AV Fistula Vein Transpositions

FistulaFirst
FistulaFirst
…Vein Transposition
A-V Fistulae
Lawrence M. Spergel, MD, FACS
Clinical Chair, Fistula First Breakthrough Initiative
Director, Dialysis Management Medical Group
San Francisco, California
Median
antebrachial v.
In each patient:
-Which veins and arteries
have been identified as
being suitable (i.e. what
are my vein conduit and
arterial inflow options)
- Which AVF option do I
select—and Why
.
-Where is the best site for
anastomosis
1º Autogenous A-V Fistula Options
Simple Direct A-V Fistulae
>Radial-Cephalic (Forearm)
>Brachial-Cephalic (Arm)
-Proximal Radial-Median antebrachial (Forearm)
-Posterior tibial-Saphenous (Ankle)
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
> .Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup. fem. a.-Saphenous v.
-Femoral vein (thigh): Sup. fem. a.-Fem. v.
1º Autogenous A-V Fistula Options
Simple Direct A-V Fistulae
-Radial-Cephalic (Forearm)
-Brachial-Cephalic (Arm)
-Proximal Radial-Median antebrachial (forearm)
-Posterior tibial-Saphenous (Ankle)
4. Left Ankle AVF (Posterior Tibial-Saphenous AVF)
46 y.o. Asian male with
exhausted access sites--
non-diabetic, excellent pedal
pulses, normal saphenous vein
4. Left Ankle AVF (Posterior Tibial-Saphenous AVF)
Patient Selection is Critical:
* non- or mild diabetic
* no significant distal
vascular disease/ good pulses
* generally not for the elderly
* normal venous ultrasound
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1º Autogenous A-V Fistula Options
Simple Direct A-V Fistulae
>Radial-Cephalic (Forearm)
>Brachial-Cephalic (Arm)
-Proximal Radial-Median antebrachial (forearm)
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
> .Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup. Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.-Femoral v.
Vein Translocations
Vein Transposition A-V Fistulae
Three Cardinal Rules for Transpositions
- Superficial
- Safe position for
cannulation
- Away from incisions
1º Autogenous A-V Fistula Options II
Simple Direct A-V Fistulae
>Radial-Cephalic (Forearm)
>Brachial-Cephalic (Arm)
-PRA-Median antebrachial (Forearm)
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
> .Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup. Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.- Sup.Femoral v.
1º Autogenous A-V Fistula Options II
Simple Direct A-V Fistulae
>Radial-Cephalic (Forearm)
>Brachial-Cephalic (Arm)
-PRA-Median antebrachial (Forearm)
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
> .Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup.Fem. a.-Saphenous
-Femoral vein (thigh): Femoral a.-Femoral v.
Distal radial-cephalic
transposition (straight)
Proximal radial-cephalic
transposition (loop)
Cephalic v. is transposed
superficially through a
subcutaneous tunnel
Or a proximal radial
(or brachial) a.- cephalic v.
side-to-side anastomosis
Distal cephalic v. turned
up to proximal radial a.
because of unsuitable
distal radial a.
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Proximal Radial (or Brachial)-Cephalic AVF
(with tri-directional flow)
o
1 A-V Fistula Options II
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
-Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup. Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.-Femoral v.
Forearm basilic v. needs to be
transposed for safe cannulation
Basilic vein
Distal radial-basilic
transposition (straight)
Forearm Radial-Basilic Transposition
transposed
basilic vein
to distal
radial a.
L. Scher
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Proximal radialbasilic
transposition
(loop)
Inadequate distal
arteries
o
1 A-V Fistula Options II
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
-Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup.Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.-Femoral v.
Case # 1
Brachial-cephalic
transposition
Cephalic v. transposition
Proximal vein is compressed
while injecting heparinized
saline to dilate vein as well as
to check for leaks
No upper extremity veins
identified on physical exam.
Imaging by venogram identified
suitable left cephalic v.
Cephalic v. transposition
Note that vein is:
1. superficial
2. positioned for safe
cannulation
3. away from incisions
Case # 2
Note: Consider PRA for Inflow
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o
1 A-V Fistula Options II
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
-Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup.Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.-Femoral v.
Brachial-basilic v.
transposition (as a 1-
or 2-stage procedure)
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Brachial-basilic transposition
Medial brachial
cutaneous n.
. . . . . . .. . .. . . . .
Basilic vein
… . . . . . . . . . . . .
. . . .
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..
. . … . . .. . . . …
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Brachial-basilic transposition
Note transposed basilic vein is
superficial, lateral and away
from incisions
Anastomosis is distal to
antecubital crease to provide
maximum length of fistula—also
permits use of PRA as inflow
Brachial-basilic transposition
Bleeding Complications Associated
with Non-transposed, Superficialized
Basilic v.
Important to obtain
additional length of vein
to enable translocation
o
1 A-V Fistula Options II
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
-Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup.Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.-Femoral v.
Shanzer et al
Brachial-brachial transposition
Spergel et al
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o
1 A-V Fistula Options II
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
-Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup.Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.-Femoral v.
distal saphenous v.
ligation
.
Transposed
Saphenous
v. loopAVF
Saphenous vein translocation
to forearm
o
1 A-V Fistula Options II
Transposed Superficial Femoral v. AVF
Vein Transposition A-V Fistulae:
-Cephalic vein (forearm): Radial a.-Cephalic v.
-Basilic vein (forearm): Radial a.-Basilic v.
-Cephalic vein (arm): Brachial a.-Cephalic v.
-Basilic vein (arm): Brachial a.-Basilic v.
-Brachial vein ( arm): Brachial a. –Brachial v.
-Saphenous vein (thigh): Sup. Fem. a.-Saphenous v.
-Femoral vein (thigh): Femoral a.-Sup.Femoral v.
Gradman et al,
JVS Feb. 2005
Re-op. for
2-yr.
Ischemia Infection Patency
Historical
Group I 9* 0 87
(26 accesses)
Study
Group II** 0*** 0 94
(22 accesses)
* 3 banded accesses thrombosed
**Group II patient selection based on
reducing risk factors for steal/ischemia:
-absence of significant PVD
-no elderly/frail
*** 0/14 tapered accesses thrombosed
Additional /CreativeAVF options
-Translocations (saphenous v. to
forearm, other)
- Retrograde/Reverse flow
constructions(arterial anastomosis
proximal/retrograde AVF flow)
- Composite constructions
- “Blind” constructions
For questions related to the
FistulaFirst initiative, please contact
your local ESRD Network at:
http://www.esrdnetworks.org/
AND
visit the FistulaFirst Website:
FistulaFirst.org
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