facilitate successful cannulation of arterialized veins with inaccessibility. However, a fundamental resolution regarding the clinical value of this technique has not yet been reached, and a certain risk of mis-cannulation and patient burden inevitably remains. Additionally, ultrasound guidance requires advanced technical skill. Given these facts, adjunctive elevation should be used to improve the accessibility by decreasing the depth and lengthening the accessible segment of the arterialized vein, which will in turn minimize the incidental risk of mis-cannulation and its related complications.
The elevation technique was recently adapted to one- or two-stage TBBAVF construction as an alternative combined superficialization procedure of tunnel transposition, as mentioned earlier (Figs. 1, 2). Furthermore, several reports have suggested the practical feasibility of AVF creation combined with the elevation of deeply located forearm and upper arm cephalic veins in a one- or two-stage procedure [10, 22, 23].
The outcomes of various elevation procedures were evaluated in a retrospective study conducted by Bronder et al. [10]. The authors assessed 295 cases of vein elevation (172 brachiocephalic fistulas, 70 brachiobasilic fistulas, 46 radiocephalic fistulas, and 7 superficial femoral vein fistulas) performed in a one- or two-stage procedure. The two-stage procedure included revisional elevation implemented within certain terms after fistula construction. The authors demonstrated that these elevations provided acceptable functional primary and secondary patency as a whole and found no significant differences in any outcomes based on the anatomic site of elevation or whether the procedure was performed in one or 2 stages [10].
Lipectomy and Liposuction
Lipectomy and liposuction are mostly utilized for patients with obesity as a surgical revision to improve routine cannulability. These procedures avoid the tunnel transposition- or elevation-related adverse events attributable to the impairment of the venous wall and configuration or superimposition of the scar. The substantial durability and safety of lipectomy to superficialize the deep arterialized forearm cephalic vein after creation of a radiocephalic fistula were demonstrated by Bourquelot et al. [24] in a single-center prospective study of 49 consecutive patients. Several reports have suggested the feasibility of ultrasound-guided liposuction to reduce the subcutaneous adipose tissue overlying the planned cannulation segments of the AVF, but this procedure is yet to be studied in a large series [25].
Conclusion
Superficialization of the venous part of a fistula is characterized by methodological diversity. Tunnel transposition and elevation are reliable procedures to maximize the availability of a deeply located autologous vein in the constructive process of an alternative form of an AVF, especially a TBBAVF. Elevation as well as lipectomy and liposuction are also utilized in revisional interventions to improve accessibility by approximating the distance from the skin to the arterialized vein.
Both careful assessment of the adaptability of superficialization and adequate comprehension of the inherent advantages and limitations of each superficialization modality will facilitate the optimal construction and maintenance of the alternative autologous AVF. This is especially important in patients who cannot undergo conventional AVF construction or in whom cannulation difficulties are encountered. Utilization of the techniques described here could lead to better outcomes and successful management of HD.
Acknowledgments
The authors thank Mr. H. Kobayashi, Medical Technologist at Central Clinical Laboratory, Kansai Rosai Hospital for his constructive comments and invaluable input.
Disclosure Statement
The authors have no conflicts of interest to disclose.
Funding Source
The authors received no funding for this work.
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