1 Autogenous A-V Fistula Options

FistulaFirst
The National Vascular Access
Improvement Initiative (NVAII)

Surgical Approaches to
A-V Fistula Construction:
Vein

Transpositions

Lawrence M. Spergel, MD, FACS

Clinical Chair, NVAII
Director, Dialysis Management Medical Group
San Francisco, California

1 A-V Fistula Options I

Simple Direct (nontransposed) AVF Options:
1. Radial a.-Cephalic v.
(forearm)
2. Brachial a.-Cephalic v.
(upper arm)

2
2a

2a. Gracz variation (ante-cubital)

I Simple Direct A-V Fistulae

>Radial-Cephalic (Forearm)
>Brachial-Cephalic (Arm)
-Proximal Radial-Median antebrachial (forearm)

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.
-Saphenous vein (thigh): Femoral a.-Saphenous v.
-Femoral vein (thigh): Sup. Fem. a.-Fem. v.
Vein Translocations (vein relocated to another anatomic site)

Strategies to Increase Autogenous Fistulae

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1 A-V Fistula Options II

Vein Transposition A-V Fistulae:

The objective of transposition is not only
to superficialize the vein, but to ensure
that the vein is positioned for safe cannulation
and is not directly beneath an incision.

3
Median
antebrachial v.

3. Proximal Radial a.Median Antebrachial v.

(forearm)

Strategies to Increase Autogenous Fistulae

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1 A-V Fistula Options II

1 Autogenous A-V Fistula Options

I Simple Direct A-V Fistulae

>Radial-Cephalic (Forearm)
>Brachial-Cephalic (Arm)
-PRA-Median antebrachial (Forearm)

Vein Transposition A-V Fistulae:

II Vein Transposition A-V Fistulae:

Prior to considering transposition,

vessel mapping and evaluation of
all AVF options are critical

-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.
>
-Saphenous vein (thigh): Femoral a.-Saphenous v.
-Femoral vein (thigh):
Vein Translocations

Sup. Fem. a.-Fem. v.

Radial-cephalic
transposition
(straight or loop)

Strategies to Increase Autogenous Fistulae

1o A-V Fistula Options II

Vein Transposition A-V Fistulae:

Loop transposition of
cephalic v. to proximal
radial a. (distal radial a.
was diseased)

-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.
-Saphenous vein (thigh): Femoral a.-Saphenous v.
-Femoral vein (thigh): Sup. Fem. a.-Fem. v.

Forearm basilic v. needs to be

transposed for safe cannulation

non-transposed
basilic vein..
Note: frequent
hemorrhage from
needle puncturing
back wall of nontransposed vein
when forearm rests
on needle during
dialysis

Basilic vein

Radial-basilic
transposition (straight)

transposed
forearm basilic
vein to distal
radial a.

Course of transposed basilic vein

Radial-basilic
transposition (loop)

Strategies to Increase Autogenous Fistulae

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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.
-Saphenous vein (thigh): Femoral a.-Saphenous v.
Transposed basilic
vein to proximal
radial artery

-Femoral vein (thigh): Sup. Fem. a.-Fem. v.

Brachial-cephalic
transposition

Venogram revealed suitable

left cephalic v. (basilic v. was
destroyed by recent PICC line.

No upper extremity veins

identified on physical exam.
Mapping by venogram identified
suitable left cephalic v.

Cephalic v. transposition

Note that additional vein

is mobilized distally to
permit anastomosis to be
as distal as feasible.

Mandatory proximal continuation

of contrast study reveals patent
central venous system

Cephalic v. transposition

Cephalic v. transposition

Proximal vein is compressed

while injecting heparinized
saline to dilate vein as well as
to check for leaks

Strategies to Increase Autogenous Fistulae

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1 A-V Fistula Options II

New tunnel is created:

1. superficially,
2. in a safe location for
cannulation, and
3. away from incisions

Brachial-basilic vein
transposition (as a 1or 2-stage procedure)

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.
-Saphenous vein (thigh): Femoral a.-Saphenous v.
-Femoral vein (thigh): Sup. Fem. a.-Fem. v.

Brachial-basilic transposition

Medial brachial
cutaneous n.

Basilic vein

..

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 conduit

Strategies to Increase Autogenous Fistulae

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1 A-V Fistula Options II

Transposed
Saphenous
v. loop 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.
-Saphenous vein (thigh): Femoral a.-Saphenous v.
-Femoral vein (thigh): Sup. Fem. a.-Fem. v.

Option: Saphenous vein

translocation to forearm if lower
extremity arterial insufficiency

distal saphenous
v. ligation

Strategies to Increase Autogenous Fistulae

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.
-Saphenous vein (thigh): Femoral a.-Saphenous v.
-Femoral vein (thigh): Sup. Fem. a.-Fem. v.

Saphenous v. translocated
to right forearm

Vein Transpositions: Additional Considerations

1. Femoral vein transposition should be last resort
because of associated morbidity
2. If cephalic or basilic vein not suitable on mapping,
consider use of brachial vein associated with
brachial artery. If brachial vein is suitable, consider
2-stage transposition because of small size of vein
and likelihood of injury
3. Transposed virginal basilic & brachial veins usually
require extended period for maturation, so early
planning and construction critical in order to avoid
prolonged catheter use.