1. Transposition Arterio-Venous fistulae; not giving up on autologous vascular access
Dr. Chathu Sahabandu, Dr. Nalaka Gunawansa
National Institute for Nephrology Dialysis and Transplantation

2. Preferred Placement Sites for Arteriovenous Fistula / Graft
A wrist (radial-cephalic) primary arteriovenous fistula. Easiest to create, has a lower blood flow, its use as the first access, preserves the upper arm vessels for later attempts.
An elbow (brachial-cephalic) primary arteriovenous fistula. Easy to cannulate,presents a long length of vein for cannulation, higher blood flow.
A transposed brachial-basilic vein fistula. Requires more surgical skill, vein must be elevated and transposed to make useable, less area for cannulation, Steal syndrome more common.
An arteriovenous graft of synthetic material.

3. Vein Transposition A-V Fistulae

4. Brachiocephalic Arteriovenous Fistula
Radial-Cephalic Arteriovenous Fistula

5. Transposed Basilic vein Arteriovenous Fistula & Graft

6. An Autologous Arterio-Venous Fistula (AAVF) is the key to long-term success with hemodialysis.
AAVF should always be considered the preferred option before considering prosthetic access.
However, most patients referred to our specialized unit have exhausted their preferred superficial AAVF options.
We studied the place of Transposition AVFs (TAVF) as an alternative to prosthetic access.

7. Radiocephalic AVF in the forearm in a patient with a previously thrombosed wrist AVF.

8. A radiocephalic AVF at the anatomical snuffbox.

9. 3 Possible configurations for AVFs at the antecubital fossa
3 Possible configurations for AVFs at the antecubital fossa. A, B - Standard brachiocephalic fistula. C - Gracz fistula.

10. Three Cardinal Rules for Transpositions
Superficial
Safe position for cannulation
Away from incisions

11. Brachial-basilic transposition
Important to obtain additional length of vein to enable translocation

12. Methods
A prospective analysis of all AAVF performed at our institution from June 2012 to April 2014.
A TAVF was attempted in all those who had exhausted cephalic vein AVF options in both arms.
Primary transposition was done if the basilic vein diameter was >4mm.
In all others, a staged transposition was done after 4-6 weeks.
The arterial inflow was brachial artery at the elbow.
When the basilic vein was also not patent, the brachial vein was used.
All patients had preoperative duplex imaging by the operating surgeon.

13. There were 503 consecutive AAVF performed in this period, including 87 TAVFs.
58/87 (66%) were staged. The basilic vein was used in 81 and the brachial vein in 6.
Mean follow-up was 11 (2-23) months.
Primary patency and primary assisted patency rates were 76% and 90% respectively.
The difference in primary patency rates between primary (70%) and staged (78%) transpositions was not statistically significant (p=0.09).

14. Functional patency of autogenous AV fistulas for hemodialysis.
Authors
Nguyen TH, Bui TD, Gordon IL, Wilson SE.
Journal
J Vasc Access Oct-Dec;8(4):  
129 patients were identified who underwent 155 autogenous AV fistula constructions.
The average age was 62.1 (range 40-84) years old.
114 radiocephalic
41 brachiocephalic fistulas.
57 (50%) radiocephalic fistulas allowed successful hemodialysis – after 13+/-5 weeks
with a primary patency of 13+/-4 months.
28 (68%) brachiocephalic fistulas reached successful hemodialysis - after 6+/-2 weeks
with a primary patency of 16+/-7 months.

15. Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly.
AuthorsWeale AR, et al. Show all Journal
J Vasc Surg Jan;47(1): doi: /j.jvs
a total of 658 patients had a RCAVF
297 had a BCAVF.
median age was 68.5 years
Age did not influence the site of the first surgical access
Female sex Female sex
Diabetes was the only factor associated with an increase risk of BCAVF nonuse.
primary patency rates at 1 year for RCAVFs were 46.0% and 2nd year 27.1%
primary functional patency rates for BCAVFs at 1st year was 39.3% and 2nd year 31.0%

16. 503 consecutive AAVF performed
87 TAVFs. 58/87 (66%) were staged.
basilic vein was used in 81
brachial vein in 6.
Mean follow-up was 11 (2-23) months.
Primary patency - 76%
primary assisted patency - 90%
difference in primary patency rates between primary (70%) and staged (78%) transpositions was not statistically significant (p=0.09).

17. Thank you