Modified basilic vein transposition surgery for vascular access: Lengthening the basilic vein

Introduction

Basilic vein transposition (BVT) surgery plays an essential role in vascular access in hemodialysis patients, especially when other options are unavailable. In 1976, Dagher et al. introduced the BVT technique. ¹ Since then, BVT surgery has undergone several modifications and adaptations. ² One of the complications that can affect the function and lifespan of the fistula is the development of a pseudoaneurysm caused by multiple punctures of the vein at the same site. ³ Additionally, one factor that appears to improve the fistula’s performance is the basilic vein’s length, which is available for puncture during hemodialysis cannulation. We believe that increasing the length of the basilic vein during the second stage of BVT surgery will allow more areas of the patient’s arm for hemodialysis puncture. This could reduce the likelihood of complications, such as the formation of a puncture-induced pseudoaneurysm, by minimizing the probability of puncturing previously punctured sites. ³

Patient selection

This technique is considered for patients who lack a suitable cephalic vein for AVF creation or those whose brachiocephalic fistula has failed. The procedure is appropriate when there is no evidence of limb edema or thrombosis in the deep venous system and the basilic vein has a diameter greater than 2.5 mm with appropriate anatomy. A critical anatomical requirement is at least one basilic vein branch in the cubital fossa (like the median cubital vein) measuring over 2 mm in diameter, with the basilic vein extending along the medial aspect of the forearm.

Technique

After ultrasound-guided venous mapping confirms the basilic vein’s anatomical suitability, the patient becomes a candidate for AVF surgery if appropriate. In the first stage, the branch of the basilic vein in the cubital fossa (median basilic vein) is anastomosed to the superior surface of the brachial artery using a 6/0 Prolene suture.

One month after the surgery, or once the vein diameter reaches at least 4 mm, the patient is eligible for the second stage. In this second stage, following venous mapping with ultrasound and precise marking of the vascular route, a longitudinal incision is made on the medial aspect of the arm, extending to the medial side of the upper forearm (Figure 1). Subsequently, the basilic vein is meticulously explored and freed from the arm and forearm.OPEN IN VIEWER

Once the basilic vein is fully liberated and its side branches ligated, exploration is performed to free the median basilic vein up to the site of the first-stage anastomosis (Figure 2). Using Putz scissors, the median basilic vein is carefully dissected at its junction with the basilic vein, and the resulting defect is repaired using a 7/0 Prolene suture (Figure 3).OPEN IN VIEWER

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Figure 3.

The median basilic vein is controlled and cut at its origin, while the defect in the basilic vein wall is repaired with 7/0 Prolene suture.

The distal end of the basilic vein in the forearm is transected, and after spatulation, it is anastomosed end-to-end to the distal end of the median basilic vein. Following creating a flap in the arm, the basilic vein is positioned in a tension-free curved manner in the appropriate location. After the final evaluation of the anastomosis, the subcutaneous tissue and skin are closed (Figures 4 and 5).OPEN IN VIEWER

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Figure 5.

Basilic vein after elevation and transposition.

Discussion and conclusion

In this modified approach, the basilic vein is tracked down to the forearm, and a more extended segment of it is freed to be anastomosed end-to-end with the distal portion of the median basilic vein. It is important to note that in the first stage, the median basilic vein was anastomosed to the superior surface of the brachial artery to prevent tension and preserve alignment after the basilic vein is transposed in the second stage.

We performed this modified technique at our center on 39 carefully selected hemodialysis patients. After reviewing their 1-year follow-up, none of the patients experienced significant arteriovenous fistula (AVF) complications, particularly the formation of pseudoaneurysms. We believe this approach, which extends the basilic vein’s usable length for cannulation, may reduce the likelihood of pseudoaneurysm formation by providing multiple puncture sites and minimizing the risk of repeated needle insertions at the same site. As a result, it may enhance the fistula’s longevity and functionality in hemodialysis patients. Further clinical studies will be necessary to validate the efficacy of this technique in a broader patient population.