Comprehensive Evaluation of Clinical Consequences in Diverse Fistula Elevation Procedures

Background: Arteriovenous fistula (AVF) superficialization is a recommended alternative autologous vascular access(VA) in patients for whom conventional AVF creation is not possible because of insufficient superficial veins. This procedure utilizes a deeply located vein as an outflow conduit in AVF creation and makes the vein accessible for cannulation. Tunnel transposition (TT) is employed in a standard manner as a superficializationtechnique. However, TT tends to be exclusively applied to the basilic vein in the upper armbecause of anatomical considerations and inherent procedural limitations. We recently reported that elevation transpositioncan serve as a simplified minimally invasive substitute forTT (Contrib Nephrol. 2019;198:1-11). In AVF superficialization employing elevation transposition (i.e., fistula elevation procedure [FEP]), three potential outflow veins are available in the upper arm: the cephalic, basilic, and brachial veins. This study was performed to comprehensively evaluate the clinical consequences of three valid FEP techniques, ascertain whether they are reasonable alternatives to autologous VA, and determine which, if any, have superior performance. Methods: The demographic and outcome data of 111 patients who underwent the FEP were retrospectively collected and analyzed. The outcomes of the three fistula techniques were assessed and compared in terms of patency rates, requirements for VA intervention therapy (VAIVT), and complication rates. Results: The basilic, cephalic, and brachial vein-based FEP was performed in 63.1%, 23.4%, and 13.5% of cases, respectively. The overall cumulative primary and secondary patency rates were 76.2% and 98.2% at 1 year and 70.7% and 97.0% at 2 years, respectively. VAIVT was required in 32.4% of cases, and the patency rates at 1 and 2 years after VAIVT were 65.3% and 62.0%, respectively. There were no significant differences in these patency rates among the three FEP types. Minor complications occurred in only 4.5% of cases. Conclusion: Our results suggest that the FEP provides three equivalentlyreliable options to accommodate the deeply located venous anatomy of the upper arm on individual-patient basis. The diversity of the FEP may help to expand the applicability of autologous VA.