Transposition,Elevation,Lipectomy and V-Wing for Easy Needling

Abstract

Purpose

The purpose of this study is to report surgical techniques to facilitate cannulation of deep matured veins.

Methods and Results

1) Basilic vein tunnel superficialization with rerouting in an anterior tunnel is mandatory for brachial-basilic arteriovenous fistula (AVF), mostly performed in a second surgical stage. The elevation technique, which could necessitate cannulation of the vein through the overlying scar, is not advisable. 2) Femoral vein superficialization is a one-stage surgical operation. Complications of this high-flow AVF are distal ischemia (diabetes and occlusive arterial disease are contraindications), iliac vein stenosis due to intimal hypertrophy and cardiac issues. Nevertheless, we have achieved high long-term patency rates (N = 70). Primary patency rates at 1 and 9 years were 91% ± 4% and 45% ± 11%, respectively. Secondary patency rates at 1 and 9 years were 84% ± 5% and 56% ± 9%, respectively. 3) Lipectomy for superficialization of the forearm radial-cephalic AVF is described for obese patients. Subcutaneous tissues are resected using two transverse incisions. Mobilization of the vein is avoided. At 3 years (N = 49), we recorded 63% ± 8% and 88% ± 7% primary and secondary patency rates, respectively. Anterior transposition of the forearm basilic vein is not necessary when using microsurgery for creation of distal ulno-basilic AVF. 4) VWING is a novel surgically implanted device to help buttonhole technique cannulation. It is too early to draw any conclusion from the preliminary published reports.

Conclusions

Tunnel-transposition and lipectomy are efficient techniques to allow easy needling of deeply situated upper-arm basilic vein, and cephalic vein in obese patients, respectively.

Keywords

Arteriovenous fistula Cannulation Haemodialysis Lipectomy Superficialization V-Wing

Introduction

After the creation of an arteriovenous fistula (AVF), a well-dilated arterialized vein may be too deep for routine punctures, either due to the deep anatomical situation of the vein (basilic vein in the upper arm/femoral vein), or due to obesity (cephalic vein). Superficialization to enhance needling may be performed by tunnel-transposition, simple elevation of the vein or lipectomy. Implantation of a subcutaneous needle guide (VWING) has also been reported recently.

Methods

Superficialization of the upper arm basilic vein

A brachial basilic AVF must be combined with a tunnel-superficialization of the vein. We frequently performed the operation in two separate surgical stages (1).

The first stage (Fig. 1a) includes a skin incision in the medial part of the elbow crease allowing for a side-to-end anastomosis between the brachial artery and the median antecubital vein. When this branch of the basilic vein is absent, the upper part of the forearm basilic vein is used. In some instances, the anastomosis is created on the radial artery below the elbow in order to arterialize a longer segment of the vein and eventually to avoid postoperative distal ischemia associated with high flow. On the contrary, in cases of early bifurcation of the brachial artery (15% of the population), the surgeon will have to choose between the large ulnar-interosseous artery, which is more deeply situated and carries the risk of high flow, and the radial artery, which is usually of very small calibre. Finally, we routinely use prophylactic haemostasis (2) (Esmarch elastic bandage and pneumatic tourniquet) for this first stage, and a surgical microscope (mandatory for children (3)) for creation of the anastomosis.

Fig. 1

Two-stage superficial tunnel-transposition of the basilic vein in the upper arm. Operative diagrams: (a) first stage, (b) second stage. Reproduced with permission from (1): Marzelle J, Bourquelot P. Abords vasculaires d'hémodialyse: principes, abords artérioveineux natifs. EMC - Techniques chirurgicales - Chirurgie vasculaire 2014;9(3):1-2'7. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Second-stage superficialization (Fig. 1b) is mandatory, as the basilic vein that is superficial at the elbow, will rapidly find its way under the aponeurosis, before joining the brachial vein. Usually, the superficial part of the vein is not long enough for routine bi-puncture. Moreover, attempts to cannulate the arterialized vein before its superficialisation, even in the thinnest patients, may result in significant haematoma and fibrosis, making further superficialization difficult.

One month after AVF creation, clinical and duplex examinations are necessary to check the patency of the anastomosis, to calculate the brachial artery flow and to identify any possible stenosis of the basilic vein. A juxta-anastomosis stenosis should be corrected during the second operation by a more proximal re-anastomosis between the vein and the artery. A pre-existing downstream low-grade stenosis of the vein should be treated by endovascular angioplasty during the second-stage operation or 4 weeks later by percutaneous angioplasty. A long or high-grade stenosis and any other major complication such as distal ischemia are contraindications to performing the superficialization. On the contrary, the identification by duplex scanning of a “short” basilic vein due to its low insertion into the brachial vein is not a contraindication, as superficialization of the brachial vein will also be performed.

The second-stage superficialization is achieved through a longitudinal skin incision along the medial upper arm over the arterialized vein. Preventive haemostasis is possible using a HemaClear^® (4) sterile single-use surgical tourniquet, which is narrow. The entire vein is dissected free with suture-ligations of side branches and careful attention to adjacent neurovascular structures (medial brachial cutaneous nerve). The vein is marked on its anterior aspect and divided at its lower extremity, flushed with heparinized saline solution, avoiding any pressure-dilation of the vein, and transposed through a separate anterior semi-straight superficial tunnel, taking great care to avoid any angulation or twisting at either extremity of the tunnel. Occasionally, when the diameter of the vein is large (∼6 mm) without major juxta-anastomosis intimal hyperplasia and with normal pre-operative flow rate (>600 mL/min), a vein-to-vein re-anastomosis can be performed. More frequently, a new artery-to-vein anastomosis is created above the first. Four weeks should elapse postoperatively before the first puncture (Fig. 2). The most frequent secondary complication is stenosis at the upper limit of the superficialization.

Fig. 2

Superficial tunnel-transposition of the basilic vein. Postoperative view. Reproduced with permission from (1): Marzelle J, Bourquelot P. Abords vasculaires d'hémodialyse: principes, abords artérioveineux natifs. EMC - Techniques chirurgicales - Chirurgie vasculaire 2014;9(3):1-2'7. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Although the preference for the two-stage operation is not evidence-based, we rarely use one-stage superficialization, except in cases of upper arm basilic veins more than 4/5 mm diameter, the consequence of a previous long-lasting AVF in the forearm. One-stage dissection and tunnelization might be dangerous for the nonpreviously arterialized and dilated vein, especially in obese patients and children.

Simple elevation of the basilic vein (5), as opposed to tunnel rerouting, is open to criticism. This procedure includes re-approximating the deep fascia and subcutaneous tissue of the arm beneath the vein and suturing the skin over the vein. Location of the fistula on the inner aspect of the upper arm makes positioning for cannulation difficult. Moreover, cannulation through the overlying scar may be difficult, especially in cases of keloid hypertrophy, and bleeding necrosis may occur at puncture sites.

In the upper limb, tunnel superficialization may also apply to radio-cephalic fistulae (RCF) and to brachiocephalic fistulae in obese patients. Once again, the two-stage procedure with tunnel-transposition is to be preferred in order to avoid dissection of a nonpreviously dilated vein.

Superficialization of the femoral vein

When all access options in the upper limbs are exhausted, a superficial tunnel transposition of the femoral vein in the thigh (Fig. 3) (6 –8) can be a valuable alternative to arteriovenous (AV) grafts in the torso or thigh (9, 10). Superficialization of the femoral vein has higher patency and lower infection rates. It is a one-stage procedure, due to the large calibre of the vein.

Fig. 3

Superficial tunnel transposition of the femoral vein in the thigh. Reproduced with permission from (6): Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our initial experience. J Vasc Surg. 2001;33(5):968-975. Copyright © 2001.

A longitudinal skin incision is made from the inguinal crease to the knee. The femoral vein is dissected from the adductor hiatus up to its junction with the deep femoral vein and transposed in a straight subcutaneous tunnel over the anterior thigh, lateral to the skin incision. A direct side-to-end anastomosis to the distal femoral artery is made. Prophylactic anticoagulation is used postoperatively. Distal ischemia related to such high-flow AVF is a major risk and diabetic/atheroma patients with significant peripheral arterial occlusive disease must be excluded. The risk of congestive heart failure is another drawback of high flow, as well as iliac vein stenosis. Nevertheless, in our experience (8) (N = 70 patients), primary patency rates at 1 and 9 years were 91% ± 4% and 45% ± 11%, respectively. Secondary patency rates at 2 and 9 years were 84% ± 5% and 56% ± 9%, respectively.

Lipectomy for superficialization of the forearm cephalic vein

Lipectomy (Fig. 4a, b) has been described (11) as an alternative technique for superficialization of the forearm cephalic vein, with removal of the subcutaneous fat between the vein and the skin after previous radio-cephalic AV anastomosis at the wrist. Compared with tunnel-superficialization, this technique limits dissection of the vein at its anterior surface and avoids the risks of kinking and twisting the vein at the upper limit of the superficialization. It may subsequently reduce the high rates of secondary vein stenosis of the upper part of the vein, which are reported after tunnel-transposition. Lipectomy, compared with tunnelled transposition, is a less time-consuming operation. Moreover, the transverse incisions used for lipectomy have much better aesthetic outcomes than the forearm longitudinal scar.

Fig. 4

Lipectomy-superficialization of the forearm cephalic vein. Operating diagram shows the arm (a) before, (b) during and (c) after lipectomy. 1, skin; 2, fat; 3, fascia superficialis; 4, vein. Reproduced with permission from (11): Bourquelot P, Tawakol JB, Gaudric J, et al. Lipectomy as a new approach to secondary procedure superficialization of direct autogenous forearm radial-cephalic arteriovenous accesses for hemodialysis. J Vasc Surg. 2009;50(2):369-374. Copyright © 2009.

The surgery is performed under echo-guided regional anaesthesia and preventive haemostasis. Two transverse skin incisions are made over the cephalic vein, 8 cm apart. The dissection of subcutaneous tissue and superficial fascia is facilitated by elevation of the skin with hooks. Posteriorly, they are dissected starting from the anterior surface of the vein towards both extremities of the skin incision. Anteriorly, the subcutaneous fatty tissue is separated from the skin, with the exception of the most superficial part (1 mm deep). This approximately 4 cm long dissection is performed distally and proximally from each incision site. The tissues are then cut on both sides 2 cm away from the vein and excised. The tourniquet is released and the haemostasis process is completed. A juxta-anastomosis vein stenosis may be treated simultaneously by creation of a more proximal anastomosis through an elective incision at the wrist. Partial lipectomy is performed in patients who have a fistula that is already being used for single-needle dialysis within a too short juxta-anastomosis area.

In our hands (11), immediate technical success was achieved in 47 of 49 patients (96%). The first failure was due to a large subcutaneous haematoma that resulted in irreversible thrombosis of the vein. The second failure was due to overlooked tortuousities of the vein, which were treated successfully by third-stage conventional repeat tunnelling. Mean vein depth decreased from 8 ± 2 mm to 3 ± 1 mm according to duplex ultrasound imaging. The mean vein diameter increased from 6 ± 1 mm to 8 ± 2 mm. The mean flow rate changed from 755 ± 150 mL/min to 794 ± 215 mL/min, which was not significant. Primary patency rates (Fig. 5), including initial failures, were 71% ± 7%, 67% ± 7% and 63% ± 8% at 1, 2 and 3 years, respectively. Secondary patency rates were 98% ± 2%, 94% ± 4% and 88% ± 7% at 1, 2 and 3 years, respectively.

Fig. 5

Lipectomy (N = 47 radial-cephalic AVFs). Kaplan-Meier curves of primary (solid line) and secondary patency (dashed line) rates (standard errors <10%). Reproduced with permission from (11): Bourquelot P, Tawakol JB, Gaudric J, et al. Lipectomy as a new approach to secondary procedure superficialization of direct autogenous forearm radial-cephalic arteriovenous accesses for hemodialysis. J Vasc Surg. 2009;50(2):369-374. Copyright © 2009.

Lipectomy addresses a problem mainly encountered in obese patients. However, some nonobese patients can also be candidates for lipectomy when the cephalic vein runs relatively deep while approaching the elbow or when the expected dilation of the vein seems to be hampered by a thick fascia superficialis entrapping the vein. On the contrary, some patients with thick subcutaneous tissues can develop a well-matured, easy to puncture fistula if the vein enlargement is sufficient to flatten the subcutaneous tissues and decrease the actual depth of the vein.

In our experience, lipectomy may also be performed for superficialization of the upper arm cephalic vein in obese patients. In these cases, preventive haemostasis with a wide classical tourniquet may be impossible, but a narrow HemaClear^® tourniquet is appropriate. The volume of subcutaneous tissue to be resected may be significant in the lower third and mid third of the upper arm. Lipectomy does not include the upper third where the vein tends to be extremely deep. For all of these reasons, the indications for lipectomy are not straightforwardly predictable at the time of fistula creation, and lipectomy should always be a second-stage intervention, performed only if clinical and imaging follow-up shows evidence of the need for superficialization. In addition, we know from our experience with brachial-basilic fistulas that a secondary stage of superficialization is much easier to perform when the vein diameter has increased and the vein wall has been made thicker by some weeks of arterialization.

In patients who have already undergone dialysis through a RCF but with a very short juxta-anastomosis cannulation area that allows for single-needle dialysis only, puncture will remain possible at the former site immediately after partial lipectomy. This partial lipectomy operation is much easier to perform if the deep vein segment has not previously been damaged by attempts at cannulation. In such partial superficialization, the lipectomy technique offers another major advantage over the previously used partially tunnelled transposition technique, which includes the construction of a vein-to-vein anastomosis prone to subsequent stenosis. In conclusion, positive outcome after lipectomy confirms that deep location of the vein should not be a contraindication for the creation of distal RCFs. It might even be hypothesized that incident obese dialysis patients will eventually have the highest proportion of RCFs because their forearm veins are more likely to have been preserved from previous attempts at cannulation for blood sampling or infusion.

Liposuction (12) may offer another option for lipectomy, but it has not proved popular, probably because of concerns over injury to the vein during the procedure, despite echo-guidance.

Transposition of the forearm basilic vein

The posterior location of the vein is the main reason why the basilic veins are often the only preserved veins in both forearms. A series of 89 transpositions of forearm veins was reported (13) in 1997 that did not specifically address the problem of deep location. Most cases involved forearm basilic veins that were transposed from their initial dorsal to a volar location for easier cannulation and excellent 91% success rate, with an 84% primary patency rate reported at 1 year and 69% at 2 years. Unfortunately, we experienced much less favourable results with this technique of transposition in the forearm, especially in obese patients. As for basilic veins in the upper arm, the development of a stenosis in the upper limit of the transposition was almost inevitable.

Our current experience with AVF using the wrist basilic vein (14) is that, with the exception of obese patients, anterior transposition of the vein to the radial artery is not necessary if a surgical microscope is used for the anastomosis between the ulnar artery and the basilic vein, which are small calibre vessels. Cannulations require placing the limb in the flexed-elbow position, which can be uncomfortable for both patients and nurses. However, the elbow can return to its natural resting position for the duration of dialysis treatment once access has been gained and needles secured to the skin. The first cannulations after fistula creation may be slightly challenging because of the mobility of the vein. With this technique we observed, initial failures included, primary patency rates in adults at 1 and 2 years were 42% ± 6% and 30% ± 7%, respectively; secondary patency rates at 1 year and 2 years were 60% ± 6% and 53% ± 7%, respectively.

Venous Window Needle guide (VWING)

VWING (Vital Access Corp, Salt Lake City, Utah, USA) is a novel device designed to help cannulation of AV fistulas that are normally dilated but too deeply situated in obese patients. The 17.7 mm in length device is made of a single piece of titanium (Fig. 6) and is available in 7 and 9 mm widths for variations in vessel diameter and in 4, 6, 8 and 10 mm heights to accommodate variations in AVF depth. The device is sutured to the anterior AVF wall. Cannulation is performed using the buttonhole technique 3 weeks after implantation.

Fig. 6

Venous Window Needle guide (VWING). Reproduced with permission from (16): Jennings WC, Galt SW, Shenoy S, et al. The Venous Window Needle Guide, a hemodialysis cannulation device for salvage of uncannulatable arteriovenous fistulas. J Vasc Surg. 2014;60(4):1024-1032. Copyright © 2014.

The first report was published by Hill et al According to the conflict of interest statement of their publication (15), the nine authors from Salt Lake City, USA, who are presumably veterans of Star Wars, have a proprietary interest in the VWING device. The two other authors performed the first in-man trial in Auckland and Hamilton, New Zealand. This titanium device was implanted surgically on the surface of the arterialized vein in nine patients with difficult-to-access fistulae (mean depth = 8 mm). It was necessary to remove fatty tissue over the devices to position the implants at an average of approximately 3 mm below the skin surface. Additional vein mobilization was needed in two patients. Forty-two percent of the devices were observed postoperatively to be rotated in relation to the skin (20°-40°). Only one device was not easily palpable at 3 months. The buttonhole cannulation technique (sharp and blunt needles, short length tunnel) guided by transcutaneous palpation of the device was used over a 6-month period, successfully in 94% of the needling attempts. No infection was observed.

The second report was published by Jennings et al (16). They included 51 patients with implantation of 82 devices at 11 trial sites in the U.S. Device palpability at the time of the implant procedure was rated as “easy” for 76 (93%) devices. Successful fistula access was achieved using the device in 96% of the patients. Sepsis resulting from infection of a VWING site occurred in one patient. This device was removed and local superficialization was performed, leaving the fistula intact. Superficial access site cellulitis, reported in three patients, was cured by antibiotics.

Summary

The creation of an AVF may necessitate a superficialization of the vein to allow for routine cannulation with two needles. In association to the brachio-basilic fistula, the superficialization of the basilic vein is always necessary. From our personal experience, we recommend the two-stage procedure and the tunnel-rerouting rather than a simple elevation of the vein. On the contrary, the superficialization of the femoral vein is a one-stage operation, due to the large size of the vessels. The superficialization of the forearm cephalic vein is performed in a second surgical procedure, using the lipectomy technique, which can also be applied to the upper-arm cephalic vein. In our opinion, it might be too early to decide whether VWING is a new expensive gadget or a new blessing from God (17) for haemodialysis patients.

Footnotes

Acknowledgements

The authors thank Doreen Raine, translator, for her collaboration (info@doreenraine.fsnet.co.uk)

Financial support: None.

Conflict of interest: The authors have no conflict of interest.

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