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Brachial artery transposition (BAT) is not a well known method for obtaining vascular access (VA) for maintenance haemodialysis. This study evaluated the outcomes of BAT.
This multicentre retrospective cohort study included 233 consecutive patients who underwent BAT between January 2012 and December 2013. The indications were inadequate vessels for obtaining VA, severe heart failure, hand ischaemia, central vein stenosis/occlusion, or a history of catheter/graft infection. The transposed brachial artery was used only for arterial inflow and other routes were used for outflow.
BAT was successful in 227 patients, and adequate blood flow was achieved during dialysis sessions. The first successful cannulation was after a median of 18 days. BAT was performed using superficial veins as the return route in 127 patients and arteriovenous fistula (AVF) creation in 63 patients to prevent maturation failure. In 41 patients with central venous catheterisation, the transposed brachial artery was used for arterial inflow. The complications of BAT were impaired wound healing in 14 patients, including skin necrosis in two; large aneurysms in six, including a mycotic pseudo-aneurysm in one; arterial thrombosis in five; hand ischaemia in five; lymphorrhoea in four; and haematoma/bleeding in three. The transposed brachial artery was abandoned in four, three, three, and one case of arterial thrombosis/stenosis, haematoma/bleeding, skin necrosis, and large aneurysm, respectively. Access to the return routes failed in 48 cases because of vein damage caused by cannulation in 22, AVF thrombosis/stenosis in 14, catheter infection in six, and catheter occlusion in six. At two years, the primary patency rates of the transposed brachial artery and access circuit were 88% and 54%, respectively.
BAT is a safe and effective technique. The patency was high for the transposed brachial artery but adequate for the access circuit. BAT can be considered for patients with an unobtainable standard arteriovenous access.
Brachial artery transposition (BAT) has been employed as a tertiary option for vascular access in several countries; however, it has not been widely adopted. Small, single centre studies have been published. This paper describes a multicentre retrospective experience of 233 consecutive BAT procedures with a mean follow up of 19 months. The primary application was for cases in which the continuation of arteriovenous fistula or graft was problematic (i.e., central vein obstruction, hand ischaemia, or heart failure) and when anatomical data predicted maturation failure. BAT is a safe procedure with adequate patency of the access circuit.
Many guidelines recommend creating an arteriovenous fistula (AVF) as the primary option for vascular access (VA).
When an AVF cannot be created, an arteriovenous graft (AVG) is the secondary option. According to the 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS), haemodialysis catheter placement is one of the tertiary modalities for VA in patients for whom AVF or AVG placement is no longer feasible.
However, “superficialisation” is also used to describe moving a vein closer to the skin in a patient whose AVF is difficult to access because of the distance between the skin and the access. In this report, the brachial artery was moved laterally from its normal position to permit easier cannulation. Therefore, the term “transposition” is used. In 2017, the Society performed an investigation into the methods of VA by sex and found that 1.6% of male patients and 2.0% of female patients underwent haemodialysis with BAT.
Thus, the percentage of BAT performed has not changed for 10 years. BAT is also performed in China; however, only abstracts written in Chinese are available. Generally, BAT is believed to have a high patency rate and relatively easy cannulation, because the diameter of the brachial artery is usually > 4 mm. BAT is also considered free of maturation failure.
Furthermore, the surgical technique of BAT is not difficult, as it can be performed without vessel anastomosis. Although BAT has been used for several decades in Japan because of these advantages, few studies have reported on its safety and efficacy across multiple facilities. Therefore, a multicentre, retrospective, observational study was conducted to evaluate the short and long term outcomes of VA created using this technique. Furthermore, this study aimed to thoroughly discuss the drawbacks and advantages of BAT.
From 1 January 2012 to 31 December 2013, a total of 5 054 VA related procedures were performed at 10 participating hospitals (Supplementary Information 1). During this period, consecutive patients who underwent BAT were included. The indications for BAT were as follows: (1) inadequate vessels for VA creation, (2) severe heart failure, (3) hand ischaemia, (4) central vein stenosis/occlusion, or (5) a history of catheter/graft infection.
This study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Institutional Review Board of Shizuoka General Hospital (approval number 15–03–83) and the respective participating hospitals. Informed consent was not required, because this was an observational study and only existing medical data were used.
Before surgery, the brachial artery was evaluated using duplex ultrasound. A brachial artery diameter of > 4 mm was a good indication. A diameter of > 3.5 mm was allowable. If severe calcification of the brachial artery was identified, BAT was not recommended. If there were no superficial returning routes to be regularly cannulated, BAT was contraindicated. A vein diameter available for the return route of > 4 mm was preferable but > 3 mm was permissible.
Selection for types of brachial artery transposition
The transposed brachial artery is used only for the arterial inflow of the VA and is not intended to accept the return of dialysed blood. Therefore, BAT was sometimes used in combination with another VA. The types of BAT were divided into three groups. Fig. 1 shows an algorithm for the BAT selection strategy.
Conventionally, when BAT was performed, superficial veins were used for blood return. This method was defined as simple BAT to distinguish it from BAT with an AVF or BAT with a central venous catheter (CVC). As shown Fig. 1, simple BAT was selected in patients with hand ischaemia, severe heart failure, or central vein occlusion/stenosis.
Left ventricular ejection fraction < 30% was one of the criteria for recommending BAT. There is no established recommendation on the appropriate VA modality for an ejection fraction of 30–40% in Japanese guidelines.
Hand ischaemia with or without arteriovenous access was defined clinically by the presence of a sense of coolness, skin discoloration, pain, or paraesthesia. Hand ischaemia with high flow access was an especially good indication for BAT. After fistula ligation, the remaining collateral veins were available for venous return. Fig. 2 demonstrates a large non-thrombosed vein used for return routes. In cases with milder ischaemia, techniques to preserve arteriovenous access (e.g., distal revascularisation interval ligation) were alternative options. In cases of central vein stenosis/occlusion, an AVG was not created in order to avoid the arm swelling caused by continuous high flow in the arteriovenous access. Importantly, if BAT was selected, access flow occurred only during haemodialysis treatment and severe arm swelling did not occur. After an AVG or CVC infection, BAT is an option that may avoid recurrent infection from another AVG or CVC.
For cases of active severe limb ischaemia, equivalent to stages 3 and 4 in the definition of VA induced ischaemia in the 2018 ESVS guideline, treatment of ischaemia should be performed first, although hand ischaemia is one of the indications for BAT.
Brachial artery transposition with an arteriovenous fistula
BAT is combined with an AVF in patients considered to be at high risk of maturation failure. An AVF was considered to be at a high risk of failure when it failed to achieve an access flow of > 500 mL/min, vein diameter of > 4 mm, depth of < 6 mm, and length of > 10 cm.
The ultrasound dilution method and duplex ultrasound were used to measure access flow. Recent Japanese and European VA guidelines further suggest that AVF with an inadequate artery and/or vein diameter of < 2 mm or a vein cannulation site < 10 cm in length represent a high risk of maturation failure.
A single venous cannulation site with a diameter of > 4 mm and a depth of < 6 mm was required.
Brachial artery transposition with a central venous catheter
BAT with a CVC was the final option in patients who did not have an adequate return route and in whom another complex or tertiary VA could not be created. One of the complications of CVC was insufficient blood flow.
Fig. 2A–C briefly illustrates the surgical technique. Antiplatelet or anticoagulation agents were discontinued pre-operatively, if permitted by a physician. An approximately 15 cm longitudinal incision was made on the medial side of the brachial artery, under either regional or local anaesthesia. The brachial artery was dissected and exposed from the antecubital fossa towards the axilla. The side branches of the brachial artery were ligated. Attention was paid to the median nerve, which lies adjacent to the brachial artery. The brachial artery was transposed to the ventral aspect of the upper arm. The subcutaneous tissue beneath the brachial artery was sutured to superficialise it. Finally, the skin was used to cover the transposed brachial artery. The estimated length of transposed artery available for cannulation was approximately 10–12 cm.
The cannulation method for the transposed brachial artery was basically the same as that for an AVF. On the removal of the cannula, adequate pressure was applied to the brachial artery to prevent bleeding. The brachial artery was tightly compressed for 5–10 min, followed by further pressing for 10 min with moderate pressure. In Japan, a guiding metallic needle within a 16–19 gauge flexible polypropylene sheath with side holes (e.g., Argyle Medicut Safety Cannula; Covidien Japan, Inc., Tokyo, Japan) is often used for puncturing. Nakamura et al. reported the illustration of the needle.
To reduce the risk of aneurysm formation in the transposed brachial artery, a rope ladder technique is preferable.
After the operation, the patients were followed up every six months in each facility. When the patients returned to the participating facilities, data on patient demographics, comorbidities, medications, dialysis treatment (blood flow rates, duration, and needle size), patency, and complications were collected. Follow up was continued until kidney transplantation, death, or final patency measurement.
The BAT surgical procedure was considered successful when the cannula could be placed routinely and delivered an adequate blood flow for the entire dialysis session. Primary patency of the transposed brachial artery was defined as the interval from BAT until the first intervention for dysfunction or patency measurement of the transposed artery. Secondary patency of the transposed brachial artery was defined as the interval from BAT until the abandonment of the transposed brachial artery or patency measurement. The primary patency of the access circuit was defined as the interval from the time of BAT until any intervention to the whole access circuit including a return route, or patency measurement. The secondary patency of the access circuit was defined as the interval from BAT until access abandonment.
The Kaplan–Meier method was used to assess the primary and secondary patencies of the transposed brachial artery and those of the access circuit. Analysis was performed using GraphPad Prism (version 5.0 for Windows; GraphPad Software Inc., San Diego, CA, USA). The patient survival rate was also estimated using the Kaplan–Meier method. The log rank test was used to compare patency rates.
Patient characteristics and brachial artery transposition success rate
During the study period, 233 patients underwent BAT (4.6% of VA related procedures). Inadequate vessels for VA creation (n = 117), severe heart failure (n = 73), hand ischaemia (n = 16), central vein stenosis/occlusion (n = 9), or a history of catheter/graft infection (n = 8) were the primary reasons for the selection of BAT. Other minor reasons included frequent CVC dysfunction (n = 4), hypotension (n = 4), or frequent arteriovenous access occlusion (n = 2). The characteristics of the patients who underwent BAT are shown in Table 1. The mean patient age was 71.4 years (range 21 – 93 years).
Table 1Characteristics of the patients who underwent brachial artery transposition (BAT) for vascular access
In 127 patients (55%), simple BAT was performed, with superficial veins cannulated for the return route. BAT was performed together with AVF creation in 63 patients (27%) with a high risk of maturation failure. In this group, an AVF was created in 11 radiocephalic (17%), 41 brachiocephalic (65%) (31 cases in the median cubital region and 10 cases in the upper arm region), three brachiobasilic (5%), five forearm ulnar-basilic (8%), one forearm radial-basilic (0.2%), and two brachial-superficialised brachial veins (0.3%). In 41 patients (18%) with a CVC, BAT was performed to obtain a drawing route because of insufficient blood flow from the catheter.
Bilateral BATs were performed in 14 patients, mainly because the return route ipsilateral to the older transposed brachial artery was wasted (six cases of arteriovenous access dysfunction including four cases with thrombosis, two cases of vessel damage, and two cases of CVC dysfunction). Dysfunction of the transposed artery occurred in four patients (two stenosis, one thrombosis, and one aneurysm). In 13 cases, ipsilateral venous routes were available as return routes. Bilateral transposed arteries were used as inflow/outflow routes in only one case. Generally, the transposed brachial artery is not used as a return route.
Five obese patients (body mass index > 30 kg/m2) were included, all of whom experienced no complications throughout the study period. The mean operation time was 99 min (range 40 – 353 min). In the case with the longest operation time (353 min), BAT and AVF ligation were performed simultaneously because of severe heart failure. The mean post-operative follow up duration was 19 months (range 0 – 73 months). The most frequently used needle size was 17G (45%), followed by 19G (41%), 16G (12%), and 18G (2%). The average duration of dialysis session was 228 min (range 180 – 300 min). Most patients underwent three dialysis sessions per week. The average dialysis blood flow rate was 184 mL/min (range 100 – 250 mL/min).
In 227/231 patients (98%), the transposed brachial artery was available with adequate blood flow for haemodialysis. The first successful cannulation was achieved at a median of 18 days after transposition. In two cases, BAT was performed in anticipation of initiating haemodialysis treatment; however, neither of these pre-dialysis patients required haemodialysis treatment during the study period because their kidney function did not deteriorate. BAT was not successful in the following four patients: patient 1, who had alcoholic cirrhosis, died of pneumonia before cannulation; patient 2 died of severe heart failure before the first cannulation; patient 3 had thrombosis of the transposed brachial artery soon after the operation; and patient 4 had a transposed brachial artery that could not be cannulated because of skin necrosis.
Patency rates and patient survival rates
The primary patency of the transposed brachial artery itself was high, with a rate of 93% and 88% at one and two years, respectively (Fig. 3). The secondary patency of the transposed brachial artery was also high, with a rate of 96% and 93% at one and two years, respectively (Fig. 3). The primary patency of the access circuit was 65% and 54% at one and two years, respectively, and the corresponding secondary patency was 75% and 64% at the same intervals (Fig. 4).
The patients were grouped according to the access types of BAT: simple BAT, BAT with an AVF and BAT with a CVC (Table 2, Table 3). The primary and secondary patencies of the transposed brachial artery itself in each group were not different. The primary patency of the access circuit of simple BAT was better than that of BAT with an AVF (p < .001). However, the difference in the secondary patency of the access circuit between simple BAT and BAT with an AVF was not significant (p = .56). The secondary patency of the access circuit of BAT with a CVC was lower than that of simple BAT (p = .038). The patient survival rates were 84% and 74% at one and two years, respectively (Fig. 5).
Table 2Brachial artery transposition (BAT) patency rates for vascular access in three categories: simple BAT, BAT with arteriovenous fistula (AVF), and BAT with central venous catheter (CVC)
The post-operative complications are shown in Table 4. Forty patients (17%) developed 47 complications. Impaired wound healing occurred in 13 cases (5.6%), including two cases with severe skin necrosis requiring surgical debridement (0.9%). One of the reasons for impaired wound healing was a longer skin incision, which was needed for an adequate length of artery transposition. After debridement, the transposed brachial artery was available in one case. In the other case, there was brachial artery bleeding accompanied by skin necrosis, and ligation of the brachial artery was performed before the first cannulation. Fortunately, the clinical symptom of hand ischaemia did not appear. Wounds were non-invasively treated in the other 11 cases.
Table 4Operation related complications in 233 patients undergoing brachial artery transposition (BAT) for vascular access. Forty patients (17%) developed 47 complications
Six patients (2.6%) developed a large aneurysm (> 20 mm). In five of the six cases, the aneurysms were followed up without any intervention because there were no signs of rupture or infection: the remaining transposed artery could be cannulated in four cases and the transposed brachial artery was abandoned in one case because cannulation was difficult while avoiding the aneurysm. The remaining one large aneurysm was surgically removed because of infection. Reconstruction of the brachial artery was performed with vein patch angioplasty to maintain the function of the transposed brachial artery.
Five patients (2.1%) developed brachial artery thrombosis. Two patients had ischaemia and were managed by surgical thrombectomy. Three patients did not have symptoms of ischaemia. In one patient without symptoms of clinical ischaemia, thrombectomy was performed to maintain the function of the transposed brachial artery. In two cases, thrombectomy was not performed because the patients’ general conditions were relatively worse. These patients underwent haemodialysis treatment via a CVC.
In five patients, first onset hand ischaemia occurred during the study period. As mentioned earlier, two patients had brachial artery thrombosis and underwent thrombectomy caused by hand ischaemia which was equivalent to stage 3 in the definition of VA induced ischaemia in the 2018 ESVS guideline.
The hand ischaemia resolved and the BAT could be cannulated after the surgery. In the other three patients who had ischaemia which was classified in the stage 1, brachial artery thrombosis was not detected. Symptoms were persistent, however, they could tolerate the ischaemia. The transposed artery was available for haemodialysis. They were followed up without surgery.
Skin infection occurred in five cases, including two skin necrosis cases and one infected aneurysm case, as described above. Lymphorrhoea occurred in four patients. Four patients showed brachial artery stenosis. There were three haematoma/bleeding events requiring surgery. Subcutaneous haematoma was surgically removed in one case. Bleeding occurred in the case with skin necrosis and infected aneurysm. CVC was selected in one case because of cannulation pain. Cannulation of the brachial artery was abandoned in one case because of the difficulty of puncturing the vessel.
Causes of access failure
In BAT cases, both arterial and return routes were necessary. The causes for access failure are described separately.
Complications from the transposed brachial artery resulted in abandonment of 11 BATs because of impaired wound healing with severe skin necrosis in one case, aneurysm in one case, thrombosis with ischaemia in two cases, stenosis in two cases, haematoma/bleeding in three cases, and cannulation related problems in two cases.
The main reason for failure of the access circuit was dysfunction of a return route. In simple BAT cases, needle punctures cause haematoma, phlebitis, thrombosis, and thickening of the vessel wall resulting in vessel damage. In cases of BAT with an AVF, interventional treatment of the AVF was sometimes needed to maintain the returning routes. In cases of BAT with a CVC, catheter replacement was required when catheter infection or total occlusion occurred.
Vessel damage of the return routes in 22 patients and recovery of cardiac function in three patients were the reasons for the loss of access in the simple BAT group. A new AVF was created after the improvement of cardiac function in three patients. AVF thrombosis in 10 patients and AVF stenosis that could not be treated using angioplasty in four patients were the causes of discontinuation of VA in the BAT with an AVF group. Catheter occlusion in six patients and catheter infection in six patients were the causes of abandonment of the VA.
In this study, the outcomes of VA created using BAT were evaluated. The findings have shown that BAT was a safe and effective alternative method for VA creation in patients in whom VA could not be achieved using conventional techniques. Moreover, BAT showed high primary and secondary patency rates.
Occasionally, BAT (brachial artery superficialisation, in previous reports) is selected as an alternative, permanent VA strategy, especially in Japan. Originally, Brittinger et al. reported the use of a superficialised femoral artery for haemodialysis access in 1969.
Arterial superficialisation including 41 brachial arteries and one femoral artery was performed in patients with vessels not suitable for arteriovenous access, in those with heart failure, or in those with frequent access failure. The patency rate of the superficialised artery was 87% three years post-operatively. In 2012, superficialisation of the radial artery was reported in seven patients by Weyde et al. in Poland.
The indications for radial artery superficialisation were longstanding forearm AVF that had irreversibly clotted and the absence of other prospects for AVF creation. Recently, in a single centre observational cohort study, Nakamura et al. reported the efficacy of brachial artery superficialisation in 24 cases.
Patients who underwent BAT were relatively older and had a lower body mass index. BAT is sometimes performed for frail elderly patients with a high risk of hand ischaemia, heart failure, or central venous occlusion.
BAT differs from AVFs in several aspects. The AVF is usually recommended as the primary option for VA because of the low complication rate.
Conversely, BAT is advantageous in that no waiting time for VA maturation is required. The diameter of the brachial artery is generally adequate for cannulation. Another advantage of BAT is the high patency rate.
When an arteriovenous access is created, anastomosis construction is mandatory. Artery-vein or graft-vein anastomosis generates wall shear stress that may lead to proliferation of vascular cells with neointimal hyperplasia, which eventually causes juxta-anastomosis or graft-vein anastomosis stenosis.
In contrast, the brachial artery is simply transposed in this operation. Therefore, the arterial blood flow is almost physiological except during the haemodialysis session. Such haemodynamically normal flow should provide better patency for this method. Furthermore, BAT itself has a significantly lower risk of infection than AVG creation or CVC placement because no artificial material remains within the body. In addition to such advantages, superficialisation or transposition of the vessels is also useful in obese patients.
However, cannulation for a return route in these patients is sometimes difficult.
BAT also has several disadvantages. The most frequent problem is the lack of a return route. The transposed brachial artery is available only for arterial inflow. In most cases, adequate normal veins are used for blood return. Therefore, if the veins used for the return route have been wasted, the transposed artery becomes difficult to use.
In the present study, the dialysis flow rates in patients who underwent BAT were very low. This characteristic was not peculiar to patients with BAT. According to a national survey, the average dialysis blood flow rate in all haemodialysis patients in Japan was 198 mL/min. In that survey, the average blood flow rate of the transposed brachial artery during haemodialysis was slightly lower (185 mL/min) than those of an AVF (198 mL/min) and an AVG (193 mL/min).
However, the Kt/V was similar in all groups (1.37 in AVF cases, 1.45 in AVG cases, and 1.37 in BAT cases) because the risk of recirculation was low. In patients with BAT, a different route was used for blood return. Patients with a temporary CVC showed the lowest mean flow rates (154 mL/min) and the lowest Kt/V (0.97). Recently, frailty has become extremely common among patients on dialysis, and arteriovenous access creation is difficult in an increased proportion of frail elderly patients. Although BAT has been used for decades as an alternative VA technique, it has not been widely adopted. Hence, it was important and timely to evaluate the efficacy and safety of BAT.
This study had several limitations. It was a retrospective observational study with a limited number of patients treated over a relatively short period. The study was conducted only in Japanese facilities. A plastic catheter is usually used for VA cannulation in Japan, which may not be typical in other countries. These points should be considered when comparing the present findings with those from previous and future studies.
BAT is a safe and effective technique. In this study, the patency of the transposed brachial artery itself was high. The patency of the access circuit was acceptable as a tertiary VA. Although further investigations are needed, BAT can be considered an alternative method of VA creation in patients in whom VA cannot be achieved using conventional techniques.
Conflict of interest
The authors thank Drs. Kei Miyanaka (Department of Nephrology, Kumamoto City Hospital) and Satoko Suemitsu (Department of Nephrology, Kinki Central Hospital) for data collection. We are also grateful to all patients for their invaluable participation.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
In Japan, brachial artery transposition (BAT) is a tertiary haemodialysis procedure.1 Ninety-one per cent of Japanese receive dialysis with an arterial venous fistula (AVF), one of the highest rates in the world.2,3 Notably, most western access guidelines do not discuss BAT.4,5
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