Superficialización de la vena basílica. Pierre BOURQUELOT, Paris

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1 Superficialización de la vena basílica. Pierre BOURQUELOT, Paris 1

2 Basilic Vein Superficialization. Pierre BOURQUELOT, Paris 2

3 (Upper arm) Basilic Vein 3

4 Technique 2-stage Basilic Vein Tunnel-Superficialization (BVTS)

5 Preoperative Examination 2-stages BVTS

6 Clinical Examination Median Antecubital Vein Basilic Vein 6

7 Duplex Scan Basilic Vein Median Antecubital Vein 7

8 CO 2 Phlebography Brachial Veins Basilic Vein Median Antecubital Vein 8

9 Phlebography (Infant) Central Veins Basilic Vein 9

10 First Stage End to side anastomosis: between the brachial artery and the median antecubital vein

11 Basilic Vein at the Elbow MEDIAN ANTECUBITAL VEIN BASILIC VEIN 11

12 BVTS : 1 st stage A side-to-end anastomosis is created between the brachial artery and the median antecubital vein. When this branch of the basilic vein is absent, the upper part of the forearm basilic vein is used. We routinely use preventive haemostasis and surgical microscope 12

13 BVTS : Second Stage 2 months later, after Duplex scan The dramatic enlargement of the diameter of the vein and thickening of its wall facilitate dissection and transposition through an anterior subcutaneous tunnel. Usually, the vein is reconnected to the brachial artery or end-to-end venous anastomosis is done.

14 BVTS : 2nd stage A longitudinal skin incision is made along the medial upper arm. The vein is dissected free with ligation of side branches, and careful attention to adjacent nerves. 14

BVTS : 2nd stage The vein is divided at its lower extremity, flushed with heparinized saline solution and transposed through a separate anterior

15 BVTS : 2nd stage The vein is divided at its lower extremity, flushed with heparinized saline solution and transposed through a separate anterior superficial tunnel, taking great care to avoid any angulation or twisting. Most frequently, a new anastomosis is created above the first one. 15

16 BVTS Four weeks should elapse postoperatively before the first cannulation. 16

17 BVTS 1-year old child (8kg) was first used at 1.5 y. and ligated 3 years after successful kidney transplantation 17

18 Basilic V. Elevation with skin closure above the vein, is not recommended. Cannulation through the overlying scar may be difficult in case of scar keloid hypertrophy. 19

19 BVTS : One stage vs. two-stage procedure 1976 Dagher : one-stage El Mallah, 40 randomised patients: Primary Patency (15 mos) = 50% (1-stage) and 80% (2-stage) 2015 Kakkos Lazarides, randomized trial : 2 stages transposition achieves higher rates of maturation and secondary patency. 20

20 BVTS vs PTFE Primary Patency Primary patency rate after 2 years for Basilic (86%) was far superior to PTFE (49%). Complications occurred two and a half times more frequently in the PTFE group. 100 % 50 0 [VALE UR]% [VALE UR]% 2 year (p<0,001) Coburn J Vasc Surg, BVTS 47 PTFE 21

21 BVTS vs. AVF Median Duration >1000 accesses in 544 consecutive patients over a 13-year period. The median duration of BVTS exceeded 5 years, in contrast to distal AVF (>7 years) and to Graft (<1 year) PTFE BVTS Rodriguez NDT, 2000 Br-Cephalic R-Cephalic 22

22 Personal data Basilic Vein Tunnel Superficialization

23 Bourquelot : 434 AVF / 380 children PATENCY RATES % months R-Cephalic B-Basilic B-Cephalic Graft Pediatric Nephrol,

24 Bourquelot: 106 Adult Patients 110 BVTS in 106 ESRD adult During 2-year interval mean age = 59 years (21 to 86) 26% = obese (BMI > 30.0) 1st AVF in 23% of patients diabetes = 35%, hypertension = 82% mean follow-up: 18 months

25 Early Complications (after stage 1) 6 juxta-anastomosis stenoses: surgery 2 AVF conversions into PTFE grafts 3 severe hand ischemia : 2 ligations, 1 PTFE distalisation

26 First Cannulation No maturation problems after the second stage. Cannulation authorised from the 4th week, only because earlier punctures would expose to subcutaneous bleeding at removal of needles.

27 Late Complications (after stage 2) 16 stenoses located in the upper part of the superficialised vein PTA + stent in 1 case 1 acute thrombosis successfully treated by interventional radiology 1 high flow (2 l/min) + grade I distal ischemia

28 BVTS after 9 years

29 Immediate result after PTA

30 Late Complications (after stage 2) 16 stenoses mainly located in the final part of the superficialised vein PTA + stent in 1 case 1 acute thrombosis successfully treated by interventional radiology 1 high flow (2 l/min) + grade I distal ischemia

31 Late Complications (after stage 2) 16 stenoses mainly located in the final part of the superficialised vein PTA + stent in 1 case 1 acute thrombosis successfully treated by interventional radiology 1 high flow (2 l/min) + grade I distal ischemia

32 Distalisation-PTFE de l anastomose artérielle Cephalic/Basilic vein PTFE Brachial artery

33 BVTS - Bourquelot Primary patency Secondary patency 61% 81% 34

34 Discussion BVTS can be created in the vast majority of patients. Unfortunately, the basilic vein is sometimes damaged, especially after previous placement of prosthetic graft. 2 stage-bvts achieves much better results than traditional 1- stage BVTS.

35 Conclusion 2 stage-bvts: Try it, You'll Like It!

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