Extending outflow brachial vein length for transposition arteriovenous fistulas

Transposition arteriovenous fistulas (T-AVF) play an important role in establishing autogenous vascular access for many hemodialysis patients. When the basilic vein is not available, one of the paired brachial veins offers a reliable T-AVF option, generally as a two-staged operation. Uncommonly, the brachial vein outflow conduit dissipates into multiple small branches communicating with the paired brachial vein or occasionally with a residual proximal segment of the basilic vein. We utilized parallel outflow vein component segments to create additional outflow vein length necessary for successful T-AVFs in these patients. We identified four patients where a vein length extension technique utilizing parallel and overlapping vein segments with an end-to-end anastomosis gained adequate length for successful T-AVFs. All transpositions were based on a first stage AVF with access outflow established into a brachial vein. Three of the operations utilized paired brachial vein segments and one gained needed access outflow length with a brachial vein anastomosis to a residual proximal basilic vein segment. All four patients had functional T-AVFs at 4, 5, 7, and 14 month follow-up. None of the patients developed arm swelling. Creating a longer transposition AVF venous outflow segment using parallel and overlapping vein segments with an end-to-end anastomosis gained the adequate length needed for successful T-AVFs in these four patients.