A comparison between transposed brachiobasilic arteriovenous fistulas and prosthetic brachioaxillary access grafts for vascular access for hemodialysis.

Objective: Patients requiring access for hemodialysis in whom radiocephalic or brachiocephalic arteriovenous fistulas cannot be formed or have failed present a significant clinical challenge. We compare outcomes in patients undergoing transposed brachiobasilic arteriovenous fistulas (BBAVF) with expanded polytetrafluoroethylene brachioaxillary access grafts in a single European center.

Methods: We identified all patients undergoing a first upper limb tertiary-access procedure-that is, either BBAVF or brachioaxillary access graft for hemodialysis-between January 1, 2000, and December 31, 2005. The median follow-up was 18.1 months (interquartile range, 8.7-34.9 months). Successful use for dialysis, primary patency, secondary patency, and patient survival was assessed.

Results: A total of 185 patients were identified; 71 had a BBAVF, and 114 had an access graft. The median age was 64.3 years (interquartile range, 50.7-74.4 years). The groups were well matched for age, sex, ethnicity, diabetes, and number of prior access procedures. Significantly fewer BBAVFs were successfully used for dialysis: 69.0% BBAVFs compared with 89.4% access grafts (P = .001; chi(2)). One- and two-year primary patency rates were 45.3% and 40.0%, respectively, for BBAVF and were 56.4% and 43.2% for access grafts (P = .579; log rank). Furthermore, there was no significant difference in secondary patency between the two procedures (P = .868; log rank). We found that surgeons in training had no influence on the primary patency of either BBAVF or access grafts. However, infective complications necessitating an operation were significantly higher in the access graft group (6.2% vs 0%; P = .031; Fisher exact test).

Conclusions: Although more difficult to establish, BBAVFs provide patency at least equivalent to that of brachioaxillary access grafts. However, infective complications are fewer in the BBAVF group. As such, we believe that BBAVF should be the first choice of the vascular access surgeon when fistulas using the cephalic vein are not possible or have failed.