Tunnel-transposition with veno-venous or veno-arterial re-anastomosis versus skin-flap elevation for second-stage superficialization of brachiobasilic arteriovenous fistula

IntroductionArteriovenous fistula is the preferred vascular access for patients with chronic kidney disease on hemodialysis. Brachiobasilic arteriovenous fistulas are valued for their durability and long-term patency in patients with unsuitable superficial venous anatomy. The basilic vein, located deeper within the arm, offers a larger diameter. However, due to its depth, surgical interventions like superficialization or transposition are necessary to make the vein accessible for routine cannulation. This study compares the outcomes of three different surgical techniques used during the second stage of brachiobasilic arteriovenous fistula superficialization.Patients and MethodsThis retrospective study analyzed data from patients who underwent a second-stage brachiobasilic arteriovenous fistula between January 2020 and February 2023. The procedure involved elbow brachiobasilic AVF, resulting in vein dilatation and arterialization, followed by superficialization using techniques like skin-flap elevation or tunnel-transposition with veno-venous re-anastomosis or veno-arterial re-anastomosis. Follow-ups included routine clinic visits, duplex ultrasound scans, and monthly surveillance visits.ResultsA study of 238 second-stage brachiobasilic arteriovenous fistula procedures revealed no significant differences among the three groups. The skin-flap elevation technique had shorter operative times and higher technical success rates but was associated with higher postoperative complications like hematomas, infections, and nerve injuries. The veno-venous re-anastomosis and veno-arterial re-anastomosis groups had lower complication rates, particularly nerve injuries and steal syndrome, but required longer operative times and had lower technical success rates.ConclusionSuperficial tunneling techniques provide better healing and less complications as compared to skin-flap elevation.