Randomized Controlled Trial Comparing Primary and Staged Basilic Vein Transposition

Abstract

ObjectiveIt is unclear if brachio-basilic vein fistula should be performed as a primary or staged procedure, particularly for smaller basilic veins. Our aim was to report on a randomized controlled trial comparing these two techniques.MethodsSixteen patients with a basilic vein ≥2.5 mm were randomized into primary transposed brachio-basilic vein (TBBV) fistula (n = 9) and staged TBBV fistula (n = 7). Patients with basilic veins enlarged by previous arteriovenous fistulas were excluded. Baseline characteristics of the two study groups, including vein size, were comparable (median basilic vein diameter 3.5 mm, range 2.8–4.1 mm). The staged group had a brachio-basilic vein fistula performed first followed by the transposition procedure performed at least 6 weeks later to allow the basilic vein to enlarge. TBBV fistula maturation at 10 weeks, primary, assisted-primary, and secondary patency were the primary outcome measures. Early failures were included in the calculation of patency rates.ResultsTransposed brachio-basilic vein fistula maturation rate after primary procedures (3/9, 33%) was lower compared to maturation rate after staged procedures (7/7, 100%, P = 0.011, Fisher’s exact test), which led to premature termination of the trial. Time to hemodialysis [median (interquartile range)] of primary and staged procedures was 54 (51.5–113.5) days and 97 (93–126) days, respectively (P = 0.16). One-year primary and assisted-primary patency rates of primary and staged procedures were equivalent (44 vs 57%, P = 0.76 and 44 vs 71%, P = 0.29, respectively); however, there was a trend toward a better 1-year secondary patency after staged procedures (86 vs 44% for primary procedures, P = 0.09).ConclusionsAmong candidates for TBBV fistula with a small basilic vein, staged transposition achieves higher maturation rates compared to primary procedures, a difference reflected in long-term secondary patency.Trial registration, identifier NCT01274117.

A Systematic Review and Meta-Analysis of Randomized Trials Comparing Two-Stage with One-Stage Brachio-Basilic Vein Fistulas

“…At present there is some evidence to support staged BBVF; a single-centre randomized-controlled trial (RCT) reported improved maturation rates with procedure staging compared to primary procedures [ 7 ], although it had several faults, including the absence of preoperative vessel mapping since the study was performed before this technique was first reported. A much smaller study reported similar results [ 8 ]. The equivalent results of case-control studies [ 9 , 10 ], suggest that staging might not be necessary, however these findings could be the result of bias as primary procedures are performed in patients with basilic veins enlarged by the presence of previous more proximal AVFs and staged procedures are usually performed in patients with basilic veins of smaller diameter (e.g., <4–5 mm).…”

“…Two decades ago staging of BBVF was introduced [ 5 ], with a brachio-basilic AVF being performed during the first stage followed by superficialization during the second stage after a period of several weeks, again in the form of transposition [ 6 ], or elevation [ 7 ]. Two-stage procedures have several advantages [ 8 ]. First, interval arterialization makes staged transposition easier, because the basilic vein is enlarged (typically between 6–10 mm) [ 8 ].…”

“…Two-stage procedures have several advantages [ 8 ]. First, interval arterialization makes staged transposition easier, because the basilic vein is enlarged (typically between 6–10 mm) [ 8 ]. Second, interval arterialization makes staged transposition safer by possibly increasing usage rate, because a small (e.g., <4–5 mm) and thin-walled basilic vein superficialized in a one-stage procedure may fail.…”

Basilic vein transposition for unsuitable upper arm hemodialysis needle access segment may attenuate concurrent hand ischemia

“…21,22 Several studies on two-step BVT procedures show that cannulation was not performed earlier than four to seven weeks after the transposition step. 23,24 The BVTs in the current study can be regarded as delayed two-step procedures and the results indicate that a transposed basilic vein is safely cannulated from day one on precluding the use of temporary lines.…”

Basilic elevation transposition may improve the clinical outcomes for superficialization of basilic arteriovenous fistula veins

“…3,[8][9][10]14 A recent randomized controlled study was prematurely terminated because of clear superiority of the two-stage approach. 29 Percutaneous or surgical interventions are needed for maintaining the patency and managing complications of basilic fistulas, but their use varies widely in the published reports. 3,7,14 These interventions reduce the primary patency but are needed to promote the long-term survival of the fistulas.…”