Primary and staged transposition arteriovenous

fistulas
Michael R. Arroyo, MD,a Matthew J. Sideman, MD,a Lawrence Spergel, MD,b and
William C. Jennings, MD,a Tulsa, Okla; and San Francisco, Calif

Background: The use of catheters or prosthetic grafts for vascular access has significantly higher mortality and morbidity risks,
in addition to higher costs, than arteriovenous fistulas (AVF). Many patients have a difficult access extremity due to complex
medical illnesses, previous vascular access procedures, intravenous catheters, diabetes, vascular disease, female sex, age, and
other complicating factors. Transposition AVFs (AVF-T) have been used for these individuals to avoid catheters and grafts. We
report our experience with primary and staged basilic vein AVF-Ts and staged brachial vein AVF-Ts.
Methods: From our database of consecutive vascular access operations, we reviewed patients from May 2003 to September
2006 for all upper extremity AVF-Ts. A primary AVF-T was used when the basilic vein was continuous with a minimum
diameter of 4 mm and of adequate length. When the basilic vein was 2.5 to 4 mm, the procedure was staged. The proximal
radial artery was used for inflow, if possible. When the basilic vein was not suitable, a radial vein or brachial vein
anastomosis was performed as the first stage of a planned brachial vein AVF-T. The second stage operations of staged
AVF-Ts were generally done 4 to 6 weeks after the primary AVF construction. All patients were evaluated with
preoperative ultrasound imaging by the operating surgeon.
Results: From a database of 412 consecutive vascular access patients, 78 upper extremity transposition procedures were
identified. Of these, 57 patients (73.1%) were women, 44 (56.4%) were diabetic, and 46 (59.0%) had previous access surgery.
Fifty-eight operations were staged procedures. The basilic vein was used in 68 AVF-T, the brachial vein in six, and cephalic vein
in four. The anastomosis was based on the proximal radial artery in 60 patients. Mean follow-up was 18 months (range, 3-48
months). Primary patency, primary assisted patency, and cumulative patency were 45.7%, 93.5%, and 96.0% at 12 months and
27.6%, 86.5%, and 88.9% at 24 months, respectively. No prosthetic grafts were used in the study period.
Conclusion: Both primary and staged AVF-T procedures were successfully used in patients with difficult access extremities.
AVF-Ts were durable, although many required an interventional procedure for maturation or maintenance. Cumulative
(secondary) patency was 96.0% at 12 months and 88.9% at 24 months. The absence of an adequate basilic vein does not
preclude the use of a staged AVF-T because the brachial vein offers a suitable alternative. ( J Vasc Surg 2008;47:1279-83.)

The National Kidney Foundation Kidney Disease Out-
comes Quality Initiative (NKF-KDOQI) and the Fistula
First Breakthrough Initiative, “Fistula First” (FFBI) rec-
ommend an arteriovenous fistula (AVF) as the optimal
vascular access for hemodialysis patients.1,2 Catheters and
prosthetic grafts (AVG) used for vascular access are associ-
ated with higher rates of complications and procedures, in
addition to higher mortality rates and significantly higher
costs than AVFs.3-6 Several other countries have much
higher AVF rates than the United States7; however, impor-
tant progress has been recently demonstrated in several
reports, through concerted team efforts and the use of
preoperative imaging such as ultrasound vessel map-
ping.2,8-10 Creation of AVFs in most, if not all, patients has
been shown to be an attainable goal.11,12
Approximately 350,000 patients require long-term he-
modialysis treatment in the United States, with the number
From the Department of Surgery, University of Oklahoma College of
Medicine, Tulsa,a and Dialysis Management Medical Group.b
Competition of interest: none.
Presented at Vascular Access for Hemodialysis X Symposium, Phoenix, Ariz,
May 18-19, 2006.
Reprint requests: William C. Jennings, MD, FACS, Professor, Department
of Surgery, M. L. Todd Chair, University of Oklahoma College of
Medicine, Tulsa, 4502 E 41st St, Tulsa, OK 74135 (e-mail: william-
Jennings@ouhsc.edu).
0741-5214/$34.00
Copyright © 2008 by The Society for Vascular Surgery.
doi:10.1016/j.jvs.2008.01.047
of patients increasing faster than the general population.13
A significant number of these individuals have difficult
access extremities due to complex medical illnesses and
previous vascular access procedures. They often have a
history of multiple intravenous catheters, diabetes, periph-
eral vascular disease, or female gender.14-16 Many of these
individuals no longer have adequate superficial veins for
direct AVF construction and require transposition of an
otherwise inaccessible basilic, brachial, or deep cephalic vein to
avoid AVGs and catheters. This report focuses on strategies
and outcomes for construction of upper extremity AVF trans-
positions (AVF-T) in these challenging patients.
METHODS
All individuals undergoing AVF-Ts by the communi-
cating author from May 2003 to September 2006 were
identified from a vascular access database of consecutive
operations. Our surgical approach has been to construct an
autogenous vascular access for each patient. The patients in
this study were not suitable candidates for any of the many
direct AVF options where outflow veins are available for
direct cannulation.1,2,17 A basilic vein AVF-T was our next
choice for vascular access, followed by a brachial vein
AVF-T when the basilic vein was not available.
All patients had preoperative vessel mapping by ultra-
sound imaging that included complete venous and arterial
imaging of both upper extremities. Minimal acceptable
1279

1280 Arroyo et al
vessel diameters included 2.5 mm for outflow veins and an
arterial intraluminal diameter of 2.0 mm. Venous measure-
ments were recorded with a tourniquet in place. Ultra-
sound imaging was a key element in identifying patients not
suited for construction of simple direct AVFs and selecting
those individuals where an upper extremity AVF-T was
feasible. Venography was obtained when there was a history
of arm swelling or multiple central catheters to evaluate for
central venous stenosis or occlusion. The complete ultra-
sound examination was routinely performed by the operat-
ing surgeon during the initial consultation. The surgeon
again used ultrasound in the operating room for a brief/
focused examination to map and mark key vessels and
confirm the surgical plan and incision site.18
Basilic vein AVF-Ts were constructed in the upper arm
or, less commonly, in the forearm as determined by the
availability of an adequate arterial inflow site and vein
quality, length, and size.17 Primary basilic vein AVF-Ts
were used when physical examination, ultrasound evalua-
tion, or venography found the vein to have a minimum
diameter of 4 mm with a tourniquet applied and adequate
length to allow dialysis access when the vein was tunneled
into the new subcutaneous pathway. When the basilic vein
was present but with a diameter of 2.5 to 4 mm, a staged
AVF-T was constructed 4 to 6 weeks after an initial inflow
AVF construction. Our requirement of a minimum 4-mm
basilic vein diameter for primary AVF-T construction
evolved with the experience of the communicating author
over several years. A brachial vein AVF-T was chosen when
no other upper extremity veins were available. All brachial
vein AVF-Ts were performed as staged operations.
Cephalic vein AVF-Ts were uncommon in this series of
patients. In our experience, most cephalic vein AVFs are
used directly, even in most obese patients, where the button-
hole technique (same site cannulation) allows access through
the shorter superficial portion of these fistulas. In addition,
our practice is to establish retrograde flow through forearm
veins when at all possible, expanding the number of access
sites available associated with simple direct fistulas. Deep,
nonaccessible upper arm or forearm cephalic veins in obese
patients were transposed as primary procedures when the
vein diameter was ⬎4 mm. Smaller veins (2.5 to 4 mm)
underwent staged AVF constructions. If possible, AVF-Ts
were constructed using the proximal radial artery (PRA) for
AVF inflow. The brachial artery was used for inflow if a direct
anastomosis to the PRA was not feasible. Outflow veins se-
lected for the AVF anastomosis included the median cubital,
basilic, radial, deep communicating, and brachial vein(s).
Staged AVF-Ts were allowed to mature from 4 to 6
weeks before the second procedure. If maturation of the
outflow vein was not deemed successful by clinical and
ultrasound examination, a fistulogram was obtained before
the second stage transposition and an angioplasty per-
formed if necessary. The second stage AVF-T was con-
structed when the outflow vein diameter was ⱖ6 mm and
physical and ultrasound examinations found no evidence of
stenosis with flow volumes ⱖ400 mL/min. Any angio-
plasty during the patient’s care, including those between
JOURNAL OF VASCULAR SURGERY
June 2008
Fig 1. Staged basilic vein transposition. The arteriovenous fistula
transposition is based on a first-stage proximal radial artery to
median cubital vein arteriovenous fistula.
staged procedures, converted the follow-up of that individ-
ual patient from primary to primary assisted patency.
The initial AVF for a staged basilic vein AVF-T was
constructed using the PRA with venous outflow through
the median cubital vein when possible, adding vein length
for the later staged AVF-T. The first-stage AVF anastomo-
sis used the median cubital, deep communicating, or me-
dian antebrachial vein, or both. The second-stage proce-
dure consisted of transposition of the matured basilic vein.
The median antebrachial nerve crosses anteriorly to the
basilic vein in the upper arm, therefore division and reanas-
tomosis of the basilic vein was necessary to preserve sensa-
tion in the medial forearm distribution (Fig 1). To allow
tunneled passage of the basilic vein, the mature vein was
divided at a branching point near the elbow, most often
where the forearm basilic vein joined the median cubital
vein. Selection of such a branch point for division allows
construction of a broad end-to-end anastomosis.
Transposed brachial veins were elevated and positioned
anteriorly to the incision to avoid repeated needle access
through the surgical scar (Fig 2). In constructing a staged
brachial vein transposition, the initial AVF anastomosis was
created using the PRA if possible. The radial vein, when
adequate, was used for outflow into a brachial vein for a
later staged AVF-T. The radial vein juncture with the deep
communicating and brachial vein often offered a broad
hood for the PRA anastomosis. When the radial artery or
adjacent veins were not adequate for the first stage AVF, a
brachial artery– brachial vein AVF was created. Staged up-
per arm cephalic AVF-Ts were elevated to the side of
segmental incisions, again to avoid cannulation through
scar tissue. Initial cannulation of primary or staged trans-
posed vein segments for dialysis was allowed in approxi-
mately 4 weeks. A surgical video of a typical staged basilic
vein AVF-T based on a first-stage PRA AVF is available on
the Fistula First Breakthrough Initiative (FFBI, Fistula
First) Web site.2 Anesthesia was generally provided by
regional block with sedation.
JOURNAL OF VASCULAR SURGERY
Volume 47, Number 6
Fig 2. Staged brachial vein transposition. This arteriovenous fis-
tula transposition is based on a first-stage proximal radial artery to
radial vein arteriovenous fistula. The transposed brachial vein is
elevated anteriorly to the incision to avoid repeated needle access
through the surgical scar.
Patients were followed up in the surgery clinic until the
access was fully functional for dialysis. No routine surveil-
lance was undertaken after the fistula was used; however,
patients were re-evaluated in the surgery clinic if the dialysis
nursing staff reported problems such as low flow rates,
recirculation, abnormal postcannulation bleeding, or high
dialysis pressures.
Primary patency was defined as the time (months) with
uninterrupted patency and without intervention. Primary as-
sisted patency was the time of uninterrupted patency from the
original AVF construction where any interventional proce-
dure was necessary. Cumulative (secondary) patency was the
period from the original AVF construction, regardless of in-
terventions or thrombosis, until abandonment of the access or
until completion of the study period.15 The study was ap-
proved by our Institutional Review Board.
RESULTS
From a database of 412 consecutive vascular access
patients, 78 upper extremity AVF-T procedures were iden-
tified; 57 (73.1%) were women and 44 (56.4%) were dia-
betic. Forty-six patients (59.0%) had previous access sur-
gery in either arm, and 24 (30.8%) had at least one previous
access operation in the ipsilateral arm of the AVF-Ts re-
ported here. When first evaluated, 72 patients (92.3%) were
using catheter-based dialysis. Four individuals had preop-
erative venography, and none had central venous occlusion.
Upper arm AVF-Ts were constructed in 72 patients
(92.3%) using 65 basilic, six brachial, and one cephalic vein
transposition. Six individuals had forearm procedures using
three basilic and three cephalic vein transpositions. Fifty-
eight operations (74.3%) were staged procedures.
Seven AVF-Ts failed and were not salvaged; of these, a
successful thigh autogenous access was later created in two
patients, and two others are being evaluated for a new
access. The remaining three patients declined other access
Arroyo et al 1281
Fig 3. Kaplan-Meier access patency curve shows arteriovenous
fistula transposition primary patency (solid line), assisted patency
(dashed line), and cumulative patency (dotted line).
operations and were maintained on catheter-based dialysis.
Five of the access failures were staged AVF-Ts, and two of
these used a brachial vein. Three of the seven patients with
failed AVF-Ts were diabetic and two were men.
The arteriovenous anastomosis was based on the PRA
in 60 patients. Five patients with staged procedures re-
quired an angioplasty before the second stage AVF-T. One
required surgical revision before the staged AVF-T.
Mean follow-up was 18 months (range, 3-48 months).
Primary patency, primary assisted patency, and cumulative
patency were 45.7%, 93.5%, and 96.0% at 12 months and
27.6%, 86.5%, and 88.9% at 24 months, respectively (Fig
3). Other autogenous accesses were created in the other
372 vascular access patients in the study period, including
370 direct AVFs and two saphenous vein thigh transposi-
tions. Cumulative patency was ⬎90% for these patients.
Twenty-seven of these patients had failed AVFs that were
patent for a mean of 13 months (range, 1-32 months).
Eight eventually had successful new AVFs, one patient
changed to peritoneal dialysis, and the rest were lost to
follow-up with catheter-based dialysis. No grafts were used
in vascular access patients during the study period.
Functionality, defined as full use in the dialysis unit with
removal of the access catheter, was achieved in all but two
of the AVF-T patients. Two other individuals had not
started dialysis at the end of the study period. They had
mature AVF-Ts that were judged ready for use (successful).
Major complications included an infected hematoma
after an unsuccessful initial access attempt that required
operative débridement and caused the greatest delay in
time to access use. This patient had had multiple failed
AVFs, grafts, and catheters placed elsewhere before our
procedures. A second patient required ligation of an AVF-T
for bleeding after an angioplasty performed 5 weeks after
the transposition. Minor wound complications, such as
postoperative hematomas and small wound separations,
resolved with local care and observation but delayed initial
use of AVF-Ts in three other patients.
The mean time to use of primary AVF-Ts was 2.0
months (range, 1.2-5.0 months). Two patients had staged
AVF-Ts after the initial AVF had been created elsewhere

1282 Arroyo et al
and were referred for nonmaturation with AVF outflow
into a basilic vein. In 14 individuals, staged AVF-Ts were
created after a period of time where the initial PRA AVF
had been successfully used for dialysis through the upper
cephalic or median antebrachial veins, or both. When these
direct access sites failed, the original AVFs remained patent,
with outflow via the median cubital vein into the basilic vein
that was then used for staged transposition at a mean of 12
months (range, 7-47 months) after the original operation.
Excluding these “later” staged AVF-Ts, the mean time to
use of staged AVF-Ts was 4.0 months (range, 2.5-9.0
months).
During the follow-up period, 14 patients died of causes
not related to the AVF-T operations. A single patient with
a brachial artery AVF-T inflow required surgical treatment
for steal syndrome (DRIL procedure). A second patient
with brachial artery AVF-T inflow underwent an outflow
banding procedure by interventional radiology (Miller pro-
cedure).
Most patients—54.3% by 1 year and 72.4% by 2 years—
required an interventional procedure. Most interventions
were by balloon angioplasty after a fistulogram. During the
study period, 48 individuals required at least one balloon
angioplasty, 14 patients had two procedures, and four
patients underwent three or more treatments. The most
common site of narrowing was at the proximal “swing
point” of the transposed vein segment where it exits the
native path of the axillary vein and enters the new subcuta-
neous tunnel. These transition segments are likely subject
to greater turbulence and shear force. Other common
lesions were at the arterial anastomosis and at the veno–
veno anastomosis required after vein division for tunneling
and transposition of staged basilic vein AVF-Ts. Conven-
tional balloon angioplasty was used in our patients when
indicated. We avoid stents within the usable area of an
autogenous fistula and place stents only in central venous
lesions that have recurred after conventional balloon angio-
plasty. Seven individuals required eight surgical interven-
tions: two aneurysm repairs and six revisions in five patients.
Patients with primary and staged AVF-Ts had a similar
likelihood of interventional procedures.
DISCUSSION
Arteriovenous fistula transpositions were first reported
by Dagher et al19 in 1976 and have been shown to increase
the number of AVFs created in dialysis patients.8 Previous
reports have described successful AVF-Ts using not only
the basilic vein for access but also the brachial vein, forearm,
and thigh veins.20-27 Staged AVF-Ts have previously been
described.5,28 Hill et al29 found AVF-Ts using basilic veins
⬎4 mm in diameter had a higher success rate than AVF-Ts
using smaller veins.29 A randomized study by El Mallah30
found a 2-year cumulative patency of 50% for one-stage
AVF-Ts and 80% for two-stage procedures. Segal et al31
concluded a basilic vein ⬎3 mm was the minimal size for
successful AVF-Ts based on venography and operative eval-
uation, but preoperative ultrasound mapping was not used.
JOURNAL OF VASCULAR SURGERY
June 2008
Aggressive use of interventional techniques has shown
a high rate of success in maturing and salvaging AVFs32-34
and was a key component in the postoperative care in many
of these patients. Maturation of the venous outflow conduit
should occur within 4 to 6 weeks in most patients.35
Interventional procedures after transposition were often
needed to ensure an adequate sized vein for cannulation
with the needed blood flow to remain patent and offer
functional dialysis. We do not believe that an AVF that
requires assisted maturation should be considered an AVF
failure and do not hesitate to obtain a fistulogram and
possible angioplasty if there is a question of adequacy.
Ultrasound evaluation of AVF maturation by real-time
imaging and reliable flow measurement was important in
making the decision for obtaining a fistulogram and helped
in planning the interventional procedure.
Endoscopic vein harvest has become common in car-
diac surgery and is increasingly used in peripheral vascular
bypass operations. This technique has been applied in ba-
silic AVF-Ts and may offer fewer wound problems, less
trauma to the transposed segment, and less overall inflam-
matory changes within the arm. We are currently using this
technique and our early experience is promising.
A literature review by Dix et al36 found an overall mean
1-year cumulative patency for AVF-Ts of 75%; however,
recent publications have suggested that the Fistula First and
K/DOQI Guidelines’ emphasis on AVF creation may lead
to more AVF-T failures or persistent catheters as more
difficult access patients are selected for autogenous access
procedures.37 Wolford et al38 reported only 11% primary
patency and 40% secondary patency of their AVF-Ts at 2 years,
leading them to reconsider their aggressive all-autogenous
access policy. Their review noted a wide range of AVF-T
outcomes reported by other authors.22,39,40 Our study found
that preoperative ultrasound examination by the operating
surgeon and selective use of staged procedures resulted in
successful, reliable, and durable AVF-Ts in a large majority of
these challenging patients.
Steal syndrome has been reported in 5% to 20% of
access patients, with brachial artery upper arm AVFs at
significant risk. Using the PRA for inflow when possible
minimizes the risk of steal syndrome and supplies reliable
arterial inflow.12 No patients in this study required surgical
intervention for steal syndrome when inflow was supplied
by the PRA. In our patients, where the brachial artery was
used for arterial inflow, the size of the anastomosis was
limited according to the diameter of the brachial artery to
lower the risk of distal ischemia.
CONCLUSION
Both primary and staged transposition procedures may
be successfully used in patients with difficult access extrem-
ities. Transposition AVFs are durable. Cumulative (second-
ary) patency was 96.0% at 12 months and 88.9% at 24
months. The absence of an adequate basilic vein does not
preclude the use of a staged transposition because the
brachial vein offers a suitable alternative. No grafts were
used in any vascular access patient during this study period.
JOURNAL OF VASCULAR SURGERY
Volume 47, Number 6 Arroyo et al 1283

AUTHOR CONTRIBUTIONS 19. Daghe F, Gelber R, Ramos E, Sadler J. The use of basilic vein and
brachial artery as an A-V fistula for long term hemodialysis. J Surg Res
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Data collection: MA, WJ venous fistula. Am J Surg 1999;177:489-91.
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Critical revision of the article: MA, MS, LS, WJ tions. J Vasc Surg 2003;37:821-6.
Final approval of the article: MA, MS, LS, WJ 22. Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula con-
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