Abstract
Background:
We describe a technique to mature a basilic/brachial vein in the mid-arm in preparation for a second stage loop proximal brachial artery to basilic/brachial vein arteriovenous graft (BBAVG). This can occur after a failed basilic/brachial vein transposition or a lack of adequate veins in the distal arm. This allows a mature vein to be used in an end-to-end configuration as an outflow to a BBAVG while preserving proximal vessels for the future.
Methods:
This single-center retrospective study was performed from 2015 to 2021, including 104 AVG patients divided into three groups: (1) Patients who failed a basilic vein transposition and had an enlarged vein suitable for an AVG outflow; (2) Patients who had a small caliber basilic/brachial vein after the transposition, requiring a mid-arm brachial artery to brachial/basilic arteriovenous fistula (AVF) creation with a subsequent AVG extension; (3) and lastly, patients who had no distal arm veins available and required a primary brachial artery to basilic/brachial AVF with AVG extension. A survival analysis was performed looking at time to loss of primary and secondary patency, calculated with Kaplan-Meier estimates and Cox regression models adjusted for covariates.
Results:
The median follow-up time was 11 months (IQ = 11–30 months). The survival analysis showed 28% lost primary patency at a median time of 9 months, and 14% lost secondary patency at a median time of 61 months. Overall secondary patency of the vascular access measured at 12 months was 85.6%. Loss of primary (p = 0.008) and secondary patency (p = 0.017), as well as patency during the first 12 months (p = 0.036), were all significantly associated with increased age when adjusting for covariates.
Conclusions:
Our results suggest that the graft extension technique using a mature vein from a previous fistula can result in reliable and durable access. This is important for patients with limited access for hemodialysis, as the axillary vein is preserved for future use if needed.
Keywords: Vascular access, hemodialysis, arteriovenous fistula, arteriovenous graft, brachial vein
Background
The arteriovenous fistula (AVF) remains the best vascular access for patients on hemodialysis (HD), showing better survival and lower complication rates than arteriovenous grafts (AVG) and tunneled dialysis catheters (TDCs).1 Ideally, having a mature AVF created before initiating renal replacement therapy will avoid the need for a central venous catheter (CVC) associated with increased complications, morbidity, and mortality.2–6
Unfortunately, the anatomy and the vessel conditions in chronic kidney disease (CKD) patients are not always conducive to autologous AVF creation. In the absence of suitable veins for AVF creation, the remaining access options are either a TDC or AVG creation, with AVGs being the more favorable option. TDCs are problematic for multiple reasons, including the commonly encountered long-term complications of infection, stenosis, and catheter dysfunction.7 Compared to AVFs and AVGs, TDCs are associated with the greatest all-cause and infection-related mortality. As a result, the aforementioned are the least desirable choice for long-term vascular access.8
AVGs can be created in a variety of anatomical locations. Still, the two most common configurations are the forearm loop graft using the brachial artery and a suitable vein in the antecubital fossa, and the straight upper arm graft using the brachial artery to either the axillary, proximal brachial, or proximal basilic veins.9–11 Lower extremity thigh grafts are possible but should only be considered if no other access option exists, as thigh grafts have higher morbidity than upper extremity AVGs.12
We decided to classify patients who underwent a proximal brachial artery to basilic/brachial vein arterio-venous graft (BBAVG) according to the status of the outflow vein:
Adequate enlargement of the proximal vein after a failed transposition, resulting in a proximal brachial artery to basilic/brachial vein arteriovenous graft (BBAVG).
Non-enlargement of the proximal vein requiring a mid-upper arm brachial artery to basilic/brachial vein AVF to enlarge the proximal vein and allow the creation of a BBAVG afterward.
Creation of a primary mid-arm brachial artery to basilic/brachial vein fistula due to lack of suitable distal arm veins and subsequent BBAVG creation. These patients are usually destined to have axillary vein as outflow.
This study aims to report the performance of this BBAVG method in terms of primary and secondary patency of the vascular access while trying to preserve the more proximal vasculature for future use in case of graft failure.
Materials and methods
Study participants
We performed a retrospective review of 104 patients over the age of 18 with diagnosis of end-stage renal disease (ESRD) on HD, who underwent a brachial-brachial arteriovenous graft (BBAVG) extension between January 2015 and May 2021 at the University of Miami Hospital and Jackson Memorial Hospital. BBAVG was considered in any of the three categories described above. Preoperative workup consisted of a focused physical examination and duplex ultrasound vein mapping of bilateral upper extremities. Additionally, bilateral upper extremity venograms were performed in selected patients with a history of previous dialysis CVCs or if central venous stenosis was suspected by a malfunctioning or non-maturing fistula.
Electronic medical records pertaining to patient history, operative reports, and subsequent interventions were reviewed for the data collection. The entire study was performed in accordance with the ethical principles of the Declaration of Helsinki and regulatory requirements at both institutions. Patients provided written consent to participate in the study. The ethics committee and Institutional Review Board at the University of Miami approved the study.
Operative technique
The technique for the two-stage BBAVG extension was used in Group 2 and 3 patients. Group 1 patients had an adequately enlarged proximal basilic/brachial veins; therefore, not requiring further maturation. The steps are depicted in Figures 1 and 2. A mid-brachial artery to brachial or basilic vein AVF was performed in an end to side fashion. As shown in Figure 3(a), it is functionally important that the anastomosis be nearly the same size as the diameter of the brachial artery. The anastomosis cannot exceed 0.5 mm more than the brachial artery diameter to prevent steal phenomenon. Following this technique also minimizes the occurrence and/or extent of pulsatility that develops in the fistula, which is advantageous because pulsatile flow leads to fibrosis of the media, which results in access failure over time.
Figure 1.
Diagram of primary BBAVG procedure in two-stages (patients from group 3).
Figure 2.
Diagram of BBAVG creation after a failed basilic transposition (patients from group 1).
Figure 3.
(a) Mid brachial artery-brachial vein AVF. Brachial vein (arrow) enlarged to 7 mm, (b) thickening of the brachial vein wall (arrow), and (c) end-to-side brachial artery anastomosis (white arrow). Banding of inflow segment (yellow arrow). End-to-end brachial venous anastomosis (blue arrow).
After the first stage procedure, patients were followed up 4 weeks post-operatively to evaluate progress and possible complications. We allowed 6–8 weeks of maturation time, and unless complications arose, then proceeded with the second stage graft extension. During this second stage procedure, the previous incision was extended centrally, and proper dissection was performed to expose the enlarged outflow brachial/basilic vein as close as possible to the original anastomosis. The fistula was tied close to the anastomosis, and the proximal brachial artery was then exposed within the same incision.
A 7–8 mm Bovine Carotid Artery Graft (Artegraft, North Brunswick, NJ) was used for the extension. It was flushed following the company’s instructions and then subcutaneously tunneled in a loop fashion before placement. The procedure was facilitated by using two counter incisions above the elbow. The arterial anastomosis was done perpendicularly in an end-to-side fashion and allowed to be 8–12 mm in diameter. Since we could not perform a short arterial anastomosis, we had to band the inflow of the graft to 5 mm approximately in order to match a 4–7 mm standard configuration. This will decrease the possibility of a steal syndrome and potentially reduce further neointimal hyperplasia at the venous anastomosis. The tapering was done utilizing medium size clips. The residual lumen was verified by direct measurement accommodating a 5 mm dilator. The banding technique and arterial anastomosis can be seen in Figure 3(c).
Following the initial BBAVF creation, the brachial vein was expected to enlarge and thicken to approximately 7–8 mm, as can be seen in Figure 3(b) and (c). This enlarged brachial vein matched the bovine graft, and the venous anastomosis was then performed in an end-to-end spatulated fashion. This procedure was performed by a board-certified vascular surgeon, and patients were managed by a multidisciplinary vascular access team at the mentioned institution.
Definitions
The primary endpoint of the study was the loss of primary patency, defined as time from the initial access creation of the BBAVG to permanent failure that required any intervention (endovascular or surgical) in order to maintain or restore blood flow, following the standards of the Society for Vascular Surgery.12 The SVS also defined secondary patency as the time from BBAVG creation until it is no longer used as an access due to failure, despite the interventions.12 For the purpose of survival analysis, accesses that did not have a defining event for loss of follow-up or death due to other causes unrelated to the surgical procedure were accounted as censored data. Loss of primary and secondary patency rates were estimated using Kaplan-Meier survival analysis. Overall 12-month patency was defined as the vascular access that were used and stayed patent throughout the first year of follow-up, regardless of the interventions performed. Secondary endpoints include association of demographic traits, comorbidities, and characteristics of AVF with the access failure or abandonment at any point after the first access placement.
Statistical analyses
Statistical analyses were performed using STATA (version 17, College Station, TX). An alpha value of 0.05 was used for statistical significance. The primary analysis was the loss of primary and secondary patency of the BBAVG, using Kaplan-Meier survival estimates and Cox regression models with covariate adjustment. The secondary outcome was statistical association between baseline covariates and overall 12-month patency, evaluated using a multivariate logistic regression adjusted for age, sex, ethnicity, major comorbidities, history of previous AVF, and history of hemodialysis catheter. Continuous variables are presented as mean (standard deviation) or median (interquartile range) and were analyzed using student’s t-test for normally distributed data or Mann-Whitney U test for non-normal distribution as appropriate. Categorical variables are expressed as the number of subjects (%) and compared using Fisher’s exact test.
Results
Demographics, clinical, and AVG characteristics of the study population
A total of 104 patients were identified as having undergone a BBAVG surgical intervention. Baseline patient demographics can be seen in Table 1. The average age was 63 (±14) years old, with a higher proportion of women (65%) over men (35%). African Americans accounted for most of the patients (68%), followed by Hispanics (16%) and Caucasians (15%) in similar numbers. All the patients had hypertension, 62% had diabetes mellitus, 27% had coronary artery disease, and 17% had peripheral vascular disease as comorbidities. About half of the patients were on antiplatelet therapy (aspirin) and statins at the time of the surgical procedure, and 20% used either an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB). The most prevalent location of the graft was on the left arm (82%). Ninety-seven percent had a history of a CVC.
Table 1.
Baseline characteristics of the study population.
| Age—mean in years (SD) | 63 (±14) |
| Ethnicity—N (%) | |
| African American/Haitian | 71 (68) |
| Hispanic | 16 (15) |
| Caucasian | 17 (16) |
| Gender—N (%) | |
| Male | 36 (35) |
| Female | 68 (65) |
| Comorbidities—N (%) | |
| Hypertension | 104 (100) |
| Diabetes mellitus | 65 (62) |
| Coronary artery disease | 28 (27) |
| Peripheral vascular disease | 18 (17) |
| Medications—N (%) | |
| Antiplatelets | 54 (51.9) |
| Statins | 54 (51.9) |
| ARB/ACEI | 20 (19.2) |
| Location—N (%) | |
| Left | 85 (82) |
| Right | 19 (18) |
| Previous AVF—N (%) | 78 (75) |
| Deceased—N (%) | 13 (12) |
N: number; SD: standard deviation; ARB: angiotensin receptor blocker; ACEI: angiotensin-converting enzyme inhibitor; AVF: arteriovenous fistula.
During the preoperative evaluation, 23% had a nicely enlarged vein more proximally, but the peripheral and mid-segment were still not suitable for transposition; therefore, the graft extension was created directly to the remaining stump (Group #1). Thirty-three percent had a transposition failure with inadequate enlargement of the proximal vein requiring a new mid-arm AVF creation to enlarge the vein and proceed with the graft extension (Group #2). The remaining 44% of the cases were planned as a primary BBAVG after creating a mid-arm brachial artery to basilic/brachial vein av fistula due to inadequate distal veins to perform a basilic/brachial vein transposition (Group #3).
Loss of patency outcomes
Out of the 104 patients, 12% (n = 13) expired during the time of follow-up due to unrelated causes, and only one death was related to malfunctioning access. Almost 60% (n = 62) of the patients maintained primary patency throughout the entire study, with an average time to follow-up of 11 months (11–30 months). Loss of primary patency occurred in 28% (n = 29) with a median cumulative time of 9 months after the initial BBAVG creation (Figure 4). Loss of secondary patency occurred in 14% with a median cumulative time of 61 months (Figure 5). The overall patency of the vascular access at 12-month follow-up regardless of interventions required was 85.6% (Table 2). The Cox regression analysis for primary patency did not reveal any association with demographic variables or comorbidities. However, there was a statistically significant lower risk of loss patency at 12 months at younger ages (OR: −0.57, CI: −0.12 to −0.003, p = 0.038) by multivariate logistic regression. In the case of secondary patency loss, Cox analysis demonstrated a slight risk reduction of 7% associated with increased age while adjusting for all other covariates (HR 0.93, CI: 0.88–0.98, p = 0.017).
Figure 4.
Kaplan-Meier survival curve of time to loss of primary patency of the BBAVG.
Figure 5.
Kaplan-Meier survival estimates curve of time to loss of secondary patency of the BBAVG.
Correct: Kaplan-Meier survival curve of time to loss of secondary patency of the BBAVG.
Table 2.
Patency of brachiobrachial arteriovenous grafts and interventions.
| Loss of primary patency—N (%) | 29 (28) |
| Time to loss of primary patency—median in months (IQR) | 8 (4–14) |
| Loss of secondary patency—N (%) | 14 (14) |
| Time to loss of secondary patency—median in months (IQR) | 61 (42–66) |
| Type of Intervention—N (%) | |
| Thrombectomy | 8 (25) |
| Angioplasty | 11 (35) |
| Banding | 4 (12) |
| Surgery and ligation | 3 (9) |
| Fistulogram | 5 (16) |
| 12-month follow-up patency—N (%) | 89 (85.6) |
| Time of follow-up—median in months (IQR) | 11 (11–30) |
N: number; SD: standard deviation; IQR: interquartile Range.
The most frequent intervention performed on the graft was balloon angioplasty, required in 35% (n = 11), followed by thrombectomy in 25% (n = 8), fistulogram in 16% (n = 5), banding in 12% (n = 4), and as a last resource, surgery, and ligation in 9% (n = 3) (Table 2). The reasons for BBAVG ligation and creation of new vascular access were persistent steal syndrome, pseudoaneurysm, aneurysmal AVG, and thrombosis of the graft that could not be solved despite multiple interventions. The majority of AVGs requiring any type of intervention either for revision or to restore flow had only one intervention (n = 21), 12% required two or more interventions to maintain patency of the graft, and the maximum number of interventions performed to the same graft and recorded at our institution were four. In total, eight patients stopped using the vascular access due to kidney transplant.
Discussion
Since the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) established the Fistula First Initiative in 2003, the prevalence of newly created AVFs in ESRD patients rose from 32% to 63% toward the end of 2014.1 This rise in AVF creation has naturally led to a greater number of overall problems encountered with AVF maturation and functionality.13,14 Despite the broad use of preoperative venous mapping to select an optimal access site, we are seeing longer maturation times and increasing primary failure rates with AVFs.15 Consequently, patients depend on tunneled CVCs for more extended periods and are subject to all the risks associated with these catheters. We have also appreciated the increased number of intravascular interventions needed to achieve AVF maturation, which results in longer hospital stays and elevated hospital costs.16 While, in theory, AVFs are the best option for HD access, the benefit can only occur if the AVF is created in a patient whose anatomy meets the minimum requirements for a successful fistula and when the AVF is ready for cannulation. An appropriately planned AVG has a crucial role in the patient population with no viable anatomy for a successful AVF.17
The two-stage BBAVG extension originated from observations of failed brachiobasilic AVF transpositions. In our experience, we found that patients with a failed brachiobasilic AVF had non-maturation of the juxta-anastomotic segment of the fistula; however, the vein did enlarge in the more proximal segment. We resected the non-mature venous segment and connected a graft in an end-to-end fashion to the enlarged and thickened proximal basilic vein. We attributed the success of this technique to the following: (1) the closely aligned circumferences of the graft and the enlarged proximal vein preventing mismatch and (2) the thickening of the proximal basilic vein, decreasing its compliance to a level similar to the graft. Analyzing the principles underlying successful graft creations from previously failed brachiobasilic AVF transpositions led to the idea of applying a nearly identical two-stage graft technique to the brachial artery and vein.
Our BBAVG technique offers patients with limited access options a possibility to preserve the axillary vein for future access use. The initial creation of the brachial-brachial/basilic fistula allows for enlargement and thickening of the proximal segment brachial vein, which optimizes the overall success of the second-stage graft anastomosis. Vessel size is a determining factor for successful maturation and overall access longevity.18–20 The two-stage AVG procedure uses this logic in that creating a temporary first-stage brachio-brachial/basilic AVF enlarges and thickens the brachial/basilic outflow vein, optimizing the overall success of the second stage graft anastomosis.
Importantly, we were able to preserve more proximal vasculature with patency rates comparable to existing data on AVGs. A recent meta-analysis reported primary patency and secondary patency of 40% and 60% at 2 years, respectively.21 Additionally, other studies have shown a 23% primary patency at 1 year for newly placed AVGs.22 Notably, groups that use a similar approach but different surgical technique have shown a primary failure rate for BBAVG that ranges from 7.4% to 37.5%.23 Our results of primary failure were 28%, which is still within the range reported on the available literature. The most recent publication by Fumagalli et al.23 had secondary patency at 12 months of 76.3%, compared to our 85.6% results overall patency at 1 year. Consequently, the technique proposed in this article has shown to be a reasonable and durable alternative for vascular access creation in patients requiring hemodialysis without adequate superficial veins. Prospective studies using a larger patient population should be conducted to evaluate for reproducibility of this study.
Limitations
We are limited by the retrospective nature of this study as well as the variability in data documentation in the electronic medical records. Furthermore, all the procedures were performed by a single vascular access surgeon at two closely affiliated institutions, making this study less representative of the general population. Lastly, only a single graft type was used in all cases (Artegraft Bovine Carotid Artery Graft, North Brunswick, NJ). No other graft materials (biologics, PTFE, non-PTFE prosthetics) were used in this study, and consequently, the results may not be generalizable to all graft types.
Conclusion
Based on our results, we suggest that the technique of creating a BBAVF with a graft extension can lead to a durable access for HD, which preserves the axillary vein for future use. We found a primary patency rate similar to the existing literature, and the secondary patency rate shows promising results, for which we recommend further studies for validation. We believe our results demonstrate that using a larger diameter and thicker vein at the time of AVG creation, by means of a first stage brachial-brachial AVF, followed by a second stage graft placement using an end-to-end venous anastomosis improves patency.
Article highlights.
Type of Research:
Single-center retrospective chart review.
Key findings:
A proximal brachio-brachial arteriovenous graft extension was created in 104 patients on hemodialysis in three situations: (1) failed basilic vein transposition with enlarged proximal vein; (2) failed basilic vein transposition with small proximal vein requiring mid-arm brachial artery to basilic/brachial vein av fistula to enlarge the vein; (3) Primary mid-arm brachio-brachial av fistula when there was no cephalic or distal basilic or brachial vein sufficient for standard AV fistula formation in the upper limb. Only 28% lost primary patency and 14% lost secondary patency over a median of 9 and 61 months respectively. Overall patency at 12 months regardless of interventions was 85.6%.
Take home message:
A mid-arm brachio-brachial arteriovenous fistula (AVF) as a first procedure to enlarge and thicken the outflow vein coupled with an end-to-end graft extension of the outflow vein is an alternative for patients requiring a permanent vascular access for hemodialysis without sufficient distal arm superficial or deep veins for a standard AVF. It has high rates of patency with preservation of more proximal veins.
Table of contents summary:
A brachio-brachial arteriovenous fistula (AVF) with graft extension technique in patients with end-stage renal disease requiring a permanent vascular access for hemodialysis and without sufficient veins for standard AVF formation in the upper limb had satisfactory patency rates and durability with preservation of the proximal vasculature.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Diabetes and Digestive and Kidney Diseases grants [R01-DK098511] (to L. H. Salman and R. I. Vazquez-Padron) and [R01-DK121227] (to R. I. Vazquez-Padron); National Heart, Lung, and Blood Institute grant [K08-HL151747] (to L. Martinez); and the US Department of Veterans Affairs Merit Award [IBX004658] (to R. I. Vazquez-Padron).
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approval
The ethics committee and Institutional Review Board at the University of Miami provided approval.
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