In the absence of suitable cephalic vein, the brachiobasilic vein complex represents the best option for arteriovenous access. However, the basilic vein is too deep to cannulate and requires transposition to be accessible. Transposition can be performed during fistula creation (single-stage BBTx) or at a second operation after initial fistula creation (two-stage brachiobasilic transposition (BBTx)). The best approach is unknown. A PubMed search using “Basilic vein transposition” as the primary search term was performed to identify articles addressing this controversy. Meta-analysis was then performed using those papers that provided the inspected data points with student’s t-test used to compare maturation and patency rates between the groups. A total of 37 manuscripts were judged of adequate quality for analysis. Based on the available data, overall maturation rates, 1-year primary patency rates, and overall complication rates seem to be equivalent between single- and two-stage BBTx, while 1-year secondary patency is greater in the two-stage group (79% vs 85%). A large prospective randomized clinical trial with clear definitions of maturity, patency, and complications is needed to definitively answer the question of whether one strategy is better than the other.
BackgroundChronic in-center hemodialysis (HD) patients may experience more morbidity and mortality after the weekend. Since our Veterans Administration Hospital HD unit is closed on the weekend, non-traditional HD schedules were created. Some schedules contained a 4-day weekend compared to the usual 3-day weekend. We hypothesized that there are more frequent cardiovascular events (CVEs) and higher mortality after longer interdialytic intervals.MethodsPatients (n=85) were placed on HD schedules as they became available. The usual interdialytic interval group consisted of patients dialyzing on Mon-Wed-Fri or Mon-Tue-Fri (longest interdialytic gap 3 days, n=29), and the long interdialytic interval group consisted of patients dialyzing on Mon-Wed-Thu, Mon-Tue-Thu, Tue-Wed-Fri, or Tue-Thu-Fri (longest interdialytic gap 4 days, n=56).ResultsAll-cause mortality was not different between groups, and CVEs occurred more frequently in the usual interdialytic interval group (maybe due to higher mean potassium and phosphorus concentrations). However, within each group, a similar pattern of CVE occurrence as a function of time after dialysis was observed. Compared to CVEs occurring during the 2 days after HD (the lowest frequency), CVEs occurred 2–3 times more frequently during and immediately after HD and 5–7 times more frequently during the third and fourth days after HD. The greatest risk of CVE occurred during the fourth day after HD, which exists only in the long interdialytic interval group.ConclusionIn chronic HD patients, CVEs are most likely to occur after the longest interdialytic intervals.
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