Ulnar Artery-Forearm Basilic Vein Arteriovenous Fistula: Is It an Acceptable Option for Increasing Use of Autogenous Arteriovenous Fistula?

Jung, In Mok

Abstract

PURPOSE: An Ulnar artery-forearm basilic vein arteriovenous fistula (UBAVF) is not often used for hemodialysis access because the vessels are anatomically deep structures, the basilic vein is often not well developed, and access to this vein for subsequent puncturing is difficult, and the arm position is uncomfortable because of its position on the medial side of the arm. To evaluate the role of this fistula in selected patients with no other accessible autogenous cephalic veins and failed autogenous vein fistula, we conducted this study. METHODS: From March 1998 to August 1999, 164 arteriovenous fistula (AVF) formations were done in 151 patients who required chronic hemodialysis in Seoul and Chungnam National University Hospitals by one surgeon. Among them, ten (6.1%) UBAVFs were included. UBAVF formation could be considered in all cases of primary AVF and failed AVF, but the following criteria were necessary for selection of ulnar-basilic fistula: (1) No accessible forearm cephalic veins on either sides, (2) Presence of pulsation of radial, ulnar arteries and a normal Allen test, (3) Luminal diameter of the basilic vein greater than or equal to 3 mm and confirmation of patency of the proximal venous outflow by manual percussion. Single incisions were used in the majority of cases, and longer maturation time before initiation of hemodialysis was recommended compared with other autogenous vein fistulas. One- and two-year primary patency rates and the early failure rate were analyzed and compared with those for vein fistulas of the other sites. Satisfaction of patients with this fistula was evaluated by direct or phone communication with the patients and dialysis nursing personnel. RESULTS: Mean age was 45.1 years (21-67 years) and male to female ratio was 6:4. Four cases (40%) were done as a primary AVF, and six were as a second or more AVF. Mean follow-up period was 15.3 months, and no major complications occurred, except for one case of early thrombotic occlusion. Difficulty of needle can nulation by dialysis nursing personnel and uncomfortable arm positioning during hemodialysis werenegligible. Early failure occurred in one case and a total of three fistulas failed during the follow-up period. One-and two-year primary patency rates of UBAVF were 78.8% and 67.5%, respectively. There were no statistically significant differences in patency rates between UBAVF and other autogenous vein fistulas during the same period. CONCLUSION: In my experience, UBAVF in selected patients demonstrated a low early failure rate, an acceptable patency rate, and minimal complications. Difficulty of needle cannulation and uncomfortable arm positioning during hemodialysis were minimal, but agreement and education about postoperative discomfort, even planning of vein transpositions, must be considered. In addition, because of location in the forearm, preservation of more proximal vasculature for future hemodialysis access procedures was possible. I recommend selective use of this fistula to increase the use of autogenous vein fistula and to maximize options for hemodialysis access while reducing the dependency on synthetic graft fistula.