The National-Kidney-Foundation-Dialysis-Outcomes-Quality-Initiative1 and the National-Vascular-Access-Improvement-Initiative2 suggest the use of autogenous veins in fistula creation, encouraging conversion from functional grafts to AVF reducing mortality, morbidity and medicare costs.
We report the novel case of an urgent conversion from an infected forearm AV-loop graft to a primary transposition of the brachial vein (BVT-AVF) in a septic patient.
A 57-year-old male patient with ESRD, secondary to nephroangiosclerosis, presented with a thrombosed right forearm AV polytetrafluoroethylene loop-graft. Trans-jugular catheter was inserted for immediate haemodialysis needs but a severe ongoing sepsis quickly developed.
The superficial vein network was unsuitable (ipsilateral basilic vein being too short); an autogenous AVF that could be rapidly punctured was an imperative need.
A well developed brachial vein was identified, being the main outflow of the previous graft.
In assisted-local anesthesia, the brachial vein was disconnected at the level of the previous venous anastomosis, fully mobilized, subcutaneously superficialized and C- tunneled anteriorly to the incision with end-to-side anastomosis to the distal brachial artery.
The previous infected graft was subtotally excised.
The fistula was successfully cannulated 5 days later allowing the removal of the catheter; 3-month follow-up demonstrated primary patency with volume-flow-rate of 400 ml/min.
AVF transposition has been proved to be a well established, safe vascular access since the first report by Dagher in 1976.3
BVT-AVF has been reported in the current English literature only in recent years, since 20044, and just as single cases or short series (the longest of 58 patients by Jennings et al.5) in elective patients only;
Single-stage or, more often, two-stage transpositions have shown encouraging primary and secondary patency up to 52.0% and 92.4%, respectively.6
Although time consuming and technically challenging, primary BVT-AVF may be a viable “last-resource” option in septic patients with previously arterialized brachial veins and urgent need of HD.
- National Kidney Foundation K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000. Am J Kidney Dis 2001;37(1 suppl 1):S137-81.
- Fistula First: National Vascular Access Improvement Initiative. http://fistulafirst.org/. Accessed Nov 14, 2007.
- Dagher F, Gelber R, Ramos E, Sadler J. The use of basilic vein and brachial artery as an A-V fistula for long term hemodialysis. J Surg Res 1976;373-6.
- Bazan HA, Schanzer H.Transposition of the brachial vein: a new source for autologous arteriovenous fistulas. J Vasc Surg. 2004 Jul;40(1):184-6.
- Jennings WC. Creating arteriovenous fistulas in 132 consecutive patients: exploiting the proximal radial artery arteriovenous fistula: reliable, safe and simple forearm and upper arm hemodialysis access. Arch Surg 2006;141:27-32
- Lambidis C, Galanopoulos G. Primary brachial vein transposition for hemodialysis access: report of a case and review of the literature. Hemodial Int. 2013 Jul;17(3):441-3. doi: 10.1111/hdi.12000. Epub 2012 Nov 8.