Where possible, the cephalic vein is used for wrist or elbow level fistulas. It is usually located anteriorly, is relatively shallow, and is usually relatively straight with few branches. This is the vein most surgeons prefer to use for creation of an AV fistula. Unfortunately, the cephalic vein may be small, tortuous, and in many patients has been ruined by previous intravenous catheters.
Finding options for the patient beyond the standard wrist or elbow fistula requires that we consider using a previously underutilized resource – the basilic vein. The basilic is the biggest vein in the arm, but is placed far medially (making it an inconvenient location for cannulation), and deep. The vein runs under several layers of brachial fascia (connective tissue), is surrounded by nerves, and can be close to the brachial artery. To use it in its natural position is impractical, painful and possibly dangerous.
Since transposition of the basilic vein was described in the 1980s, experience has been growing in the use of this vein. In general, the basilic vein is mobilized through a long incision on the medial part of the arm from elbow to axilla. Branches are ligated and divided. The vein is divided near the elbow, drawn through a subcutaneous tunnel lateral to the incision, and connected to the brachial artery. Because the incision is long and creates a large raw surface that can ooze a large amount of tissue fluids, I always leave a drain in the wound and keep the patient in the hospital overnight.
In general, a basilic vein must be 4 millimeters to be usable in a first-time operation. Then, a month or more must pass before the fistula is considered for use. The one-year unassisted patency for basilic fistulas has been reported to be as low as 50%, reflecting in many studies relative inexperience with this technique.
Several strategies can be employed to increase the yield of this operation. Experience of the surgeon is important. I have done nearly 50 of these operations in the last three years, and I am still learning new tricks related to basilic fistulas. My one-year patency over the last two years is close to 90%. It is important to find a surgeon who is beyond the learning curve in this operation.
Secondly, it has been observed empirically that basilic transpositions done after previous access in the same arm are more successful. The basilic vein above a forearm graft or fistula may have been “built up” over time from receiving increased blood flow. Veins of seven, eight, ten millimeters or more are frequently seen in the outflow of forearm accesses. When the forearm access fails, the large and previously toughened basilic vein can be transposed and used for dialysis within weeks. This operation is a very high-yield procedure in the hands of an experienced access surgeon. The venous outflow of forearm grafts or failing fistulas should be examined with ultrasound to discover these options for transition to an upper arm fistula.
In patients whose median antecubital vein is patent and in continuity with the basilic vein, an antecubital fistula can be a useful first step to an upper arm fistula. The antecubital vein is fistulized in such a way to create flow to the cephalic and the median antecubital. If the cephalic vein develops, well and good. If not, frequently the median antecubital and basilic become large enough to use.
One advantage to a basilic fistula is that it always is transposed, and is usually tunneled right under the skin. Cephalic fistulas can be transposed (or superficialized), but are most often used in their native position, which is below a fascial layer, and usually deeper. A correctly tunneled fistula should be easy to palpate, visualize and cannulate.
The recent enthusiasm for PICC lines represents a threat to the basilic vein. Previously protected by depth, this vein is now being used more and more, and like the cephalic vein before it, is being ruined for use in creating dialysis access. Fortunately, experience in declotting basilic veins, or removing parts of it entirely for use as an autologous graft is growing. Nevertheless, it is my position that PICC lines in renal patients can lead to loss of fistula options, and should only be used when absolutely necessary.
In short, being able to use the basilic vein is an important option for dialysis patients whose cephalic veins are inadequate. Chances for creating a useful fistula are greatly increased when the access surgeon considers using the basilic vein and is familiar with the operation.
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