Basilic and Femoral Vein Transposition Historical Background In Dagher and colleagues reported a series of 23 upper arm basilic vein transpositions for hemodialysis. The first large series of femoral vein transpositions was published by Gradman and associates in The procedures are analogous but differ in their indications, magnitude, technique, and complications. Basilic Vein Transposition Indications An upper arm basilic vein transposition should be considered whenever a forearm fistula fails or is not feasible. Preference should be given to either a brachiocephalic fistula or a basilic vein transposition, depending on vein size.
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Basilic and Femoral Vein Transposition Historical Background In Dagher and colleagues reported a series of 23 upper arm basilic vein transpositions for hemodialysis. The first large series of femoral vein transpositions was published by Gradman and associates in The procedures are analogous but differ in their indications, magnitude, technique, and complications. Basilic Vein Transposition Indications An upper arm basilic vein transposition should be considered whenever a forearm fistula fails or is not feasible.
Preference should be given to either a brachiocephalic fistula or a basilic vein transposition, depending on vein size. Antecubital venipuncture should be discouraged and the jugular vein should be used used whenever possible for intravenous lines or pacemaker wires to preserve axial vein integrity. Duplex ultrasound with a proximal tourniquet can be used to determine the size of the basilic and cephalic veins and identify common anatomic variations. Duplex ultrasound is best conducted when the patient is hydrated, in a warm environment, and free of anxiety.
Veins should be marked and sized on a nondialysis day to limit venoconstriction associated with volume shifts. Patients with long-standing ipsilateral central venous catheters, pacemakers, or previous dialysis catheters should have an imaging study to rule out central venous occlusive disease.
The basilic vein occasionally joins the brachial vein in the midarm, rather than in the axilla. Antecubital vein variations are common. The median cubital vein, which extends from the midantecubital fossa to join the basilic vein, may be diseased, atretic, or nonexistent.
The medial antebrachial cutaneous nerve of the forearm, a sensory nerve originating directly from the medial cord of the brachial plexus, crosses directly in front of the basilic vein at or just central to the entry of the median cubital vein. Dividing this nerve can lead to medial forearm anesthesia. The median nerve lies medial to the brachial artery at the level of the elbow and must be protected from injury during dissection and retraction.
The single-stage procedure is cost effective but results in a higher frequency of primary failures. The two-stage procedure is most beneficial when the upper arm veins are of borderline size 2.
A one-stage basilic vein transposition usually matures if the basilic vein is larger than 3. If the basilic vein is smaller than 2. Figure The most common sites for anastomosing the basilic vein to the brachial artery. This may be part of either a one- or a two-stage transposition procedure. No second stage may be necessary if retrograde venous valve destruction results in maturation of forearm veins. If it does not, a second-stage cephalic or basilic vein transposition is needed.
Harvest of the Basilic Vein Whether done in one or two stages, the basilic vein must be transected distally and care must be taken to avoid injury to the medial antebrachial cutaneous nerve, which crosses anterior to the basilic vein at or just before the entry of the median cubital vein Fig.
Surgeons often encounter a stout large branch between the basilic and the brachial veins in the midarm. They should ligate or, if necessary, suture this branch carefully to avoid narrowing the lumen of the basilic vein. The basilic vein also occasionally joins the brachial vein in the midarm. Experience shows that if extra length is needed, the brachial vein may be harvested in continuity to the axilla without resulting in disabling postoperative arm edema.
The brachial vein may be the dominant arm vein and can be used when no other autogenous vein is available. However, it is more fragile and has more branches than the basilic vein. The basilic vein should be freed to the proximal arm, marked to maintain orientation and tunneled over the anterior arm before anastomosis of the vein onto the brachial artery.
Mere elevation of the vein makes for awkward cannulation and uncomfortable dialysis Fig. The benefit of decreased incisional pain has not been established. Figure A , The left basilic arm vein is exposed from the elbow to the axilla and marked for orientation before transection and tunneling. The medial antebrachial cutaneous nerve of the forearm, which crosses the basilic vein in the distal arm, should not be divided. Simple elevation of the vein, in contrast to transposition, results in medial forearm anesthesia and makes for uncomfortable and awkward cannulation for hemodialysis.
B , The basilic vein has been tunneled anteriorly and anastomosed to the distal brachial artery. Twists and kinks must be avoided. Upper arm fistulas may be originated from the proximal radial artery to reduce the incidence of steal syndrome. Operative Technique Preoperative duplex vessel mapping is essential and may be assisted by placing a tourniquet on the proximal arm with gentle massage of the venous column centrally to distend the vein.
Prophylactic antibiotics should be administered. Supraclavicular brachial plexus block can be used for anesthesia, along with 0. Additional lidocaine can be administered into the fascial compartment. General anesthesia may be an alternative.
The harvest incision extends the full length of the upper arm to the axilla. Exposure of the vein may begin anywhere along its length, but the venous anatomy is most reliably defined either in the axilla or at the median cubital vein. The basilic vein distal from its junction with the median cubital vein is occasionally harvested to gain additional length. Two-Stage Procedure First Stage An incision is made over the median cubital vein, which is dissected for a short distance.
The adjacent brachial artery is exposed, a 4- to 5-mm-long arteriotomy is made, and an end-to-side, vein-to-artery anastomosis is created with or polypropylene. Second Stage After 4 weeks, ultrasound confirms that the basilic vein is suitable, as indicated by slight thickening and enlargement of the vein.
At the second stage, the basilic vein is exposed to the axilla. A tunnel is created about 2 to 3 cm anterior to the basilic vein with a sheathed tunneler. The basilic vein is marked along its anterior surface, transected distally, gently dilated with heparinized saline, and drawn through the tunnel, with care taken to avoid rotation or kinking.
The transposed basilic vein is reanastomosed to the distal vein. Subcutaneous tissue is reapproximated with a running absorbable suture.
A drain is usually unnecessary. Skin is closed with subcuticular suture, and a sterile adhesive dressing is applied. Superficialization of the Fistula An additional popular variation involves performing an initial end-to-side basilic vein to brachial artery anastomosis. After a 4- to 6-week maturation period, the basilic vein is exposed, branches are divided and ligated, and the vein is superficialized by approximating the subcutaneous tissue below the vein.
The fistula can be accessed after healing of the skin incision. Use of the Radial Artery Variations at the second stage include creating an anastomosis to the brachial artery at a more proximal site or transecting the vein close to the original arteriovenous anastomosis.
Jennings has described a variation in which the radial artery is exposed in the proximal forearm and a side-to-side anastomosis is created to the adjacent median antebrachial, median cubital, or cephalic vein.
Before creating the anastomosis, the valves in the distal vein are disrupted with a valvulotome to allow both antegrade and retrograde flow. The upper arm cephalic vein, cubital veins, and forearm veins may dilate and mature sufficiently for dialysis. If not, the upper arm cephalic or basilic vein can be transposed. Single-Stage Procedure Most basilic veins are 4 mm in diameter or greater, and a one-stage procedure is usually possible if the vein is of sufficient size and free of intimal disease.
The vein is exposed to the axilla, and a tunnel is created 2 to 3 cm anterior to the main harvest incision. The vein is marked on its anterior surface, transected distally at the level of the median cubital vein, and drawn through the tunnel, avoiding vein rotation or kinking. The vein is anastomosed end to side to the brachial artery. In most patients the brachial artery is exposed through the main incision about 2 to 3 cm proximal to the basilic vein transection.
In the obese patient a second incision may be necessary to expose the artery. An important variation of this procedure is to begin the basilic vein harvest starting at the confluence of basilic and median cubital veins. The advantage of transecting the basilic vein at this more proximal site is that the vein is usually 4 mm or larger and is unaffected by previous venipuncture, catheters, or revision of forearm prosthetic grafts.
The obvious drawback is that there is less basilic vein for the transposition, but this has not proved detrimental in practice. If the basilic vein ends in the midarm, the surgeon needs to harvest the brachial vein in the upper arm to achieve adequate length. Only gold members can continue reading. Log In or Register to continue You may also need.
Basilic and Femoral Vein Transposition
It originates on the medial ulnar side of the dorsal venous network of the hand and travels up the base of the forearm, where its course is generally visible through the skin as it travels in the subcutaneous fat and fascia lying superficial to the muscles. Near the region anterior to the cubital fossa , in the bend of the elbow joint, the basilic vein usually connects with the other large superficial vein of the upper extremity, the cephalic vein , via the median cubital vein or median basilic vein. The layout of superficial veins in the forearm is highly variable from person to person, and there is a profuse network of unnamed superficial veins that the basilic vein communicates with. As it ascends the medial side of the biceps in the arm proper between the elbow and shoulder , the basilic vein normally perforates the brachial fascia deep fascia above the medial epicondyle , or even as high as mid-arm. There, around the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into it, just before it joins the brachial veins to form the axillary vein. Along with other superficial veins in the forearm, the basilic vein is an acceptable site for venipuncture. Nevertheless, IV nurses sometimes refer to the basilic vein as the "virgin vein", since with the arm typically supinated during phlebotomy the basilic vein below the elbow becomes awkward to access, and is therefore infrequently used.