SURGEON AT WORK
Transposition of the Basilic Vein for Arteriovenous
Fistula: An Endoscopic Approach
Bernardo D Martinez,
MD
,
FACS
, Christopher J LeSar,
MD
, Thomas J Fogarty,
MD
,
FACS
,
Christopher K Zarins,
MD
,
FACS
, George Hermann,
BS
The creation of a functional hemodialysis fistula in pa-
tients who develop end-stage renal disease (ESRD) has
critical importance. The majority of surgeons would
agree that a primary radiocephalic arteriovenous fistula
is the procedure of choice in new dialysis patients. But in
patients who lack adequate forearm vasculature second-
ary procedures are indicated. Currently, in the United
States, more than 50% of hemodialysis that is performed
occurs through polytetrafluoroethylene (PTFE) grafts.
1
Numerous reports have described the various complica-
tions of PTFE grafts, including high primary failure
rates and multiple thrombotic events during the life of
the graft. Because of the frequency of graft thrombosis in
these patients yearly surgical intervention may be re-
quired.
2,3
Recent reports on longterm upper arm dialysis
access procedures, specifically, the transposed brachio-
basilic arteriovenous fistula, have shown significant
longterm primary patency rates reaching 70% at 8
years.
4
To date there have been no descriptions of a min-
imally invasive approach to address the long morbid
upper arm dissection needed to create this fistula (Fig.
1). We describe an effective, technically simple, mini-
mally invasive surgical approach to create an upper arm
transposed brachiobasilic fistula.
TECHNIQUE
The upper extremity has multiple variations in venous
anatomic patterns, necessitating preoperative mapping
of both upper arms with duplex ultrasonography to de-
termine position and caliber of the veins. The portion of
the basilic vein used to create the vascular access arises
approximately 10 cm below the anticubital fossa, and
courses over the medial epicondyle of the humerus, to lie
within the medial bicipital furrow. This vein perforates
the deep fascia at approximately one-third the distal ex-
tent of the humerus. Using local anesthesia with occa-
sional intravenous sedation, a 2.5- to 3.0-cm slightly
curved transverse incision is made just medial and 1 cm
superior to the anticubital fossa. Dissection continues to
expose the brachial artery and the basilic vein, using
standard surgical instruments and technique. After as-
sessing the quality of these structures within this wound,
the basilic vein is liberated along its length by ligating
and dividing the visualized venous tributaries. Through
this working incision, using conventional techniques,
the beginning of a subcutaneous tunnel is created over
the basilic vein. This tunnel is extended using the Ethi-
con endovein harvesting small spoon dissector (Ethicon
Endo-Surgery, Inc, Cincinnati, OH) with a 5-mm, 30-
degree endoscope (Fig. 2). This device creates an opera-
tive working space, allowing mobilization to proceed
along the length of the basilic vein. Dissection is techni-
cally achieved with endoscopic instrumentation using
an endoscopic curved scissors, endoscopic forceps, and a
pigtail or ring linear dissector. An endoscopic endoclip-
ping device is used to obtain vascular exclusion and al-
low division of the subcutaneous venous tributaries.
Dissection proceeds along the length of the basilic
vein under endoscopic vision to carefully avoid injury to
the medial cutaneous nerve, which is found surrounding
the vein superiorly and inferiorly along its length. Next,
the basilic vein is followed as it dives and penetrates the
aponeurotic fascial plane. It is critical to meticulously
perform this maneuver to avoid injury to the median
and ulnar nerves adjacent to the vein in this region.
When the appropriate length of the vein has been
liberated above and below the anticubital fossa, a 1-cm
transverse counter incision is placed directly over the
basilic vein 2 cm inferior to where the pectoralis major
muscle inserts into the humerus. The vein is retrieved
through the uppermost incision and, under gentle dila-
tion with dilute heparin saline, all tributaries that have
No competing interests declared.
Received February 24, 2000; Revised June 30, 2000; Accepted September 13,
2000.
From St. Vincent Mercy Medical Center and Medical College of Ohio, To-
ledo, OH, Division of Vascular Surgery (Martinez, LeSar); Stanford Univer-
sity School of Medicine, Division of Vascular Surgery, Palo Alto, CA (Fogarty,
Zarins); Fogarty Research, Portola Valley, CA (Hermann).
Correspondence address: Christopher LeSar, MD, 3122 Hopewell Pl, To-
ledo, OH 43606.
233
© 2001 by the American College of Surgeons ISSN 1072-7515/01/$21.00
Published by Elsevier Science Inc. PII S1072-7515(00)00796-1