Hemodialysis access: elevated basilic vein arteriovenous fistula

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 (AV) fistula instead of using a polytetrafluoroethylene (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 19 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 (83.3%), 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.