A large-scale study of the upper arm basilic transposition for hemodialysis

The incidence of stage 5 chronic kidney disease requiring immediate hemodialysis treatment continues to rise with an increasing number of patients with an unsuitable cephalic vein or failed radio- and brachiocephalic fistulae. In these patients the basilic vein is our next autologous choice. We have previously investigated our preliminary experience and identified common failure modes, and this report describes longer-term outcomes and what we feel are results after the learning curve has been surmounted.

All patients who underwent basilic vein transposition from April 2001 to June 2008 at our institution were retrospectively reviewed. Data collected included demographics, anesthesia type, volume flow at creation, maturation rate, patency rates, post-operative complications, secondary interventions (endovascular and open surgical revision), and overall mortality.

Two hundred seventeen upper arm basilic vein transposition fistulae were created in 215 patients (53% male). Prior to basilic transposition, patients had a mean of 2.9 previous surgical access attempts. Only 14% of patients had a basilic vein transposition as their initial fistula. Mean flow at time of fistula creation was 347 (range 10-880) mL/minute, with a maturation rate of 87%. The procedural mortality rate was 0.5%. Primary and primary assisted patency rates at 6, 12, and 24 months were 63%, 40%, and 26% and 74%, 56%, and 38%, respectively, while secondary patency rates at 6, 12, and 24 months were 85%, 72%, and 65%, respectively. Fistula thrombosis was the most common complication prior to maturation (16%). Central vein stenosis (22%) was the most frequent cause of fistula failure.

Basilic vein transposition fistulae have excellent initial maturation rates (87%) with reasonably good functional (secondary) patency rates (72% at 1 year). Central venous stenosis is a major postmaturation limiting factor in long-term durability, and revisions are frequent. The optimal order of access in patients without usable cephalic veins remains a difficult challenge, but basilic vein transposition seems to stack up well versus prosthetic grafts in this situation.