Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis

Abstract

This study aimed to compare basilic vein tunnel transposition (BVTT) to basilic vein elevation transposition (BVET) technique for superficialization of a basilic arteriovenous fistula. This is a systematic review and meta-analysis comparing outcomes between BVTT and BVET for brachiobasilic arteriovenous fistula (AVF) creation. Primary endpoints were primary patency at several time intervals during follow-up and postoperative local complications, whereas secondary endpoints included primary assisted patency and secondary patency. A random effects model meta-analysis was conducted, and the I² statistic was used to assess heterogeneity. Nine eligible studies were identified, including 543 patients (247 in the BVTT group and 296 in the BVET group). BVTT group was associated with inferior primary patency rate at 6 months compared to BVET group (three studies; OR: 0.43; 95% CI: 0.22–0.83; I² = 0%; p = 0.012). However, primary patency rates were similar between the two study groups at 12 months (six studies; OR: 0.64; 95% CI: 0.33–1.22; I² = 40.7%; p = 0.176), and at 24 months (six studies; OR: 0.86; 95% CI: 0.32–2.29; I² = 74.9%; p = 0.764). No significant differences in terms of primary assisted patency, secondary patency, and postoperative complications were detected between the groups. More specifically, wound infection (BVTT: n = 9/150; BVET: n = 6/186; OR: 1.39; 95% CI: 0.48–4.06; I² = 0%; p = 0.542) and healing of the scar, particularly regarding arm edema (BVTT: n = 18/100; BVET: n = 27/165; OR: 1.11; 95% CI: 0.57–2.18; I² = 0%; p = 0.755) and hematoma formation (BVTT: n = 14/173; BVET: n = 42/209; OR: 0.40; 95% CI: 0.13–1.19; I² = 49%; p = 0.101), did not differ significantly between the two study groups. BVET achieved superior primary patency at 6 months compared to BVTT, but this benefit seems to be lost during longer follow-up intervals. Therefore, both surgical techniques provide similar long-term outcomes.

Keywords

Superficialization tunnel transposition elevation transposition basilic vein brachiobasilic fistula

Introduction

End-stage renal disease (ESRD) patients require permanent vascular access to receive hemodialysis sessions. The 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) Va-scular Access Guidelines suggest that despite the choice for the appropriate initial dialysis modality, it should be customized to patients along with a transition plan to the next access site.^1
–3 The first choice should be autogenous arteriovenous fistula (AVF) creation,^1
–3 with basilic vein being preferred as an alternative, when a radiocephalic or brachiocephalic AVF is not possible to be created or has failed.^4,5

The basilic vein lies deep in the upper arm and is accompanied by the medial antebrachial cutaneous nerve.⁶ Therefore, superficialization or transposition before use is necessary mainly due to its medial and deep location.^7,8 From a technical standpoint, this may lead to basilic vein stenosis, probably reflecting the fact that at the proximal swing segment, there might be kinking or compression, injury during surgical handling, and turbulent flow in the context of severe angulation.^9–12 Several techniques have been described in the literature for superficialization of the basilic vein.^8,13,14

Dagher et al.¹⁵ originally described transposition of the mobilized vein by rotating it anterolaterally via a subcutaneous tunnel in the arm. Currently, the two main techniques usually applied for basilic vein superficialization include basilic vein tunnel transposition (BVTT) and basilic vein elevation transposition (BVET). BVTT indicates that the basilic vein is mobilized and then transposed inside an anterolateral subcutaneous tunnel.¹⁶ On the other hand, BVET is considered more simple procedure including elevation and positioning of the vein in a subcutaneous pocket anterior to the incision.¹⁷

The aim of this meta-analysis was to systematically test whether any of these two surgical techniques provides a benefit in terms of clinical endpoints when creating brachiobasilic AVF.

Methods

Search strategy and eligibility criteria

This intervention systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines¹⁸ and was prospectively registered in the PROSPERO database (registration number: CRD42023481536). The Po-pulation/Participants, Intervention, Comparison, and Outco-me (PICO) criteria were applied in order to define the research question:

i. Population/Participants: patients undergoing brachiobasilic AVF creation

ii. Intervention: BVTT

iii. Comparison: BVET

iv. Outcomes: primary patency, postoperative complications, primary assisted patency, and secondary patency

Two independent researchers conducted a systematic search on Medline, Scopus, and Cochrane Central databases. The search algorithm included a combination of relevant keywords, including but not limited to “basilic vein,” “elevation,” “transposition,” “hemodialysis,” “arteriovenous access,” and “tunnel transposition.” Initially, 54 articles were identified, and the corresponding references were manually searched for additional relevant articles and 10 more articles were found.¹⁹ The search was conducted by two independent investigators who were blind to each other, and any disagreements or discrepancies were resolved by a third senior researcher. There were no time, gender, or geographic limitations.

Articles comparing outcomes between BVTT and BVET for brachiobasilic AVF creation were examined for inclusion. In cases of publications by the same institution, the most recent publication was included. Exclusion criteria were defined as follows: (i) studies consisting of <20 patients, (ii) studies that did not provide raw data, (iii) studies reporting on brachiobasilic AVF creation following any other surgical technique than BVTT and BVET, (iv) systematic reviews, meta-analyses, editorials, letters to the editor, comments, (v) single arm studies with no comparison group, and (vi) studies with a high risk of bias. No institutional review board approval was required. This meta-analysis utilized study level data.

Data extraction and outcomes

The process behind data extraction involved two independent investigators, who were blind to each other. When conflict emerged, the final decision was reached by consensus with a third senior investigator. The primary endpoints were the primary patency at 6, 12, and 24 months, and rate of postoperative local complications, including wound infection, arm edema, thrombosis, steal syndrome, and hematoma. Primary patency was consistently defined across the included studies as the interval from the time of transposition procedure until any intervention designed to maintain or reestablish AVF patency or the time of patency measurement.²⁰ Secondary endpoints were primary assisted patency at 12 and 24 months, and secondary patency at 12 and 24 months.

Primary assisted patency was defined as the interval from the time of transposition procedure until access thrombosis or the time of patency measurement, including intervening manipulations designed to maintain the functionality of a patent AVF. Secondary patency was defined as the interval from the time of transposition procedure until access abandonment or the time of patency measurement, including intervening manipulations designed to reestablish the functionality of a thrombosed AVF.²⁰

Risk of bias assessment

Risk of bias was evaluated by two independent investigators using the Methodological Index for Non-Randomized Studies (MINORS) tool.²¹ Scoring quality for comparative studies was classified as 0–12 low, 13–18 moderate, and 19–24 high quality. Moreover, we assessed the agreement between observers by calculating the intra-class correlation coefficient (ICC) applying a two-way mixed model.

Effect measures and synthesis methods

Random-effects model estimation was performed to account for heterogeneity among studies. Heterogeneity was assessed using the Higgins I² statistic. I² greater than 50% demonstrated significant heterogeneity.²² Odds ratios (OR) with the corresponding 95% confidence intervals (CIs) were used for the outcomes. All meta-analyses are visualized with the use of forest plots to graphically display the OR in each study as well as the pooled OR. Meta-regression analysis was used to examine potential confounding by procedure type (single vs staged procedure). A p-value of <0.05 indicated statistical significance for all tests. STATA (version 14.1; StataCorp, College Station, TX, USA) was used as statistical software.

Results

Study and patient characteristics

Nine studies^23–31 satisfied the predetermined search criteria and were included in the present meta-analysis as shown in the PRISMA flow chart (Figure 1). The studies comprised a total of 543 patients, of whom 247 patients and 296 patients were included in the BVTT and BVET groups, respectively. Among BVTT patients, 109 patients underwent one-stage procedure and 138 patients underwent two-stage procedure. With regards to the BVET group, the basilic vein was elevated in a one-stage procedure in 104 patients and in a two-stage procedure in 192 patients. All of the included studies were retrospective observational cohort analyses except for one which had a prospective study design. The mean ± standard deviation (SD) MINORS score for the nine double-arm studies was 18.1 ± 1.4 (range: 16–21, moderate quality). Inter-observer agreement in the assessment of study methodology was good (ICC: 0.84, 95% CI: 0.30–0.96, p < 0.05) (Supplemental Figure 1). Detailed study-related characteristics are presented in Table 1. Pooled estimates of baseline demographics in each group with their 95% CIs are outlined in Table 2. Time from transposition surgery to two-needle cannulation was compared between the two study groups only in two studies.^25,26 Mauro et al.²⁵ demonstrated that BVTT was associated with shorter time to two-needle cannulation in comparison to BVET (11 vs 23 days). However, Wang et al.²⁶ reported a mean time to two-needle cannulation of 34.7versus 36.8 days for the BVTT and BVET groups, respectively.

Table 1.

Study-related characteristics.

Study	Year	Country	Design	Total N	BVTT group, N	BVTT one-stage, N	BVTT two-stage, N	BVET group, N	BVET one-stage, N	BVET two-stage, N
Hossny²³	2003	Egypt	R	70	30	30	0	40	20	20
Lee et al.²⁴	2004	Taiwan	R	20	16	16	0	4	4	0
Mauro et al.²⁵	2017	Italy	R	80	40	0	40	40	0	40
Wang et al.²⁶	2017	USA	P	99	27	0	27	72	0	72
Singh et al.²⁷	2018	USA	R	58	39	0	39	19	0	19
Ergene et al.²⁸	2020	Turkey	R	71	29	29	0	42	42	0
Kim and Yun²⁹	2021	Korea	R	42	18	18	0	24	24	0
Yadav et al.³⁰	2021	India	R	50	16	16	0	34	14	20
Li et al.³¹	2022	Taiwan	R	53	32	0	32	21	0	21

N: number of patients; BVTT: basilic vein tunnel transposition; BVET: basilic vein elevation transposition; R: retrospective; P: prospective.

Table 2.

Baseline demographics.

Variables	BVTT group, n = 247	BVET group, n = 296
Male	46 (40–53)	47 (41–53)
Smoking	36 (23–50)	20 (9–34)
HTN	63 (41–83)	67 (45–87)
HLD	19 (11–30)	31 (20–43)
DM	46 (30–62)	56 (43–69)
CAD	17 (7–29)	18 (6–33)
Left arm AVF	79 (64–92)	82 (64–95)
One-stage procedure	56 (11–96)	38 (5–79)
Two-stage procedure	44 (4–89)	62 (21–95)

BVTT: basilic vein tunnel transposition; BVET: basilic vein elevation transposition; HTN: hypertension; HLD: hyperlipidemia; DM: diabetes mellitus; CAD: coronary artery disease; AVF: arteriovenous fistula; CI: confidence interval.

Data are presented as percentage % along with the 95% CIs.

Perioperative adverse events

The odds of perioperative procedure-related complications including surgical wound infection (BVTT: n = 9/150; BV-ET: n = 6/186; OR: 1.39; 95% CI: 0.48–4.06; I² = 0%; p = 0.542), arm edema (BVTT: n = 18/100; BVET: n = 27/165; OR: 1.11; 95% CI: 0.57–2.18; I² = 0%; p = 0.755), acute fistula thrombosis (BVTT: n = 14/91; BVET: n = 34/112; OR: 0.61; 95% CI: 0.29–1.26; I² = 0%; p = 0.183), steal syndrome development (BVTT: n = 2/48; BVET: n = 2/60; OR: 1.20; 95% CI: 0.17–8.78, I² = 0%, p = 0.854), hematoma formation (BVTT: n = 14/173; BVET: n = 42/209; OR: 0.40; 95% CI: 0.13–1.19; I² = 49%; p = 0.101) were not significantly different between the two groups.

Patency rates over time

Primary patency rate was calculated at 6-, 12-, and 24-month time intervals. Tunnel transposition technique was associated with inferior primary patency rate at 6 months compared to elevation transposition (three studies; BVTT: n = 48/82 vs BVET: n = 92/125; OR: 0.43; 95% CI: 0.22–0.83; I² = 0%; p = 0.012), as shown in Figure 2(a). Nevertheless, the pooled primary patency rates were similar between the two study groups at 12 months (six studies; BVTT: n = 110/169 vs BVET: n = 167/228; OR: 0.64; 95% CI: 0.33–1.22; I² = 40.7%; p = 0.176) (Figure 2(b)) and at 24 months of follow up (six studies; BVTT: n = 119/201 vs BVET: n = 147/230; OR: 0.86; 95% CI: 0.32–2.29; I² = 74.9%; p = 0.764) (Figure 2(c)). No differences were observed between the two groups in terms of primary assisted patency at 12 months (two studies; BVTT: n = 53/58 vs BVET: n = 55/64; OR: 1.71; 95% CI: 0.54–5.46; I² = 0%; p = 0.363) (Figure 3(a)) and at 24 months (three studies; BVTT: n = 85/90 vs BVET: n = 72/85; OR: 2.56; 95% CI: 0.88–7.41; I² = 0%; p = 0.08) (Figure 3(b)), and secondary patency rates at 12- (three studies; BVTT: n = 76/85 vs BVET: n = 98/113; OR: 1.14; 95% CI: 0.47–2.80; I² = 0%; p = 0.768) (Figure 4(a)) and 24-month follow-up (three studies; BVTT: n = 73/123 vs BVET: n = 85/113; OR: 0.66; 95% CI: 0.12–3.67; I² = 84.8%; p = 0.632) (Figure 4(b)).

Meta-regression analysis

Meta-regression analysis was performed for all the outcomes of primary and secondary patency rates to examine any potential correlation with the procedure type (i.e. single vs staged procedure). No associations were found. Results of the meta-regression analysis are summarized in Supplemental Table 1.

Discussion

This meta-analysis compared two surgical basilic vein transposition techniques (BVTT vs BVET) in terms of clinical outcomes, including primary patency, primary assisted patency, secondary patency rates, and postoperative complications. Our results showed that elevation transposition technique achieved superior primary patency at 6 months when compared to tunnel transposition. However, this clinical benefit seems to be lost during longer follow-up intervals (12 and 24 months). Primary assisted patency as well as secondary patency rates were also similar between the two study groups. Our analysis did not find any differences between the approaches in terms of complications, including wound infection, arm edema, thrombosis, steal syndrome, and hematoma.

To superficialize the basilic vein via tunneling, the vein is disconnected, transected distally, and passed into an anterolateral subcutaneous tunnel via tunneling tools, resulting in recreation of AVF anastomosis.^32
–35 On the other hand, elevation transposition is considered a simpler procedure that combines elevation and transposition of the basilic vein inside a custom-made subcutaneous pocket, within the subcutaneous fat, anteriorly to the long incision wound, and, thus, avoiding fistula cannulation through the incision scar.^31,36,37 In this way, there is no need for reanastomosis between the basilic vein and the brachial artery.^25,38

BVET may provide a benefit since the basilic vein is not transected and is fully visualized in the subcutaneous pocket, leading to avoidance of vein twisting, kinking, stenosis, or tunnel hemorrhage.^13,26,39 Despite this procedure simplicity, a major concern always remains regarding skin necrosis at the level of the flap. Nevertheless, our study did not find any significant difference between the two techniques. Another important difference between the two surgical techniques is that elevation transposition typically results in a more medial location of the vein and, therefore, in potential difficulty for cannulation. These problems are potentially less likely to occur with BVTT, however, this was not analyzed in our study. Besides, cannulation of an elevated brachiobasilic AVF requires advanced skills from an experienced dialysis nursing staff.²⁴ Hossny indicated a statistically significant superiority regarding dialysis nu-rses’ satisfaction with the tunnel transposed basilic vein as opposed to the elevated one. Nurses highlighted patients’ complaints, difficult cannulation, and needle displacement concerning the elevated AVF.²³ What is more, Humphries et al. in their retrospective cohort study demonstrated th-at cannulation may be difficult after basilic vein elevation.^40,41 Similar conclusions have been reached by other investigators, suggesting that although it was easy to detect the vein, multiple failed attempts for cannulation might be associated with hematoma development.²³ In spite of these findings, our meta-analysis did not reveal any statistical difference between BVTT and BVET groups regarding hematoma formation.

With regards to primary patency, Li et al. reported a significantly lower primary patency rate for tunneling compared to elevation transposition. BVTT was also associated with a greater likelihood for reintervention and a longer length of hospital stay than BVET. Primary assisted patency, though, during the follow-up period was 100% in all patients in both groups.³¹ In their prospective study Wang et al.²⁶ also concluded that BVET group achieved better primary patency rates and reduced likelihood for endovascular interventions when compared with tunneling procedure. Similarly, our analysis confirmed the superiority of BVET over BVTT, in terms of primary patency at 6 months.

Whether BVET in comparison to BVTT is a more beneficial surgical technique, is a common question in everyday clinical practice. Surprisingly, our meta-analysis proved neither superiority of elevation procedure, regarding primary patency, for follow-up periods exceeding 6 months, nor statistical difference between the two methods as far as postoperative complications are concerned. The findings of this study, however, shed light on the possible advantages of each technique along with a more global outlook on how to treat patients requiring brachiobasilic AVF creation. A randomized trial specifically designed to compare the two approaches may contribute to the best management of patients undergoing basilic vein superficialization.

The results of the present study should be viewed in the light of its limitations. First, this meta-analysis is limited by the small number of enrolled patients. Second, the retrospective design and non-blinded nature of the included studies may leave our analysis prone to selection bias. The retrospective nature of the studies, especially, did not provide granular data neither on patients’ pain status during puncturing, nor on dialysis nurses’ discomfort. Third, this study is limited by the non-randomized comparisons of the included articles.

Conclusion

This meta-analysis demonstrates that both BVTT and BVET achieved similar long-term clinical outcomes in a population of patients undergoing basilic vein superficialization, including primary patency, postoperative local complications, primary assisted patency, and secondary patency. Further studies with appropriate long-term follow-up are needed to compare these surgical techniques, particularly regarding cannulation.

Supplemental Material

sj-pdf-1-jva-10.1177_11297298241226993 – Supplemental material for Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis

Supplemental material, sj-pdf-1-jva-10.1177_11297298241226993 for Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis by Georgios Koudounas, Stefanos Giannopoulos, Alex Houser, Christos Karkos, Panagiotis Volteas and Dimitrios Virvilis in The Journal of Vascular Access

Supplemental Material

sj-pdf-2-jva-10.1177_11297298241226993 – Supplemental material for Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis

Supplemental material, sj-pdf-2-jva-10.1177_11297298241226993 for Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis by Georgios Koudounas, Stefanos Giannopoulos, Alex Houser, Christos Karkos, Panagiotis Volteas and Dimitrios Virvilis in The Journal of Vascular Access

Supplemental Material

sj-pdf-3-jva-10.1177_11297298241226993 – Supplemental material for Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis

Supplemental material, sj-pdf-3-jva-10.1177_11297298241226993 for Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis by Georgios Koudounas, Stefanos Giannopoulos, Alex Houser, Christos Karkos, Panagiotis Volteas and Dimitrios Virvilis in The Journal of Vascular Access

Footnotes

Disclosures

All authors have no relevant relationships to disclose.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Georgios Koudounas

Supplemental material

Supplemental material for this article is available online.

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