JVA ISSN 1129-7298

J Vasc Access 2015; 16 (2): 87-92 DOI: 10.5301/jva.5000299


Hemodialysis vascular access construction in the upper extremity: a review Susie Q. Lew1, Bao-Ngoc Nguyen2, Todd S. Ing3  ivision of Renal Diseases and Hypertension, Department of Medicine, The George Washington University School of Medicine and Health D Sciences, Washington, District of Columbia - USA 2 Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia - USA 3 Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois - USA 1

ABSTRACT Purpose: This article reviews the conventional vascular access types in the upper extremities for hemodialysis. Methods: We performed a literature search for autogenous arteriovenous fistula in the upper extremities. Results: The upper extremities have four potential sites: radio-cephalic or radio-basilic transposition in the forearm, and brachio-cephalic or brachio-basilic transposition in the upper arm. A preoperative Duplex ultrasound provides valuable information regarding arterial inflow and venous outflow. The surgical approach to fistula formation and final product depends on vein diameter and length as well as proximal vein patency. The discussion focuses on access outcomes and management of common complications. Conclusions: The upper extremity arteriovenous fistula is the preferred access for hemodialysis. A number of arteriovenous fistulas can be created in the upper extremities. The Duplex ultrasound identifies suitable arteries and veins for successful arteriovenous hemodialysis fistula creation. Arteriovenous hemodialysis fistula has the best long-term patency outcomes and the lowest associated morbidity and mortality. Early detection and intervention can save the fistula when complications occur. Keywords: Arteriovenous fistula complications, Arteriovenous fistula creation, End-stage renal disease, Hemodialysis, Upper extremity, Vascular access

Introduction Arteriovenous fistulas (AVFs) are the preferred long-term hemodialysis vascular access because of better primary patency and less infection than arteriovenous grafts (AVG) or central venous catheters. AVFs have the lowest incidence of morbidity and mortality because they require the fewest intervention of any access type. The upper extremities are often chosen for access sites because they offer good visibility for needle insertion with minimal infection and thrombosis risks. The radio-cephalic fistula, which was first described by Brescia et al in 1966 (1), continues to be the conduit of choice if the cephalic veins in the forearms are adequate in size. Nevertheless, less than 30% of patients are candidates for this configuration. AlAccepted: June 14, 2014 Published online: September 4, 2014 Corresponding author: Susie Q. Lew, MD Division of Renal Diseases and Hypertension Department of Medicine The George Washington University School of Medicine and Health Sciences 2150 Pennsylvania Ave, NW, Rm 3-438 Washington, DC 20037, USA [email protected]

though AVFs are more attractive than AVG because of better long-term outcomes such as lower risks of thrombosis and infection, their major disadvantage is lower rate of maturation than AVGs. The 2006 KDOQI vascular access guidelines recommend the “rule of sixes” for an ideal dialysis vascular access. (Clinical Practice Guideline) (2). “The fistula vein in general must be a minimum of 6 mm in diameter with discernible margins when a tourniquet is in place, less than 6 mm deep, have a blood flow greater than 600 mL/min, and should be evaluated for nonmaturation, if after 6 weeks from surgical creation, it does not meet these criteria.” This review article focuses specifically on the conventional access types in the upper extremities, the technical details of the initial placement and the management of subsequent complications.

Preoperative planning The conventional choices of dialysis access for patients without previous failed accesses are fairly well established. Autogenous AVF offers superior long-term patency and minimal risk of infection. Each upper extremity has four potential sites: radio-cephalic or radio-basilic transposition in the forearm, and brachio-cephalic (Gracz fistula) (3) or brachiobasilic transposition in the upper arm (1, 4-6). Surgeons have the discretion to create a brachio-basilic fistula in either a one-stage or a two-stage procedure (7). Although there is evidence that the two-stage technique results in slightly

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higher maturation rates (8, 9), it requires a second operation and delays the use of an autogenous fistula; therefore, an individualized approach should be considered. A preoperative Duplex ultrasound provides valuable information for surgeons to choose the best arterial inflow and venous outflow combination to achieve a successfully mature fistula (10). The quality of the arterial system is best assessed by segmental pressures and Doppler waveforms, whereas evaluating the venous conduits requires the exact measurements of the sizes and whether there are any sclerosis/stenosis in the superficial veins of the upper extremities. Arteries should be at least 2.0 mm in diameter and have blood flow greater than 500 mL/min to provide adequate dialysis. Veins should be at least 2.5 mm in size for a fistula and 4.0 mm for graft creation (11). Fistula maturation rate doubles if a vein is 4 mm or greater in size (11). Ultrasound also assesses the central venous system, that is, the subclavian veins, for evidence of stenosis or thrombosis with visual inspection and compression (11).

Upper extremity HD vascular access

Fig. 1 - Two diagrams of the brachio-axillary fistula constructed with translocated superficial femoral/popliteal vein. The proximal anastomosis was performed to the brachial artery above the antecubital fossa. The venous anastomosis was performed to the axillary vein within the axilla. Reproduced with permission from (15) Huber TS, et al. Use of superficial femoral vein for hemodialysis arteriovenous access. J Vasc Surg 2000;31:1038-1041.

Surgical approaches Surgical techniques to create standard fistulas with adequate veins and arteries are fairly straight forward and will not be discussed in detail. When the surgeon deems veins to be inadequate by ultrasound, several maneuvers could be applied intraoperatively to pursue the autogenous fistula. Veins with adequate diameter size but inadequate length The basilic vein becomes short when it joins the brachial vein early in the arm. In this case, the addition of saphenous veins harvested from the legs can provide the extra length needed for the lateral sub-dermal basilic transposition. If the basilic vein comes up short in the setting of a previously placed (but failed) brachio-cephalic fistula, an alternate way to increase the length of an already arterialized short basilic vein is to perform a simultaneous basilic and brachial vein transposition. The mobilized brachial vein transects near the antecubital area, whereas the basilic vein transects near the axilla. An anterior lateral tunnel allows the two veins to meet for venous anastomosis (12). Veins with inadequate diameter When both cephalic and basilic veins have small diameters by venous ultrasound, a two-stage approach anastomoses the median antecubital vein to the proximal radial artery in the proximal forearm. The arterialized cephalic and basilic veins require time to mature. If the cephalic vein matures, the second stage becomes unnecessary. However, if the basilic vein matures, it can be transposed subdermally in the second stage (7). Veins with proximal stenosis or obstruction In the setting of contralateral subclavian vein occlusion with a patent ipsilateral central venous system but without adequate ipsilateral superficial veins, contralateral basilic/

cephalic veins could be translocated to the ipsilateral arm for an autologous fistula construction. The brachial vein itself can also be used when neither the cephalic nor the basilic vein is available. If the brachial vein did not arterialize from previous fistula placement and has a diameter of less than 6 mm, a two-stage approach produces a better outcome. An anastomosis between one of the paired brachial veins to the proximal radial artery in an end-to-side manner below the elbow preserves the branching vein to allow both brachial veins to mature in the first stage. Subsequently, the second-stage surgery will transpose the larger of the brachial veins to complete the access. Because of reported high maturation rate with this technique, some would argue that the brachial vein should be used before considering a prosthetic graft placement (13, 14). Another vein that could be translocated to the arm for autogeneous fistula construction is the superficial femoral/popliteal vein (Fig. 1) (15). Unlike the saphenous vein, the superficial femoral vein dilates well and the harvested segment originally spanning from the popliteal fossa to the junction of the profunda femoral vein provides more than adequate length for an autologous conduit. Despite a high success rate, this technique could be complicated by lower extremity edema, thigh wound complication, and hand ischemia from arterial steal. Thus, this approach should be used judiciously.

Upper extremity AVF outcomes and complications The outcomes and complications of upper extremity fistulas are listed in Table I (16). Major outcomes of fistula are measured by maturation rates and long-term primary/secondary patency. The most frequent AVF complications include maturation failure, thrombosis, and aneurysm formation. Other reported complications include infection and steal syndrome, which are uncommon. As shown in Table I, although basilic transposition has the highest maturation rate, average 89%, the risks of infection and arterial steal are also higher than other configurations. On the contrary, although infection and © 2014 Wichtig Publishing

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TABLE I - O  utcomes and complications of upper extremity av fistula Access type

% maturation

1-year primary patency

1-year secondary patency




Radio-cephalic fistula




Hemodialysis vascular access construction in the upper extremity: a review.

This article reviews the conventional vascular access types in the upper extremities for hemodialysis...
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