DeWitt Daughtry Family Department of Surgery, Division of Vascular and Endovascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.
Department of Anesthesiology and pain management, University of Texas Southwestern, Dallas, TX, USA.
J Vasc Access. 2023 Nov;24(6):1227-1234. doi: 10.1177/11297298221080792. Epub 2022 Mar 18.
We describe a technique to mature a basilic/brachial vein in the mid-arm in preparation for a second stage loop proximal brachial artery to basilic/brachial vein arteriovenous graft (BBAVG). This can occur after a failed basilic/brachial vein transposition or a lack of adequate veins in the distal arm. This allows a mature vein to be used in an end-to-end configuration as an outflow to a BBAVG while preserving proximal vessels for the future.
This single-center retrospective study was performed from 2015 to 2021, including 104 AVG patients divided into three groups: (1) Patients who failed a basilic vein transposition and had an enlarged vein suitable for an AVG outflow; (2) Patients who had a small caliber basilic/brachial vein after the transposition, requiring a mid-arm brachial artery to brachial/basilic arteriovenous fistula (AVF) creation with a subsequent AVG extension; (3) and lastly, patients who had no distal arm veins available and required a primary brachial artery to basilic/brachial AVF with AVG extension. A survival analysis was performed looking at time to loss of primary and secondary patency, calculated with Kaplan-Meier estimates and Cox regression models adjusted for covariates.
The median follow-up time was 11 months (IQ = 11-30 months). The survival analysis showed 28% lost primary patency at a median time of 9 months, and 14% lost secondary patency at a median time of 61 months. Overall secondary patency of the vascular access measured at 12 months was 85.6%. Loss of primary ( = 0.008) and secondary patency ( = 0.017), as well as patency during the first 12 months ( = 0.036), were all significantly associated with increased age when adjusting for covariates.
Our results suggest that the graft extension technique using a mature vein from a previous fistula can result in reliable and durable access. This is important for patients with limited access for hemodialysis, as the axillary vein is preserved for future use if needed.
我们描述了一种在中臂成熟贵要/肱静脉的技术，以便为第二阶段的近端肱动脉到贵要/肱静脉动静脉移植物（BBAVG）环做准备。如果贵要/肱静脉转位失败或远端手臂的静脉不足，就可以使用这种技术。这允许成熟的静脉在作为 BBAVG 的流出端时采用端对端构型，同时为将来保留近端血管。
这项单中心回顾性研究于 2015 年至 2021 年进行，包括 104 例 AVG 患者，分为三组：（1）贵要静脉转位失败且静脉扩张适合作为 AVG 流出端的患者；（2）转位后贵要/肱静脉口径较小，需要在中臂肱动脉处创建肱动脉/贵要/肱静脉动静脉瘘，随后进行 AVG 延长的患者；（3）最后，没有远端手臂静脉可供使用，需要进行原发性肱动脉到贵要/肱静脉动静脉瘘并进行 AVG 延长的患者。通过 Kaplan-Meier 估计和 Cox 回归模型进行生存分析，以评估原发性和继发性通畅的时间，调整协变量。
中位随访时间为 11 个月（IQR=11-30 个月）。生存分析显示，28%的患者在中位时间为 9 个月时失去原发性通畅，14%的患者在中位时间为 61 个月时失去继发性通畅。血管通路的总体继发性通畅率在 12 个月时为 85.6%。调整协变量后，原发性和继发性通畅的丧失（=0.008 和=0.017）以及前 12 个月的通畅率（=0.036）均与年龄增加显著相关。
我们的结果表明，使用先前瘘管中的成熟静脉进行移植物延长技术可以获得可靠和持久的通路。对于需要血液透析的有限通路患者而言，这很重要，因为如果需要，腋静脉可以为将来保留。
