An incision is made over the course of the basilic vein in the proximal upper arm, immediately above the antecubital fossa (Fig. 17.2). The skin incision and the dissection are extended proximally to the axilla and distally to at least the antecubital crease. The incision can be performed as a single, continuous one or a series of shorter “skip” incisions in attempt to reduce postoperative wound complications. The basilic vein courses adjacent to the medial antecubital cutaneous nerve in the upper arm, and thus care should be taken to avoid injuring the nerve. Either the median antecubital or the forearm basilic vein can be used as part of the vein for the access, provided that it is sufficient in terms of caliber and quality. The basilic vein should be dissected throughout its course, with ligation of small branches and over sewing of larger, broad-based branches with silk sutures. The basilic vein was then transected, ligated at the most distal end, and flushed with heparinized saline while noting for any evidence of stenosis or obstruction to the flow. The distended vein is then gently draped over the upper arm in an arc, and the future course of the transposed vein is marked on the skin. The brachial artery is dissected free in the distal upper arm at the site of the planned anastomosis. A tunnel is created along the course marked on the anterolateral arm with the use of a semicircular, hollow tunneling device. The tunneler is passed deep to the subcutaneous tissue near the antecubital fossa and the axilla but immediately below the dermis 6 mm below the skin throughout the region that will actually be used for cannulation. It is important to leave a completely straight section of the vein for at least 6–10 cm for ease of cannulation. A pointed-tipped tunneler is particularly helpful because it facilitates passing of the device in the desired plane. Prior to controlling the brachial artery, heparin can be given systemically. In our practice, we routinely use a standard dose of heparin (i.e., 5000 units) that is smaller than the one used for most other open, arterial revascularizations (i.e., 100 units/kg). The artery is occluded with microvascular clamps, and a 6 mm arteriotomy is created using a #11 scalpel blade and fine arteriotomy scissors. The end-to-side basilic vein brachial artery anastomosis is performed using a running 6–0 monofilament polypropylene suture. If a proximal radial artery measures >1.5 mm and is deemed usable, the brachial artery should be preserved for future use per Society of Vascular Surgery (SVS) vascular access guidelines [10]. Depending on the wound status, optional closed-suction drain can be placed in the bed of the basilic vein harvest and brought out through a separate stab wound on the distal upper arm near the antecubital fossa. Care should be exercised during the wound closure to prevent compressing or kinking the basilic vein that constitutes the access.

The advantage of the two-stage brachiobasilic procedure is that the transposition is not performed until maturation of the vein occurs, thus avoiding a more complicated procedure with possible wound complications until there is assurance that the access will be successful. Additionally the staged approach allows the vein to arterialize and elongate, thereby increasing the available length that can be elevated or transposed rendering it less likely to thrombose [11].

During the first stage, a limited incision is created in the proximal upper arm, and both the basilic vein and the brachial artery are dissected free. The anastomosis is performed end to side using a running 6–0 monofilament polypropylene suture, and the incisions are closed. The vein is then allowed to mature over the next 4–6 weeks. The second-stage procedure is performed when/if the vein dilates sufficiently for cannulation; in our practice we generally use 6 mm as the threshold vein diameter as defined by the KDOQI “rule of 6s.” A continuous incision or a series of skip incisions is made over the course of the vein during the second stage, and the vein is dissected free. The basilic vein is dissected throughout its course, with ligation of small branches and over sewing of larger, broad-based branches. A tunnel is created on the anterolateral surface of the arm in a manner similar to the one described for the single-stage procedure. The anterior surface of the arterialized vein is marked using a marker pen, and the proximal part of the fistula near the anastomosis is controlled with a bulldog clamp followed by fistula transection. The patient is systemically heparinized. The vein is flushed with heparinized saline solution and placed inside the tunnel, with care taken not to twist the vein, using the top marks. The two ends of the fistula are re-anastomosed (venovenous anastomosis) with running 7-0 or 6-0 monofilament polypropylene suture.

While in an ideal setting the vein has sufficient length and the vein can be tunneled in a curvilinear path over the course of the upper arm (Fig. 17.3), ultimately, the management of the basilic vein is dependent on the available length and the body habitus of the patient. If the vein length is somewhat limited and there is a significant amount of subcutaneous tissue, the vein can be simply elevated and the subcutaneous tissue reapproximated deep to the vein, and the vein is simply elevated from its anatomically deep position to lie directly beneath the incision [12]. The medial antecubital cutaneous nerve overlies the basilic vein and must be addressed if the vein will be simply elevated by transecting and re-anastomosing the access (i.e., arteriovenous or venovenous). Simply elevating the basilic vein is somewhat suboptimal for two reasons. First, the mature access courses very medially on the upper arm and can be difficult to cannulate during dialysis. Second, the vein lies immediately below the skin so it would be vulnerable if the wound were to break down (and expose the access). A subcutaneous pocket can be created in this situation by elevation of skin flaps, thereby avoiding having the vein course immediately below the skin, although this option is predicated on there being a sufficient length of vein.

The procedure can be performed as an outpatient procedure; however, patients with significant comorbidities can be admitted overnight for observation. The patient’s electrolytes are checked and the patient is dialyzed as necessary. The patient’s incision and hand function are monitored closely, given the risk of access-related hand ischemia. If closed-suction drains were used, they are usually removed on the first postoperative day if drainage is minimal. Patients are followed in clinic at 2 weeks post procedure, then every 4–6 weeks until maturation of the fistula. For a single-stage brachiobasilic AVF, initial cannulation is usually performed 6–8 weeks after creation. For a two-stage brachiobasilic AVF, the AVF is assessed for maturation and patients scheduled for the transposition procedure after 4–6 weeks. Initial cannulation is usually performed at least 3 weeks following the second procedure.

The extensive dissection required during the vein mobilization is associated with increased risk of subsequent hematoma (3–7 %) compared to non-transposed AVF [4, 5]. Hematoma has been reported to predispose to fistula thrombosis in most cases and thus may require evacuation to preserve the newly created AVF [13]. This has led some to recommend placement of drains in the incisions, though this is not a standard practice [11]. Additionally, hematoma formation can occur during early attempts at cannulation before the tunneled has healed and the vein fully matured; thus, some recommend a period of at least 6 weeks following a single-stage AVF creation before cannulation.