Factors affecting cardiac function in dialysis patients include arterial blood pressure, anemia, intra-vascular volume and the arteriovenous fistula (AVF). We investigated the acute and chronic effects of basilic vein transposition (mean upper arm brachial artery-basilic vein anastomosis) on both the cardiovascular system and the oxygen status.
Sixteen patients with end stage renal failure were enrolled in this study. Patients with heart failure, pericardial effusion or valvular heart disease were not included in the study. Echocardiography (preoperatively and six months after, stages 1 and 2 respectively) and a Swan-Ganz catheter (perio-peratively) were used to assess the hemodynamic status during the phases of AVF construction. Flow measurements were made in the parts of the AVF system before, during and after the constru-ction of the AVF.Moreover, at the same time phases blood sampling from the arterial line and the pulmonary artery catheter was performed, in order to assess oxygen and acid-base status.
Cardiac output, cardiac index, stroke volume, stroke volume index, left ventricular stroke work in-creased statistically significant 20 and 30min after the AVF construction and they returned to base-line at 40min after the procedure. On the contrary, systemic vascular resistance decreased statisti-cally significant 20 and 30min after the operation and they remained decreased for the whole study period. No other differences were recorded regard-ing the hemodynamic, oxygen and acid-base status. As far as the echocardiographical findings are con-cerned, ejection fraction showed a tendency to increase but not significantly in contrast to the inter-ventricular septum which increased statistically significant in both systole and diastole (p<0.01). Posterior wall thickness decreased minimally in both systole and diastole. Regarding the AVF sy-stem diameters, there were no changes recorded during the study.
Basilic vein transposition in selected patients provides a well functioning AV fistula and is not an appreciable cause of circulatory or pulmonary congestion for at least a period of six months.
Brescia and colleagues were the first surgeons to describe radiocaephalic fistula in the nondo-minant arm for hemodialysis1. This still rema-ins the first choice procedure for vascular access in patients who require long term hemo-dialysis. Lack of suitable cephalic veins, led the surgeons to investigate alternative procedu-res, such as basilic vein transposition and pros-thetic vascular access grafts (polytetrafluoroe-thylene [PTFEE])2.
Use of a brachiobasilic arteriovenous (AVF) fi-stula with transposed basilic vein was first de-scribed in 1976 by Dagher3. Due to the subfa-scial localization of the vein, protecting it from venipuncture, basilic vein is usually available in the upper arm region. The primary patency of this fistula is about 60% to 70% and the long-term patency is similar to that of a graft4,5.
This special type of AVF is used, when other AVFs have failed or when the patient’s vessels are not suitable for the construction of a distal AVF6,7,8. It is well known that many patients undergoing haemodialysis, usually show an increase in cardiac output, which may be due ei-ther to the presence of AVF or to anaemia9-15.
Cardiac output and other hemodynamic para-meters can be studied by both non-invasive te-chniques, i.e. echocardiography, as well as by invasive techniques e.g. by using a Swan-Ganz catheter.
Most literature studies have investigated the hemodynamic parameters during surgical oc-clusion or manual compression of AV fistula. Futhermore, there are not many reports on the acute and late effects after basilic vein transpo-sition.
The purpose of this study was to evaluate im-mediate and long term (after six months) cardiac effects of basilic vein transposition, by using echocardiography (preoperatively and six months after the creation of AVF) and a Swan Ganz catheter perioperatively.
MATERIAL AND METHODS
This study was carried out in 16 patients with end-stage renal disease (ESRD) in the Nephro-logy Department (Hemodialysis Unit) of AHE-PA University Hospital, Thessaloniki, Greece. Informed written consent was taken from each patient. The institutional ethical committee on human research and the University thesis ap-proval committee approved the study. Patients were already on a hemodialysis pro-gram using a hemodialysis catheter. A two lu-men (12Fr. X 6’’-16cm) hemodialysis catheter (Arrow International) was already inserted in the jugular or subclavian vein, as their AVFs for hemodialysis were not functioning proper-ly. The previous AVFs had been constructed in various sites in the upper limb e.g. between the radial artery and cephalic vein or brachial artery to cubital vein, but basilic vein transpo-sition has never been performed in these pati-ents. All such patients were scheduled for an AVF construction using the basilic vein (basilic vein transposition); 6-12hrs preoperatively they un-derwent hemodialysis. Patients with heart failure, pericardial effusion or valvular heart disease were not included in the study. Pre-operative duplex ultrasound investigation (SSD-2000, Aloka Co. Ltd, Tokyo, Japan) was performed according to a standard protocol by experienced vascular technicians, measuring the diameters of brachial arteries and basilic veins in the upper arm. An echocardiographic evaluation of cardiac function was performed within 6hrs after he-modialysis in order to achieve a water balance close to the “dry’” weight. Shortly thereafter patients were transferred to the operating thea-ter for the scheduled procedure (stage 1). Left ventricular ejection fraction (EF%), posterior wall of left ventricular during diastole (PLV-Wd), posterior wall of left ventricular during systole (PLVWs), left ventricular dimension during systole (LVDs), left ventricular dimen-sion during diastole (LVDd), interventricular septum during systole (IVSs) and interventri-cular septum during systole (IVSs) were mea-sured and recorded. On the day of the study, standard monitoring included electrocardiography (ECG),pulse oxy-metry (SpO2) and invasive measurement of ar-terial pressure (IABP). In addition, a special thermodilution Swan-Ganz catheter (OptiQ SvO2/CCO Abbott Laboratories North Chica-go, IL, USA) was inserted for monitoring of central filling pressures, continuous monitor-ring of cardiac output and SVO2. The catheter was inserted by using the pre-existing vascular access for hemodialysis through an introducer sheath (Seldinger method). Measurements we-re made at the individual phases of AVF con-struction (0-5): before (phase=0), during (pha-se=1) and 10 min (phase=2), 20 min (pha-se=3), 30 min (phases=4), 40 min (phase=5) min after construction of the AVF. Results were calculated by using the following equation: Blood flow =π*V*d*d (Abbreviati-ons: π= 3,14, V= Velocity in cm/min, d= ves-sel’s diameter in cm). Detailed measurements were made in the basilic vein and brachial arte-ry before and after the AVF construction and in the transposed basilic vein with the feeding artery closed (in this case the flow is called re-trograde). Blood samples were drawn at phases 0, 1 and 2 from the peripheral arterial line and from the pulmonary artery in order to assess the oxygen and acid-base status during AVF construction. All the procedures for the AVF formation were performed under local anesthesia and sedation (small doses of propofol) by using the “one stage procedure technique. The incision was started at the antecubital crease in a vertical fa-shion just medial to the brachial artery pulse. The incision was extended through the subcu-taneous tissue; the fascia was incised and the brachial artery exposed. The medial nerve was always identified and preserved. Proceeding slightly more medially and still deep to the fa-scia, the basilic vein was visualized and traced proximally, all the way to its junction with the axillary vein. Occasionally, usually in the pro-ximal third of the arm, the medial cutaneous nerve was encountered and preserved. Once the basilic vein was mobilized and all its bran-ches were ligated, it was divided as far distal to the arm as possible and brought superficial to the medial cutaneous nerve. Then, the vein was tunneled in a more lateral, subcutaneous location. Proximal and distal control of the brachial artery was obtained and the patient was given heparin. A 6- to 7-mm arteriotomy was then made and an end-to-side anastomosis between the basilic vein and the brachial artery was constructed using fine, nonabsorbable monofilament suture. Clamps were then relea-sed and flow established in the arterialized ba-silic vein. The deep fascia was then closed with interrupted, absorbable sutures, keeping the basilic vein superficial to the fascia. The basilic vein was positioned in the subcutane-ous pocket, thereby relocating it in a more late-ral and more superficial position (Figure 1). There was also a continuous supply of oxygen via a face mask (6-8l/min).
The echocardiographic evaluation of cardiac function was performed six months later by the same operator (precisely) within 6hrs after the hemodialysis session (stage 2). The exact tim-ing of the second echocardiography evaluation was important in order to preserve a water ba-lance close to the “dry’” weight, as in the first study (stage 1). Equations were used to calculate the following cardiovascular parameters: cardiac index (CI), stroke volume index (SVI), systemic vascular resistance (SVR), systemic vascular resistance index (SVRI) pulmonary vascular resistance (PVR), pulmonary vascular resistance index (PVRI), left ventricular cardiac work (LVSW), left ventricular cardiac work index (LVSWI), right ventricular cardiac work(RVSW)and rig-ht ventricular cardiac work index (RVSWI). Equations were also used to calculate the fol-lowing oxygen transport indicators: arterial o-xygen content (CaO2), MixedVenousBloodContent (CvO2), Pulmonary Capillary O2 Con-tent (Cc’O2), Alveolar Oxygen Tension (PA-O2), Arterial-Venous Content Difference (C (a-v) O2), Venous Admixture (Qs/Qt, Shunt %), Oxygen Delivery (DO2) and Oxygen Consum-ption (VO2). The t-test, paired t-test and repeated measures ANOVA were used for statistical analysis. Their nonparametric analogues; the Wilcoxon-Mann-Whitney, Wilcoxon signed rank, and Friedman tests were used for the validation of the results due to the small sample used in the study. Statistical analysis was performed with SPSS 14.0″.
A total of 16 patients with ESRD (8 males and 8 females; mean age 48 years with range of 25 – 75 years) were studied. Demographic data are shown in Table 1. Vessel’s diameters in the AVF system are de-picted in Table 2 and flow measurements in the parts of the AVF system in Table 3. As expected, blood flow in the basilic vein in-creased statistically significant after the AFV construction. Likewise, blood flow in the pro-ximal artery increased but not in a statistically significant manner. As far as the hemodynamic parameters are concerned, CO, CI, SV and SVI increased in a statistically significant manner after the AVF construction, namely at phases 3 and 4, and they returned back to their preoperative values at phase 5. On the contrary, SVR decreased statistically significant at phases 3 and 4 and they remained decreased throughout the study period. LVSW showed similar alterations to CO and increased at phases 3 and 4 and return-ed back to baseline at phase 5.
Table 1. Patient’s demographic data
|Mean ± SD||Median|
|BMI||25,3 ± 4,79||26,39|
|Patients on hemodialysis (yrs)||3,84±4,51||1,5|
|Blood glucose (mg/dL)||124,73±24,9||119|
Table 2. Vessels diameters in AVF system
|Mean ± SD||Median|
|Transposed Basilic Vein||0,61±0,18||0,61±0,18|
|Feeding Artery after AVF Construction||0,4±0,04||0,4±0,04|
Table 3. Blood flow in the AVF system
|Blood flow (ml/ min)|
|Mean ± SD||Median|
|Basilic vein blood flow before AVF|
|Arterial blood flow before AVF|
|Blood flow in the transposed basilic vein |
with the feeding artery “open”
|Blood flow in the transposed basilic vein|
with the feeding artery “closed”
|Blood flow in the feeding artery|
Table 4. CO, CI, SV, SVI, SVR and LVSW alterations during the study
The PLVW decreased minimally in both systo-le and diastole. The individual elements of the echocardiographic evaluation at stages 1 and 2 are summarized in Table 5.
Table 5. Echocardiographic Parameters
AVFs are the preferred vascular access in dia-lysis patients due to their higher blood flow ra-tes, superior patency and low incidence of in-fections compared with either arteriovenous grafts or catheters16,17,18. Basilic vein transposition, a kind of AVF abo-ve the elbow, allows the patient to have a nati-ve fistula, while preserving deep brachial ve-nous systems for future placement of forearm or upper arm PTFE arteriovenous grafts. It is also well documented, that transposition of a basilic vein and creation of brachio-basilic a-rteriovenous fistula, result in a satisfactory pa-tency rate and provide good blood flows19,20,21. This type of AVF is usually considered as the last option for autologous vascular access for hemodialysis (HD) on the upper extremity. Depending on the diameter of the AV commu-nication and the size of the artery feeding it, an AVF increases venous return to the heart and at the same time it decreasesperipheral vascu-lar resistance22,23. This, in accordance with Starling’s law, increases CO and work of the heart. The impact on CO correlates tightly wi-th the blood flow through the AVF. In patients with compromised cardiac function, the aforementioned hemodynamic changes could result in cardiomegaly and congestive heart failure24,25,26. However, elevated CO alo-ne does not cause symptoms of congestive he-art failure or high output cardiac failure. Six months after basilic vein transposition, all the fistulas were functioning well, there were no clinical signs of pulmonary oedema or other cardiac disease (e.g. heart failure) and echocar-diographic evaluation revealed:
- The cardiac EF showed a tendency to increase, which has been recorded by other authors31,32.
- IVSs and IVSd increased statistically significant.
- PLVWs, PLVWd, LVDs and LVDd did not show any significant change, which is in agreement with other litera-ture studies33,34.
The recorded increase of the thickness of the IVS does not constitute a specific feature of LV hypertrophy, since both the ventricular wall thickness and the left ventricular dimensi-ons did not change. Therefore, establishing an AVF by transposition of the basilica vein, does not hamper the cardiac function in terms of cardiomegaly or congestive heart failure.
- Brescia M, Cimino J, Appel K, et al. Chronic hemodialysis using venipun-cture and surgically created arterio-venous fistula. N Engl J Med 1966;275:1089-92.
- Matsuura J, Rosenthal D, Clark M, et al. Transposed basilic vein versus polytratefluorethylene for brachial axil-lary arteriovenous fistulas. Am J Surg 1998;176:219-21.
- Dagher F, Gelber R, Ramos E. et al. The use of basilic vein and brachial artery as an AV fistula for long-term haemodialysis. J Surg Res 1976; ;20:373-6.
- Keuter X, van der Sande F, Kessels A, et al. Excellent performance of one-stage brachial-basilic arteriovenous fistula. Nephrol Dial Transplant 2005; ;20:2168-71.
- Lazarides M, Georgiadis G, Papaside-ris C,et al.Transposed brachi-al-basilic arteriovenous fistulas versus prosthetic upper limb grafts: A meta-analysis. Eur J Vasc Endovasc Surg 2008 ; 36 : 597 -601.
- Torina P, Westheimer E, Schanzer H. Brachial vein transposition arterio-venous fistula is it acceptable option for chronic dialysis vascular access. J Vasc Access 2008;9:39 -44.
- Lee C, Ko PJ, Liu Y, et al. Brachiobasilic fistula as a secondary access procedure: an alternative to a dialysis prosthetic graft. Chang Gung Med J 2004;27:816 -23.
- Rao RMD, Azin D G, Hood D, et al. Basilic vein transposition fistula: A good option for maintaining hemo-dialysis access site options. J Vasc Surg 2004;39: 1043-7.
- Mac Rae J, Levin A, Belenkie N. The cardiovascular effects of arteriovenous fistulas in chronic kidney disease: a cause for concern. Seminars In Dialysis 2006 ; 19 : 349-52.
- Dikow R, Schwenger V, Zeler M, et al. Do AV fistulas contribute to cardiac mortality in hemodialysis patients. Semin Dial 2002;15:14-7.
- Anderson C, Codd J, Graff R, et al. Cardiac failure and upper extremity arteriovenous dialysis fistulas. Arch Intern Med 1976;136:292-7.
- Nakhoul F, Yiglia M, Gilman R, et al. The pathogensis of pulmonary hyper-tension in haemodialysis patients via arterio-venous access. Nephrol Dial Transplant 2005;20:1686-92.
- Young P, Rohr M, Marterre W. High-output cardiac failure secondary to a brachiocephalic arteriovenous hemo-dialysis fistula: two cases. Am Surg 1996;64:239-42.
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- BazanH, Schanzer H. Transposition of the brachial vein: a new source for au-tologous arteriovenous fistulas. J Vasc Surg 2004;40:184-86.
- Van Duijnhoven E, Cheriex E, Tordoir J, et al. Effect of closure of the arteriovenous fistula on left ventricular dimensions in renal transplant patients. Nephrol Dial Transplant 2001;16:368-72.
- De Lima J, Vieira M, Molnar L et al. Cardiac effects of persistent hemodialysis arteriovenous access in recipients of renal allograft. Cardiology 1999;92:236- 9.
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Author Disclosures: Authors Theodosiadis P, GrosomanidisV, Hatzibaloglou A, Fyntanidou B, Kotso E, OloktsidouE, Skourtis Ch, have no conflicts of interest or financial ties to disclose. Corresponding author: Dr. Panagiotis Theodosiadis Consultant Anesthetist 8 Larisas str., 54249, Harilaou, Thessaloniki, Greece Tel. (Mob) +306944763219 Email: firstname.lastname@example.org