 1985 (abstr)
5. Barnett SM, Waters WC III, Lowance DC, et al: The basilic vein fistula for vascular access. Trans Am Sot Artif Intern Organs 253443461979 6. Dagher FJ, Gelber R, Ramos E, et al: The use of basilic vein and brachial artery as an AV fistula for long term hemodialysis. J Surg Res 201373-376, 1976 7. Buselmeier TJ, Santiago EA. Simmons RL, et al: Arteriovenous shunts for pediatric hemodialysis. Surgery 70:638-646, 1971 8. Mohaideen AH, Avram MM, Mainzer RA: Polytetrafluoroethylene grafts for arteriovenous fistulae. NY State J Med 76:21522155, 1976
Access:
Elevated
Basilic
Vein Arteriovenous
Fistula
BY J.B. Davis, Jr, C.G. Howell, and A.L. Humphries, Jr Augusta, 6 Vascular access in the pediatric patient with endstage renal disease (ESRD) can be a surgical challenge to perform as well as maintain. We have recently developed a new technique of elevating the basilic vein in the upper arm for the arteriovenous LAVAfistula instead of using a polytetrefluoroethylene (PTFE) graft. During the past 2 years, 66 patients with ESRD and unsuitable superficial veins have had basilic vein elevation. Of these 66 patients, four have been in children, aged 11 to 1g years. The technique of mobilization of the vein from the elbow to the axilla was similar to that described by Dagher et al except that we used one long incision. The new feature of this technique is that the vein is not rerouted laterally through a subdermal tunnel. Instead, after the AV fistula to the side of the brachial artery is created, the vein is elevated within the incision by closing the subcutaneous fascia beneath, and the skin over, the vein. Most veins could be used in 2 to 4 weeks. Of the entire group, the patency rate has been 55 of 66 (63.3%). with no infections or long-term morbidity. Of the four pediatric patients, there have been no thromboses or infections. We believe the operation to be easier to perform than the standard PTFE bridge graft. The subsequent AV fistula is easy to access, less likely to cause a “steal syndrome,” less likely to become infected, and if it does become infected, more likely to respond to treatment with antibiotics. c 1986 by Grune & Stratton, Inc. INDEX WORDS: hemodialysis.
Vascular access; arteriovenous fistula;
H
EMODIALYSIS ACCESS in the pediatric patient with chronic renal failure can be difficult to perform as well as maintain. Use of external appliances (Scribner type shunts) are limited for longterm hemodialysis because of the small size of peripheral blood vessels, which predisposes to thrombosis.’ Subsequent experience with bovine carotid heterografts revealed a high rate of complications including thrombosis, pseudoaneurysm formation, and infection.’ A current popular technique for chronic hemodialysis is the polytetrafluoroethylene (PTFE) graft fistula.3 Recently, we have developed a new technique of
From the Section of Pediatric Surgery, Department of Surgery, Medical College of Georgia Hospital and Clinics, Augusta. Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto, Ontario. May 14-I 7. 1986. Address reprint requests to C.G. Howell, MD Section of Pediatric Surgery. Medical College of Georgia Hospital and Clinics, Augusta, GA 30912-2843. 0 1986 by Grune & Stratton, Inc. 0022-3468/86/21 I2-0034$03.00/0
1182
Georgia
elevating the basilic vein in the upper arm for an arteriovenous (AV) fistula4 and even more recently have applied this new technique to children. After using this technique for 1% years we discovered that Barnett et al’ had described a similar technique for 16 adult patients in 1979. The elevated basilic vein operation is easier to perform and less likely to cause a steal syndrome or become infected. MATERIALS AND METHODS During the period January 1984 to January 1986,66 patients with FSRD and unsuitable superficial veins have had basilic vein elevation. Four of the 66 patients were children aged 11 to 19 years.
Operative
Technique
The technique of mobilization of the vein from the elbow to axilla is similar to that described by Dagher et al6 except that we use one long incision (Fig 1). The new feature of this procedure is that the vein is not rerouted laterally through a subcutaneous tunnel but instead the vein is elevated within the incision by closing the subcutaneous fascia beneath, and the skin over, the vein after anastomosing the brachial artery to the basilic vein. All four children were given general anesthesia. A 6 to 8 cm vertical incision is made over the brachial artery in the middle third of the upper arm. Meticulous dissection is required in order to ensure primary healing of the skin edges over the vein. Hemostasis is obtained with minimal use of the electrocautery. The basilic vein is found medial to the brachial artery and after extending the skin incision, is mobilized from the axilla to the elbow. Connecting veins are ligated with 4-O or 5-O silk and divided. Rarely, a vein is oversewn with 7-O polypropylene suture. An attempt is made to dissect the vein en bloc with its surrounding areolar tissue and vasa vasorum. Care is taken to preserve the medial antebrachial cutaneous nerve, which may accompany or cross the basilic vein. A 3-cm segment of the brachial artery is skeletonized just proximal to the biceps tendon, then bathed with papaverine solution. The basilic vein is transected at elbow level just below the confluence of the cubital and forearm basilic veins. Probing, irrigation with heparinized saline, and distention of the vein is avoided to minimize damage to the endothelium. The confluence is then spatulated and the edges everted. A 6-mm longitudinal arteriotomy is made and an endto-side anastomosis is performed with a continuous or interrupted 7-O polypropylene suture depending on the size of the artery. After creation of the AV fistula, the vein is compressed between the thumb and forefinger of each hand and the intervening segment is ballooned out gently to dilate it. The deep fascia is not closed; the vein is elevated into the wound by approximating the subcutaneous fascia with interrrupted 4-O polyglycolic acid sutures. The skin is closed directly over the vein with staples at l-cm intervals widely spaced to allow for adequate drainage. The wound is covered with a large bulky dressing from axilla to fingertips to ensure immobilization for three days after the operation. Most veins can be used in 2 to 4 weeks. A 9- to 18-cm segment of vein is available for needle puncture. The dialysis unit nurses are urged to use the portion of vein closest to the axilla because of the larger diameter of vein at that site.
JournalofPediatricSurgery,
Vol21,
No 12 (December), 1986: pp 1182-l
183
1183
HEMODIALYSIS ACCESS
Fig 1. Elevated basilic vein AV fistula. The basilic vein is anastomosed to the brachial artery, then elevated within the incision by closing the subcutaneous fascia beneath. and the skin over the vein.
RESULTS
A total of 66 patients were found to have a suitable vein with which an elevated basilic vein AV fistula was created. In the four pediatric patients there were no thromboses. Of the entire group of patients the patency rate of 2 years was 83.3% (55/66). Attempts to declot the vein in four of the patients was unsuccessful, and other alternate forms of vascular access were used. There were no infections in any of the 66 patients or any long-term morbidity. Minor postoperative problems included mild swelling, which was temporary, and occasional coolness of the hand, particularly in diabetic patients. Four adult patients died several months postoperatively of causes unrelated to the surgical procedure. All pediatric patients are doing well and have a functional elevated basilic vein AV fistula. DISCUSSION
The elevated basilic vein AV fistula is easier to perform than the standard PTFE bridge graft and has a patency rate comparable to the PTFE graft fistula. A
second advantage of this technique is a decreased chance of producing a “steal syndrome.“’ Because the arteriotomy need not be as long for a vein as for a PTFE graft (flow need not be as great to maintain patency), there is a decreased chance of developing a vascular steal syndrome and producing ischemia of the nerves of the involved limb. For the same reason, high output cardiac failure is less likely to occur.’ Third, there is a lower risk of infection, and if infection should ever occur, response to antibiotics should be more likely. In our experience in the past 10 years, almost every patient with an infected PTFE-graft fistula has required surgical removal and Iigation of the artery. No patient with an elevated basilic AV fistula has developed an infection of the vein. For patients with an elevated vein who require dialysis before the vein is useable, dialysis can be performed by use of an external shunt or a double lumen central line dialysis catheter. The elevated basilic vein AV fistula has been readily accepted in our pediatric population and currently remains our procedure of choice for patients with inadequate superficial veins.
REFERENCES 1. Robinson
HM, Wenzl JE, Williams CR: Internal vascular access for hemodialysis in children weighing less than fifteen kilograms. Surgery 85525-529, 1979 2. Applebaum H, Shashikumar VL, Somers LA, et al: Improved hemodialysis access in children. J Pediatr Surg 15:764-769, 1980 3. Tellis VA, Kohlberg WI, Bhat DJ, et al: Expanded polytetrafluorethylene graft fistula for chronic hemodialysis. Ann Surg 189:101-1051979 4. Humphries AL, Hamilton WF, Rives DA, et al: Elevated basilic vein AV tistula instead of PTFE graft. American Society Nephrology, Kidney Int 27:164, 1985 (abstr)
5. Barnett SM, Waters WC III, Lowance DC, et al: The basilic vein fistula for vascular access. Trans Am Sot Artif Intern Organs 253443461979 6. Dagher FJ, Gelber R, Ramos E, et al: The use of basilic vein and brachial artery as an AV fistula for long term hemodialysis. J Surg Res 201373-376, 1976 7. Buselmeier TJ, Santiago EA. Simmons RL, et al: Arteriovenous shunts for pediatric hemodialysis. Surgery 70:638-646, 1971 8. Mohaideen AH, Avram MM, Mainzer RA: Polytetrafluoroethylene grafts for arteriovenous fistulae. NY State J Med 76:21522155, 1976