Surgeon at WorkTransposition of the basilic vein for arteriovenous fistula: an endoscopic approach1

The creation of a functional hemodialysis fistula in patients 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 secondary procedures are indicated. Currently, in the United States, more than 50% of hemodialysis that is performed occurs through polytetrafluoroethylene (PTFE) grafts. Numerous reports have described the various complications 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 required. Recent reports on longterm upper arm dialysis access procedures, specifically, the transposed brachiobasilic arteriovenous fistula, have shown significant longterm primary patency rates reaching 70% at 8 years. To date there have been no descriptions of a minimally invasive approach to address the long morbid upper arm dissection needed to create this fistula (Fig. 1). We describe an effective, technically simple, minimally invasive surgical approach to create an upper arm transposed brachiobasilic fistula.