**6. Results**

Between 2004 and 2007 our team has operated on 49 patients with an upper arm venous system unsuitable for long term hemodialysis access, creating 49 brachio-brachial fistulas (Dorobantu et al., 2010). To date, this is the largest reported cohort of patients with a brachio-brachial AVF. Other groups have reported 17 (Casey et al., 2008), 20 (Angle et al., 2005) and 21 patients (Elwakeel et al. 2007). Thirty-nine patients (79,6%) had a functional fistula at the time of brachial vein transposition, after 4 weeks. The follow-up study was performed only in patients with a native functional brachio-brachial fistula after the twostep procedure. Mean follow-up period was 18.0 ± 11.1 months (range 3-37 months), longer than that of other published works, which ranged from 8 to 15.85 months. The overall patency rate at 37 months was 82.1%, compared to 75.89% at 1 year and 55.39% at 2 years reported by Elwakeel and 40% at 1 year reported by Casey. During this period, only seven patients presented with fistula occlusion 6, 6.4, 7.1, 9.4, 12.3, 23.5 and 35.0 months, respectively after superficialization.

No major complications have occurred with the patients. In 17 cases (43.6%) we noted discrete edema of the forearm, which disappeared after the first post-operative month; in only two cases has the edema extended to the entire arm. This was probably related to the greater pressure at the level of the remaining brachial vein, due to arterial pressure at the

Between 2004 and 2007 our team has operated on 49 patients with an upper arm venous system unsuitable for long term hemodialysis access, creating 49 brachio-brachial fistulas (Dorobantu et al., 2010). To date, this is the largest reported cohort of patients with a brachio-brachial AVF. Other groups have reported 17 (Casey et al., 2008), 20 (Angle et al., 2005) and 21 patients (Elwakeel et al. 2007). Thirty-nine patients (79,6%) had a functional fistula at the time of brachial vein transposition, after 4 weeks. The follow-up study was performed only in patients with a native functional brachio-brachial fistula after the twostep procedure. Mean follow-up period was 18.0 ± 11.1 months (range 3-37 months), longer than that of other published works, which ranged from 8 to 15.85 months. The overall patency rate at 37 months was 82.1%, compared to 75.89% at 1 year and 55.39% at 2 years reported by Elwakeel and 40% at 1 year reported by Casey. During this period, only seven patients presented with fistula occlusion 6, 6.4, 7.1, 9.4, 12.3, 23.5 and 35.0 months,

No major complications have occurred with the patients. In 17 cases (43.6%) we noted discrete edema of the forearm, which disappeared after the first post-operative month; in only two cases has the edema extended to the entire arm. This was probably related to the greater pressure at the level of the remaining brachial vein, due to arterial pressure at the

Fig. 4. Mobilization of the brachial vein

respectively after superficialization.

**6. Results** 

level of the brachio-brachial fistula, and numerous collaterals between the two brachial veins. In nearly all the patients we noted the presence of a collateral superficial venous network, as an adaptive reaction to the greater pressure in the deep venous system. After the superficialization and the ligation of the collaterals between the two brachial veins, this edema disappeared. We noted only one important edema of the arm, which regressed after the transposition in the subcutaneous tissue of the arterialized brachial vein. We believe that the absence of other complications like persistent forearm edema, ischemic lesions, etc, was related to the presence of two satellite brachial veins; therefore, the remaining brachial vein sustains the deep venous drainage. Other groups have reported a higher number of complications, including hematomas, wound infections (Casey, 2008) and steal syndrome which required reintervention and revascularization of the upper extremity.


Table 1. Comparison between several groups of patients with brachio-brachial fistulas

There were two cases of technical difficulties in mobilization of the brachial vein that had not been reported before: in one case we managed to maintain the native AVF (due to successful reconstruction of the arterialized vein in front of the median nerve) (figures 5 & 6), while in the other case where the arterialized vein remained too small, we were forced to make a prosthetic fistula. That was a rare event and we believe that it does not diminish the good results achieved with this technique.

No operative deaths occurred, but three patients died (after 2, 8 and 10 months) due to nonrelated causes and another three patients were lost at follow-up.

We consider that pre-operative ultrasound deep vein evaluation for the first step of the procedure is useless because the brachial vein is always a good native conduit with a variable diameter which does not influence the future of the AVF. Although there are authors that used only brachial veins with a diameter superior to 3 mm, they did not resolve the non-maturation problem (Pisoni et al., 2002).

When compared to the more traditional brachio-cephalic and brachio-basilic AVF, the brachio-brachial fistula shows similar patency and complications rates. A study published by Woo et al. in 2007, analyzing 190 patients with brachio-cephalic and brachio-basilic AVFs shows a patency rate of 56% for the brachio-cephalic and 71% for the brachio-basilic at 1 year. At 5 years, the patency rate was 40% for the brachio-cephalic and 56% for the brachio-

The Brachio-Brachial Arteriovenous Fistula 43

shown that it has good patency and low complication rates, therefore its construction can postpone the use of a prosthetic bridge graft or a long-life hemodialysis catheter by several years. The surgical technique includes the same principles of other venous transpositions, so it should be incorporated into the arsenal of techniques that are routinely used by vascular

Ahn, S.; Machleder, H., et al. (1986). Pathogenesis of perigraft seroma: evidence of a humoral fibroblast inhibitor. *Surg Forum*, No.37 (1986), pp. 460–461, ISSN 1522-666 Angle, N.; Chandra, A. (2005). The two-stage brachial artery– brachial vein autogenous

Bazan, H.A.; Schanzer, H. (2004). Transposition of the brachial vein: a new source for

Blumenberg, R.M.; Gelfand, M.; Dale,W. (1985). Perigraft seromas complicating arterial

Casey, K.; Tonnessen, B.K.; Mannava, K.; Noll, R.; Money, S.R. & Sternbergh W.C.III (2008).

Dorobantu, L.F.; Stiru, O.; Iliescu, V.A.; Novelli, E. (2006). The brachiobrachial fistula: a new

Dorobantu, L.F.; Stiru, O.; Iliescu, V.A.; Bubenek, S.; Novelli E. (2010). The brachio-brachial

Elwakeel, H.A.; Saad, E.M.; Elkiran, Y.M. & Awad, I. (2007). Unusual vascular access for

Enzler, M.A.; Rajmon, T.; Lachet, M.; Lagrader, F. (1996). Long-term function of vascular

Gabella, G. (1995). Arterial system, In Williams, P.L. (Ed.), *Gray's Anatomy*, 38th ed, pp. 1538-

Haimov M. (1978). Clinical experience with the expanded polytetrafluoroethylene vascular

Hobson, R., Croom, R., Swan, K. (1973). Hemodynamics of the distal arteriovenous fistula in venous reconstruction. *J Surg Res*, No.14 (1973), pp. 438, ISBN 0022-4804 Huber, T.S.; Carter, J.W.; Carter, R.L.; Seeker, J.M. (2003). Patency of autogenous and

systematic review. *J Vasc Surg*, No.38 (2003), pp. 1005-1011, ISSN 0741-5214 Iliescu, V.A.; Stiru, O. & Dorobantu, L.F. (2007). *Fistula arteriovenoasa protetica*, Editura

1539, Churchill Livingstone, ISBN 0-443-05717-6, Edinburgh, UK

Academiei Romane, ISBN 978-973-27-1542-0, Bucharest, Romania

patency rates. *J Vasc Surg,* No.47 (2008), pp. 202-206, ISSN 0741-5214 Choi, H.M.; Lal, B.K.; Cerveira, J.J.; Padberg, F.T.; Silva, M.B.; Hobson, R.W. & Pappas, P.J.

*J Vasc Surg,* No.42 (2005), pp. 806-810, ISSN 0741-5214

grafts. *Surgery*, No.97 (1985), pp. 192–203, ISSN 0039-6060

*Access,* No. 7 (2006), pp. 87-89, ISSN 1129-7298

Vol.21, No.5 (2007), pp. 560-563, ISSN 0890-5096

prosthesis. *Angiology,* Vol.29, No.1 (1978)

fistula for hemodialysis: An alternative autogenous option for hemodialysis access.

autologous arteriovenous fistulas*. J Vasc Surg,* No.40 (2004), pp. 184-186, ISSN 0741-

Brachial versus basilic vein dialysis fistulas: A comparison of maturation and

(2003). Durability and cumulative patency functional patency of transposed and non-transposed arteriovenous fistulas. *J Vasc Surg*, No.38 (2003), pp. 1206-1212,

method in patients without a superficial venous system in the upper limb. *J Vasc* 

arteriovenous fistula: mid-term results. *J Vasc Access,* No.11 (2010), pp.23-25, ISSN

hemodialysis: transposed venae comitante of the brachial artery. *Ann Vasc Surg*

access for hemodialysis*. Clin Transplant,* Vol.10, No.5 (1996), pp. 511-515, ISSN

polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a

access surgeons.

**8. References** 

5214

ISSN 0741-5214

1129-7298

0890-9016

basilic. Complications rates were low, including 6 cases of steal syndrome (3.15%), 7 cases of bleeding (3.68%), 3 cases of infection (1.57%) and 1 case of early thrombosis (0.52%), but greater than in the brachio-brachial AVF.

Fig. 5. The arterialized brachial vein runs under the median nerve

Fig. 6. Final result, after the vein has been divided and reconnected using an end-to-end anastomosis
