|Year : 2018 | Volume
| Issue : 1 | Page : 17-19
Radiobasilic fistula: An efficient and still underused autogenous hemodialysis vascular access
Abdullah Al Wahbi
King Saud University for Health Sciences, King Abdulaziz Medical City, Department of Surgery, Division of Vascular Surgery, Riyadh, Saudi Arabia
|Date of Submission||07-Oct-2017|
|Date of Acceptance||23-Feb-2018|
|Date of Web Publication||22-Mar-2018|
Abdullah Al Wahbi
Department of Surgery – MC 1446, King Abdulaziz Medical City, Ministry of National Guard – Health Affairs, Riyadh 11426
Source of Support: None, Conflict of Interest: None
Radiobasilic fistula (RBF) is underutilized and not considered as the second option after radiocephalic fistula (RCF). We present a case study of a 45-year-old male patient with a medical history of diabetes mellitus and chronic renal insufficiency who presented at our vascular clinic for predialysis creation of hemodialysis vascular access. RBF was performed due to the patient's young age, the high possibility of long-term hemodialysis, and the small diameter of the forearm cephalic vein (1.5 mm). Most of the guidelines recommend brachiocephalic fistula (BCF) or brachiobasilic fistula (BBF) as the second choice following RCF, despite the reported efficiency of RBF. This case supports the previous studies recommending the inclusion of RBF as the second choice for vascular access in international guidelines, in addition to BCF, BBF, and over arteriovenous grafts.
Keywords: Arteriovenous fistula, hemodialysis, renal failure
|How to cite this article:|
Al Wahbi A. Radiobasilic fistula: An efficient and still underused autogenous hemodialysis vascular access. Transl Surg 2018;3:17-9
| Introduction|| |
Hemodialysis vascular access (HDVA) is the lifeline for end-stage renal disease (ESRD) patients., The three common vascular access techniques include native arteriovenous fistulae (AVFs), arteriovenous grafts (AVGs), and central venous catheterization. Complications associated with these vascular access techniques account for the majority of hospitalization in chronic hemodialysis patients., It is essential to utilize and maintain each access, such that they function for the longest possible period before subsequent options. The number of HDVA options available during dialysis varies from patient to patient. Lack of planning and maintenance of each access can lead to the requirement of more invasive and poorly functioning access with high morbidities.
AVFs are classified based on the type of artery (radial or brachial) and vein (basilic and cephalic). These include radiobasilic fistula (RBF), radiocephalic fistula (RCF), brachiocephalic fistula (BCF), and brachiobasilic fistula (BBF). RBF is often underutilized and not considered as the second option after RCF. Compared to AVGs, RBFs have an acceptable high primary patency rate, a lower infection rate, and fewer thromboses.,, It is generally recommended to utilize the RBF before proceeding to other options.,,, The purpose of our report was to add to this recommendation.
| Case Report|| |
A 45-year-old male patient with a medical history of diabetes mellitus and chronic renal insufficiency presented to our vascular clinic for predialysis creation of HDVA. The patient had no other medical or surgical history. Clinical assessment of the upper limbs (ULs) showed that his radial, ulnar, and brachial pulses were bilaterally normal. There were no prominent superficial veins. Duplex ultrasound examination showed the forearm basilic vein patent, with an average diameter of 3.0 mm, and the cephalic vein with a diameter of 1.5 mm. Radial, ulnar, and brachial arteries were normal. Considering the patient's young age, the high possibility of long-term hemodialysis, and the small diameter of the cephalic vein, we elected to perform RBF. Under a regional cervical block, the basilic vein was marked by ultrasound. We started with a small incision over the basilic vein proximal to the wrist joint. Subcutaneous tissue was dissected, and the basilic vein was retracted by a vessel loop. Other small incisions were made along the course of the vein [Figure 1]. The vein was controlled with vessel loops at each incision site. Using gentle vein retraction with vessel loops and skin retractors, the part of the vein between skin incisions were dissected, and all tributaries divided between 3-0 silk ties. The end of the vein (proximal to the wrist joint) was divided between 2-0 silk ties. The basilic vein was pulled out through the most proximal incision and placed on the forearm toward the radial side [Figure 1]. The radial artery was dissected at the level where the transposed basilic vein ends [Figure 2]. A vessel clamp was applied at the proximal end of the basilic vein, and heparinized saline (1000 IU heparin: 1000 CC normal saline) was injected to test for leaks. The basilic vein was then tunneled subcutaneously through the forearm to the radial artery incision. A vessel clamp was applied at the proximal end of the basilic vein, and heparinized saline was injected to test for kinking, rotation, and to confirm the bulge of the vein. The radial artery was controlled with vessel loops, and end-to-side radiobasilic anastomosis was performed. After the release of the loops and clamps, a thrill was palpated over the basilic vein. Subcutaneous tissue and skin incisions were closed in the usual manner. There were no postoperative complications, and the patient was relieved from the hospital on the same day. The fistula was maturing normally at the time of follow-up visits. Dialysis was started 10 weeks' postsurgery. The hemodialysis session was successful with easy needling, optimal fistula blood flow, and no complications. On follow-up, the patient reported undergoing dialysis through the fistula, three times a week for the past 24 months without complication. A verbal consent was taken from the patient for publishing the case.
|Figure 1: The forearm basilic vein (white arrow) harvested through multiple incisions (yellow arrows)|
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|Figure 2: The harvested forearm basilic vein (white arrow) laid anterior toward the site of radial artery incision (yellow arrow)|
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| Discussion|| |
HDVA procedures, frequent admissions, and complications are frustrating to both the surgeons and ESRD patients., Fortunate patients are those who have a functioning access point for the longest period, and then comes those who still have options for an UL access. In practice, it is uncommon to have a functioning access point for many years without complications or surgical revisions. Thus, it is imperative that all options – especially UL superficial veins – are considered starting from predialysis. It is recommended to start with distally appearing veins in the UL, preserving it the longest time while exhausting all methods, before proceeding to proximal veins. According to international guidelines, RCF is the first option followed by BCF, rather than BBF as the second option.,,, Therefore, few centers consider the use of radial or ulnar basilic fistula as a second option for HDVA. Although the first use of the forearm basilic vein was reported a long time ago ,, and many centers have reported the efficacy and patency of RBF as a better option to AVGs,,,,,,,,, it is still underused. One of the reasons why the RBF is unpopular is location. Being on the medial side of the forearm, it needs to be transposed to the anterior side. Thus, long incisions over the vein course are used to bring it to the radial artery. These long incisions lead to longer surgical procedures and postoperative hematoma. This may result in many patients' unwillingness to consider RBF. Our technique for creating RBF differs from the traditional techniques. We use interrupted incisions, instead of a single long incision, which minimizes any associated complications.
In conclusion, our report (in addition to several other similar reports in the literature) has shown that RBFs have an acceptably higher 2-years patency rate, as well as fewer thromboses and infectious complications, relative to AVG. Therefore, RBF could be considered before forming an upper arm AVF or forearm AVG, and we encourage its inclusion in international guidelines.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]