The Michigan Vascular Access/MiDRE primer in Vascular Access

Chapter 16 - Transposed basilic fistulas - using the biggest vein in the arm

Where possible, the cephalic vein is used for wrist or elbow level fistulas. It is usually located anteriorly, is relatively shallow, and is usually relatively straight with few branches. This is the vein most surgeons prefer to use for creation of an AV fistula. Unfortunately, the cephalic vein may be small, tortuous, and in many patients has been ruined by previous intravenous catheters. Finding options for the patient beyond the standard wrist or elbow fistula requires that we consider using a previously underutilized resource – the basilic vein. The basilic is the biggest vein in the arm, but is placed far medially (making it an inconvenient location for cannulation), and deep. The vein runs under several layers of brachial fascia (connective tissue), is surrounded by nerves, and can be close to the brachial artery. To use it in its natural position is impractical, painful and possibly dangerous. Since transposition of the basilic vein was described in the 1980s, experience has been growing in the use of this vein. In general, the basilic vein is mobilized through a long incision on the medial part of the arm from elbow to axilla (the old technique). Branches are ligated and divided. The vein is divided near the elbow, drawn through a subcutaneous tunnel lateral to the incision, and connected to the brachial artery. Because the incision is long and creates a large raw surface that can ooze a large amount of tissue fluids, I almost always left a drain in the wound and kept the patient in the hospital overnight.

Harvesting the basilic vein through a long incision – prior to 2007. This is a one stage procedure.

Since 2006 I have returned to the operation with interrupted incisions as originally described by Dagher. There are different forms of this operation depending on the venous anatomy, whether the basilic proper or its large median antecubital branch from the antecubital fossa is used, and whether this is a one-stage (no previous fistula), or two-stage (after preliminary fistulization of a feeding vein).

Mobilizing the basilic vein via smaller "skip" incisions – after 2007. This vein was previously fistulized as a simple brachiobasilic fistula, with the second stage being performed after the vein had grown.

It has been observed empirically that basilic transpositions done after previous access in the same arm are more successful. The basilic vein above a forearm graft or fistula may have been "built up" over time from receiving increased blood flow. Veins of seven, eight, ten millimeters or more are frequently seen in the outflow of forearm accesses. When the forearm access fails, the large and previously toughened basilic vein can be transposed and used for dialysis within weeks. This operation is a very high-yield procedure in the hands of an experienced access surgeon. The venous outflow of forearm grafts or failing fistulas should be examined with ultrasound to discover these options for transition to an upper arm fistula.

The clotted median antecubital and basilic vein are thrombectomized and used for a transposed basilic fistula – still patent after 8 years

One advantage to a basilic fistula is that it always is transposed, and is usually tunneled right under the skin. Cephalic fistulas can be transposed (or superficialized), but are most often used in their native position, which is below a superficial fascial layer, and usually deeper. A correctly tunneled fistula should be easy to palpate, visualize and cannulate. The disadvantage with superficialized or transposed fistulas is that there may not be enough "padding" to provide a durable subcutaneous buffer between skin and fistula to allow a buttonhole, and buttonhole technique has led to several "vasculocutaneous fistulas" with impressive bleeding. Buttonhole technique should be employed very cautiously in these patients, if at all.

This fistula was overused in one spot, causing skin erosion and a vasculocutaneous fistula with a fibrin plug the only thing keeping the body’s life blood in. This is a surgical urgency or emergency. Such patients have been lost in the elevator on the way to surgery.

The fistula is considered for use according to the usual criteria, and time to release varies from five to sixteen weeks depending on type. Occasionally an intervention will be required with dilation of a stenosis in the outflow "swing-zone", the inflow, or mid-fistula. The one-year unassisted patency for basilic fistulas has been reported to be as low as 50%, reflecting in many studies relative inexperience with this technique, or reflecting an activist philosophy with regard to maturation procedures. The overall release rate of this fistula is nearly 95% in my series of over 500. It is important to find a surgeon who is beyond the learning curve in this operation.

This transposed basilic fistula has a swing zone stenosis, and has been stented in the past. This fistula will require repeated outflow venoplasties to keep it functioning.

The recent enthusiasm for PICC lines represents a threat to the basilic vein. Previously protected by depth, this vein is now being used more and more, and like the cephalic vein before it, is being ruined for use in creating dialysis access (see Chapter 3- Venous preservation). Fortunately, experience in declotting basilic veins, or removing parts of it entirely for use as an autologous graft is growing. Nevertheless, it is my position that PICC lines in renal patients can lead to loss of fistula options, and should only be used when absolutely necessary.

This basilic vein was damaged at both ends by a PICC line, but was removed and used as an autograft

In short, being able to use the basilic vein is an important option for dialysis patients whose cephalic veins are inadequate. Chances for creating a useful fistula are greatly increased when the access surgeon considers using the basilic vein and is familiar with the operation.

Michigan Dialysis Research and Education (MiDRE)
Saint Mary's Mercy Hospital