The Transposed Forearm Loop Arteriovenous

Fistula: A Valuable Option for Primary

Hemodialysis Access in Diabetic Patients
Jonathan Y. Gefen, MD, David Fox, MD, Gary Giangola, MD, FACS, Douglas R. Ewing, MD,
and Ira S. Meisels, MD, New York, New York

The distal forearm is the site of ®rst choice for creation of an arteriovenous ®stula for hemodi-
alysis. The archetypal procedure, the primary radial-cephalic ®stula as described by Brescia,
yields excellent functional patency for many patients. Results are much less favorable in patients
with diabetes mellitus, for whom non-maturation rates as high as 70% have been reported. This
is likely due to inadequate in¯ow caused by atherosclerotic disease of the forearm arteries in
diabetics. Secondary autologous access procedures often involve upper arm con®gurations
such as transposed brachial-basilic ®stulas. The present study focuses on a valuable alternative
for hemodialysis access in diabetic patients, the transposed forearm loop arteriovenous ®stula.
Over a 2-year period, 16 forearm loop ®stulas were created in 16 diabetic patients who either
had a failed radial-cephalic ®stula or had arterial anatomy deemed inadequate for wrist ®stula
formation. In each case, the forearm segment of the basilic or cephalic vein was transposed to
form a U-shaped loop and anastomosed to the brachial, proximal radial, or proximal ulnar artery
distal to the antecubitai fossa. Functional patency was de®ned as usability for dialysis. Patency
rates were calculated by Kaplan-Meier survival analysis. From our results we determined that
the forearm loop ®stula is an excellent but underutilized technique that exploits the forearm veins
while circumventing the distal arterial supply, thus preserving the upper arm vasculature for
future use.

INTRODUCTION tients require a secondary procedure that has

The Brescia-Cimino radiocephalic ®stula, described
in 1966,1 has been considered the procedure of ®rst
choice for vascular access for hemodialysis.2,3 Many
patients, however, have anatomy that is inade-
quate for creation of a wrist ®stula. These pa-
St. Luke's±Roosevelt Hospital Center New York, NY.
Presented at the Twenty-sixth Annual Meeting of the Peripheral
Vascular Surgery Society, Baltimore, MD, June 9, 2001.
Correspondence to: D. Fox, MD, 425 West 59th Street, Suite 7B, New
York, NY 10019, USA, E-mail: dfox@¯ashnote.net.
Ann Vasc Surg 2002; 16: 89-94
DOI: 10.1007/s10016-001-0141-5
Ó Annals of Vascular Surgery Inc.
Published online: 17 January 2002
usually involved a prosthetic graft or an upper arm
®stula.
Patients with diabetes mellitus present the sur-
geon with particular dif®culties when planning
new hemodialysis access. Whereas the Brescia-Ci-
mino ®stula has been well documented to yield
long-term patency as high as 83% overall, results
have been less satisfactory for diabetic patients. Our
own experience and those of other series indicate
signi®cantly lower rates of initial maturation and
function of Brescia-Cimino ®stulas in diabetics
than in nondiabetics.4-8
In light of the shortcomings of the Brescia-Ci-
mino ®stula in diabetics, alternative methods have
been explored. Prosthetic grafts are commonly
employed, but numerous studies have shown an

89
90 Gefen et al. Annals of Vascular Surgery

Fig. 1. Transposed forearm loop ®stula con®gurations.

increased morbidity and cost of hemodialysis using Table I.

prosthetic grafts versus autologous ®stulas.9-13
Indications n
Prosthetic grafts have been associated with short-
ened duration of patency and earlier onset of Failed Alien's test 5
complications in diabetics than in nondiabetics.14 Calci®ed wrist artery 3
The 1997 publication of Dialysis Outcomes Quality Small wrist artery 3
Initiative (DOQI) Guidelines by the National Kid- Nonmaturing Brescia-Cimino ®stula 2
ney Foundation has challenged vascular surgeons Absent or weak radial pulse 2
to signi®cantly increase the proportion of autolo- Low ¯ow velocity (19 cm/sec) 1
gous ®stulas to prosthetic grafts.15 Consequently, Total 16
interest in upper arm autologous ®stulas, such as
brachial artery±transposed basilic vein ®stulas, has METHODS
increased. This approach has improved results over
Brescia-Cimino ®stulas in diabetics,6 but it fails to During a 21-month period between 1999 and 2001,
take advantage of the more distal veins of the ex- 16 diabetic patients who had satisfactory forearm
tremity. veins, but arteries deemed inadequate for a Brescia-
In the present study, we review our early ex- Cimino ®stula, were selected for a transposed
perience with an underutilized option for autolo- forearm loop arteriovenous ®stula (AVF). Table I
gous hemodialysis access in diabetic patients, the lists the speci®c indications for selection. A failed
transposed forearm loop arteriovenous ®stula. Allen's test was the most common indication. Me-
Figure 1 illustrates some examples of the con®gu- dian patient age was 69 years with a range from 53
rations of this type of ®stula. This alternative avoids to 88 years. There were seven males and nine fe-
use of the forearm arteries, which in diabetics are males. Table II summarizes additional patient
frequently atherosclerotic and inadequate for ®s- demographics and comorbidities.
tula creation, while still making full use of the Preoperative vein mapping with Doppler ultra-
forearm veins. sound was performed in all cases. Duplex assess-
Vol. 16, No. 1, 2002 Transposed forearm loop AVF for diabetics 91

Table II. Patient demographics and comorbidities Table III. Transposed forearm loop ®stula con®g-
urations
Factor n
Con®gurations n
Comorbid conditions
Diabetes 16 Brachia artery±basilic vein 9
Hypertension 15 Brachial artery±cephalic vein 2
Coronary artery disease 7 Proximal ulnar artery±cephalic vein 2
Congestive heart failure 7 Proximal radial artery±cephalic vein 2
Tobacco use 5 Proximal radial artery±basilic vein 1
Peripheral vascular disease 4 Total 16
Prior arteriovenous access
None 11
Prior ipsilateral access 3
Prior contralateral access 2 Eight weeks were allowed for maturation of the
Postoperative anticoagulation ®stula prior to use. A baseline duplex ultrasound
Aspirin 14 scan was routinely obtained just prior to initial
Warfarin 2 cannulation. An attempt was made to perform
Total 16 surveillance duplex examinations at 3-month in-
tervals. For the purposes of survival analysis, ®s-
tulas were considered patent if successful
ment of the radial and ulnar arteries at the level of cannulation and adequate ¯ow rates for dialysis
the wrist, and brachial artery at the level of the were achieved. Fistulas that thrombosed prior to
elbow, was performed in nine cases. Duplex initial cannulation or that failed to mature after 8
imaging was performed in accordance with our weeks were assigned a patency of 0 days. Patent
previously reported protocol.16 The forearm ce- ®stulas that later thrombosed were subjected to
phalic vein was selected for use in 11 cases, and the interventional or surgical thrombectomy at the
forearm basilic vein in 5. The in¯ow artery was the discretion of the attending surgeon. Fistulas that
brachial artery in 11 cases, the proximal radial ar- demonstrated inadequate hemodialysis parameters,
tery in 3 cases, and the proximal ulnar artery in 2 signi®cant stenosis by duplex criteria, or abnormal
cases. An effort was made to utilize the proximal physical examination underwent ®stulography.
radial or ulnar arteries in preference to the brachial Balloon angioplasty was performed as indicated to
artery in order to minimize the potential risk of maintain patency. Kaplan-Meier survival curves
ischemic complications.17 Table III summarizes the were calculated using SYSTAT 9 statistical software
various ®stula con®gurations that were construct- (SPSS Science, Chicago, IL).
ed. The most common con®guration was the bra-
chial artery to basilic vein.
The procedures were performed under regional RESULTS
anesthesia with either an axillary or interscalene
nerve block, supplemented by intravenous seda- Median follow-up was 11 months with a range of
tion. A longitudinal incision was made along the 1-18 months. There were no perioperative com-
course of the selected forearm vein. The vein was plications or deaths. There were no ischemic com-
dissected free, and tributaries were ligated and di- plications or steal syndromes. There were six (37%)
vided. A U-shaped subcutaneous tunnel on the early failures due to thrombosis (n = 2) or failure to
volar aspect of the proximal forearm was created mature (n = 4). Two ®stulas occluded at 3 and 5
with Metzenbaum scissors. One or two apical months, respectively.
counterincisions were used to facilitate tunneling The occlusion at 3 months occurred in a patient
of the vein. The vein was marked with ink on the who required external compression for prolonged
anterior surface to help prevent twisting during bleeding after decannulation. Subsequent surgical
passage through the tunnel. Systemic hepariniza- thrombectomy and revision of a lacerated segment
tion was not performed. Regional heparin was used of the ®stula were performed. The patient experi-
occasionally. The arteriovenous anastomoses ran- enced a second thrombotic episode 2 months later
ged from 6 to 10 mm in size and were constructed that was treated by percutaneous thrombectomy.
in an end-to-side fashion with 7-0 polypropylene The ®stula remained patent until the patient ex-
under loupe magni®cation. Incisions were closed in pired 1 month later.
two layers with interrupted subcutaneous and The occlusion at 5 months occurred spontane-
running subcuticular absorbable sutures. ously in a patient who was then successfully
92 Gefen et al.
Fig. 2. Patency of transposed forearm loop ®stulas in di-
abetics. Dashed line represents primary patency. Solid line
represents overall patency. Italicized numerals represent
the number of patients at risk for each time interval.
treated with interventional thrombectomy. A focal
stenosis at the out¯ow end of the loop at the level
of the elbow was dilated with percutaneous balloon
angioplasty. Three months later, a new stenosis at
the apex of the ®stula was discovered on surveil-
lance duplex examination. This lesion, separate
from the previously treated lesion, was dilated with
balloon angioplasty. The ®stula remained patent at
the time of this review.
Figure 2 illustrates the Kaplan-Meier survival
curves for primary patency and overall patency.
Primary patency was 43% at 18 months. Overall
patency was 62% at 18 months.
DISCUSSION
The transposed forearm loop AVF has received little
attention in the surgical literature. In 1983, Moris
and Kinnaert from Belgium reported their experi-
ence with the brachial artery±forearm vein ®stula as
a subset of a series of AVF at the elbow.18 Elcheroth
et al. enlarged the pool of patients and extended the
results in a follow-up report in 1994.19
Our ®nding of 62% overall patency at 18
months is comparable to the results of the previ-
ously published series. Moris and Kinnaert reported
a 64% overall patency at 2 years in their 1983
study.18 Elcheroth et al. reported a 63% overall
patency at 2 years and 52% patency at 4 years in
their 1994 study.19
Annals of Vascular Surgery
The technique appears to be particularly well
suited for patients with diabetes mellitus. Diabetes
is a signi®cant factor in renal failure, accounting for
over 35% of new cases in the United States.20
These patients frequently have atherosclerotic dis-
ease of the arteries of the forearm, precluding
successful function of a Brescia±Cimino ®stula. The
transposed forearm loop ®stula receives its in¯ow
at the antecubital fossa, bypassing the diseased di-
stal vessels. Unlike other antecubital and upper arm
con®gurations, however, it makes use of the fore-
arm veins, which can be satisfactory for ®stula
function despite the presence of signi®cant arterial
disease. Reliable, long-term hemodialysis access
can thus be established, while preserving the vas-
culature of the upper arm for future use.
A wide variety of studies have found decreased
early and long-term patency of wrist ®stulas in di-
abetics. A less consistently reported ®nding is an
altered long-term outcome for diabetics, with some
studies reporting no difference,21,22 and others re-
porting a decreased long-term patency of Brescia±
cimino ®stulas in diabetics.23-26 Fernstrom et al.
reported a mean patency time of 2.5 months in di-
abetics compared to 11 months in nondiabetics with
radiocephalic ®stulas.23 Leapman et al. reported 1-
and 5-year patency rates of 42% and 18%, respec-
tively, in diabetics, compared with 56% and 30%,
respectively, in nondiabetics.24 Grochowiecki et al.
reported 1- and 3-year patency rates of 40% and
32%, respectively in diabetics, compared with 81%
and 61% in nondiabetics.6
Hakaim et al. reported a nonmaturation rate of
70% for radiocephalic ®stulas in diabetics, vs. 20%
in nondiabetics, and an overall patency at 18 months
of 33% in diabetics, vs. 80% in non-diabetics.7 They
achieved far better results in diabetics with upper
arm ®stulas than with radiocephalic ®stulas: the
nonmaturation rate was 0% for brachiobasilic and
27% for brachiocephalic upper arm ®stulas. The
overall patency at 18 months was 78% for brachio-
cephalic and 79% for transposed basilic vein ®stulas.
Lin et al. found a higher rate of early failure of
radiocephalic ®stulas in diabetics (18.1%) than in
nondiabetics (10.6%). Furthermore, in the sub-
group of elderly patients, they found an early fail-
ure rate of 28.6% in elderly diabetics, compared to
10.3% in elderly nondiabetics.5
The ®nding that the combination of diabetes with
old age markedly increases the risk of ®stula failure is
particularly remarkable in the context of the current
study. With a patient pool composed exclusively of
diabetic patients with a median age of 69, unsatis-
factory results could be expected. Instead, our re-
sults are similar to those of the previously published
Vol. 16, No. 1, 2002
forearm loop ®stula series, which included nondia-
betics and a younger patient pool. Moris and
Kinnaert included a mixed diabetic and nondiabetic
population with a median patient age of 50 in their
1983 study.18 Elcheroth et al. included a mixed
population with 59% of patients over 50 years of age
in their 1994 study.19 These results support the no-
tion that the transposed forearm loop ®stula may
provide improved function for diabetic patients.
All of the patients included in this study were
selected because of a clinical or sonographic ®nding
of arterial insuf®ciency in the forearm. Preopera-
tive duplex imaging has been demonstrated to in-
crease the use of autologous ®stulas and to improve
patency and early failure rates.27-30 However, no
consensus has been reached in identifying precise
criteria for noninvasive selection of upper extrem-
ity arteries. One approach involves assessing the
arterial size by duplex imaging. Proposals for min-
imum acceptable diameter of the radial artery lu-
men range from 1.7 mm28 to 2.0 mm29 or 2.5
mm.30 Another approach involves estimating the
arterial physiologic reserve by measuring ¯ow
volume with Doppler ultrasound. Malovrh de-
scribes a method in which clenching and un-
clenching the ®rst results in arterial dilatation and a
change from a triphasic to a low-resistance wave-
form, indicating a capacity for increased ¯ow.31
Such forms of objective assessment could help re-
®ne the identi®cation of patients most likely to
bene®t from a transposed forearm loop ®stula.
CONCLUSIONS
We consider the transposed forearm loop ®stula to
be the primary access procedure of choice for dia-
betic patients with signi®cant arterial disease of the
forearm.
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