Vein transposition in the forearm for autogenous hemodialysis access

We describe a technique of superficial venous transposition in the forearm used for the formation of an arteriovenous fistula for hemodialysis access. These modifications of the single-incision radiocephalic fistula are designed to increase options for arteriovenous fistulas by using veins and arteries that are suitable for use but are not in immediate proximity.

Arteries and veins suitable for a primary arteriovenous fistula were identified and mapped using duplex ultrasound in 89 patients. Separate incisions were used in the majority of cases, and the selected forearm vein was mobilized, angiodilated, and transposed into a subcutaneous tunnel on the volar aspect of the forearm. Before initiation of hemodialysis, duplex ultrasound scanning was performed, and the location that was most suitable for cannulation was identified. Repeat scans were performed at 3-month intervals for analysis of patency.

Superficial venous transpositions were performed using a single incision in 13 instances in which the vein was in immediate proximity to the radial artery (type A). Dorsal-to-volar forearm transposition (type B) was performed in 30 veins with anastomoses to the radial (n = 26), ulnar (n = 2), or brachial (n = 2) arteries. Volar-to-volar forearm transposition (type C) was performed in the remaining 46 veins, with anastomoses to the radial (n = 42), ulnar (n = 2), or brachial arteries (n = 2). Successful hemodialysis was accomplished in 81 of 89 patients (91%). The primary cumulative patency rate was 84% at 1 year and 69% at 2 years. The mean duration of follow-up was 14.3 months.

The use of superficial venous transposition for the formation of autogenous hemoaccess was associated with ease of cannulation by dialysis personnel, high maturation rates, reduced early failure rates, and enhanced patency rates. We recommended the use of these technical modifications to increase the use of autogenous fistulas in the forearm.