Basilic Vein Transposition to Fistula Vein for Hemodialysis Access: A Single-Center Experience

Basilic Vein Transposition to Fistula Vein for Hemodialysis Access: A Single-Center Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Basilic Vein Transposition to Fistula Vein for Hemodialysis Access: A Single-Center Experience Xingjian Li, Dan Wu, Xiaowei Song, Bo Yang, Qiongli Liu, Chang You, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9324147/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Objective This study aimed to evaluate the outcomes of basilic-to-fistula venovenous transposition as a salvage strategy for refractory outflow venous stenosis or occlusion in patients with end-stage kidney disease (ESKD). The study focused on assessing the technical feasibility, patency rates, and complication profiles associated with this procedure. Methods 9 cases of basilic-to-fistula venovenous transposition at a single center between December 2023 and March 2026 were reviewed retrospectively. Data including demographics and postoperative complications were collected. Primary and secondary patency rates were determined by using Kaplan-Meier methods. Results The mean age of the cohort was 67.8 ± 7.2 years, with 7 males and 2 females. Renal failure was complicated with hypertension in 100%, and with diabetes in 22.2%. The average follow-up time was 16.20 ± 7.34 months. All fistulas were successfully used for dialysis within 48 hours postoperatively. The primary patency rate, primary assisted patency rate and secondary patency rate was 88.9%, 100%, 100% at 3 months, 76.2%, 87.5%, 100% at 6 months, and 63.5%, 87.5%, 100% at 1 year. 2 patients experiencing wound hemorrhage at the surgical site, and no patients developed early thrombosis, hematoma, nerve injury, wound infection, or clinically significant access-related steal. Conclusion Basilic-to-fistula venovenous transposition provides an effective autogenous solution for patients with complex ESKD access obstruction refractory to endovascular therapy. This procedure offers early functional usability, a favorable safety profile, and reduces the reintervention burden. Basilic-to-fistula venovenous transposition Outflow venous obstruction Hemodialysis access Outcomes Patency Figures Figure 1 Figure 2 Figure 3 Introduction End-Stage Kidney Disease (ESKD) represents a significant global public health burden. It is estimated that by 2023, 4.59 million people worldwide will suffer from kidney failure requiring kidney replacement therapy (KFRT), with approximately 3.57 million individuals undergoing maintenance dialysis[ 1 ]. The maintenance of dialysis access is a critical factor influencing the survival rate and quality of life of dialysis patients. Autologous arteriovenous fistula (AVF) is widely regarded as the preferred vascular access[ 2 ]. Despite a lower overall complication rate of AVF compared to other access, complications such as fistula stenosis remain a significant clinical concern, particularly in elderly patients and those with multiple comorbidities. Percutaneous transluminal angioplasty (PTA), due to its minimally invasive nature, lower complication rates, faster recovery, and repeatability, is widely considered the first-line treatment for AVF stenosis or occlusion in hemodialysis patients. Other treatment strategies include stent placement, AVF reconstruction, and arteriovenous grafts (AVG)[ 3 , 4 ]. For patients with long-standing and severe stenosis or occlusion of the venous limb of the fistula, particularly those relying on a single deep venous compensatory return, conventional endovenous treatments may not yield satisfactory results. In such cases, autologous vein bypass surgery can serve as a crucial salvage strategy. We performed venovenous anastomosis between the basilic vein and the fistula vein to establish effective venous return and improve the patency of the AVF. In this study, we describe patient selection, surgical techniques, access maturation, and patency outcomes associated with this strategy. Methods Patients. This was a descriptive case series based on electronic medical records supplemented by telephone follow-up. We identified 9 patients who underwent basilic-to-fistula venous venovenous transposition at our institution between December 2023 and March 2026 and abstracted demographic characteristics, postoperative complications, and patency outcomes. Consent was waived because patients were not directly studied and the data collection was retrospective. All data were extracted from routine care documentation and analyzed in de-identified form in accordance with institutional policy. All candidates met the indications for surgical intervention included outflow venous total occlusion with single deep venous compensatory return, frequently recurrent stenosis (requiring angioplasty in 50% after angioplasty), and other lesions not amenable to endovascular interventions. During the study period, five nephrologists performed the reconstructions. Management. All patients underwent preoperative ultrasound assessment to evaluate the diameter, wall quality, and feasibility of forming a tension-free tunnel in the basilic vein, and to mark its anatomical course. The procedure was performed under local anesthesia. After preparing and draping the entire arm, a single longitudinal incision was made at the site of the marked basilic vein on the forearm. The subcutaneous tissue was dissected to expose the basilic vein. The tributaries of the basilic vein and its communication with the brachial vein were ligated or divided. The distal end of the basilic vein was then ligated with non-absorbable sutures, and the vein was dilated with saline. A second skin incision was made to expose the distal end of the fistula vein at the site of the lesion. A subcutaneous tunnel was created, through which the basilic vein was passed, and an end-to-side anastomosis was performed using non-absorbable sutures to connect the basilic vein to the fistula vein (Fig. 1 ). Finally, the vascular clamps were removed, and the patency of the basilic vein was checked. The subcutaneous tissue and skin were closed with non-absorbable sutures (Fig. 2 ). We marked the v-v anastomosis on the skin to reduce juxta-anastomotic stenosis. Follow-up. On postoperative day 1, the reconstructed segment was examined for a palpable continuous thrill and an audible bruit. On postoperative day 7, patients were reassessed for early complications, including bleeding/hematoma, surgical-site infection, and nerve injury. At Between 30 to 45 days after basilic-to-fistula reconstruction, Doppler ultrasonography was performed to assess venous diameter, depth, flow rates, and to identify any significant stenosis or aneurysms in the reconstructed segment. Subsequent follow-up assessments were conducted every 3 to 6 months. These follow-up evaluations involved a combination of history-taking, physical examination, and ultrasound assessment focused on the fistula. if any issues were identified, biplane Doppler ultrasonography was performed, including assessment of inflow arterial, venous outflow anatomy, and the flow rates and hemodynamics within the fistula. Clinical Outcomes. Complications and patency rates were evaluated as clinical outcomes. Each patient was examined during outpatient visits, and if an outpatient visit was not possible, follow-up was conducted via telephone. According to the K/DOQI guidelines, primary failure was defined as when AVF could not be used, leading to the creation of a new AVF or requiring radiological or surgical intervention within 30 days. Primary patency was defined as the time from surgery until thrombosis or any intervention aimed at maintaining or restoring patency. Assisted patency was defined as the time from surgery to the need for endovascular or surgical intervention due to stenosis to maintain patency. Secondary patency was defined as the time from access creation to the abandonment of the access[ 5 ]. Statistical Analysis. Statistical analyses were conducted using IBM SPSS Statistics (version 26.0; Armonk, NY) and R 4.3.2. Kaplan-Meier survival analysis was used to estimate the primary, assisted primary, and secondary patency rates. Data are presented as either percentages or as mean ± standard deviation. Results The demographic and baseline characteristics of the 9 patients are summarized in Table 1 . Of the patients, 7 were male and 2 were female. All patients had hypertension, and 2 patients (22.2%) had diabetes mellitus. The mean age was 67.78 ± 7.17 years. 7 patients manifested enhanced pulsation of the fistula vein and elevated venous pressures during hemodialysis sessions, whereas 2 patients developed thrombotic occlusion of the cephalic vein. Preoperative Doppler ultrasound demonstrated a mean basilic vein diameter of 2.0 ± 0.28 mm in our cohort. Among all patients, the average surgical time was 158 ± 41.80 minutes, and the mean length of hospital stay was 5 ± 1.94 days. All patients received an end-to-side anastomosis between the fistula vein and the intraoperatively dilated basilic vein. Most patients also underwent fistula outflow vein angioplasty, and 1 patient had resection of the infected segment of the fistula vein. In the postoperative period, palpable thrill returned in the fistula vein of every patient, while venous pulsation was markedly attenuated. All patients were able to successfully complete dialysis via the fistula within 48 hours postoperatively, with 1 patient having his central venous catheter removed on postoperative day 2. Mean intrafistular venous pressure during dialysis decreased significantly relative to preoperative values (166.78 ± 48.22 vs 90.00 ± 35.21, P < 0.005). Early postoperative complications were confined to wound hemorrhage in two patients, which resolved uneventfully after bedside intervention. No instances of hematoma, early access thrombosis, or nerve injury were encountered (Table 2 ). Table 1 Patient demographics and baseline characteristics Baseline Value (n = 9) Age at access placement, years 67.78 ± 7.17 Men 7 (77.8) Body mass index, kg/m² 21.8 ± 3.8 Comorbidities Diabetes mellitus 2 (22.2) Hypertension 9 (100) Cardiovascular diseases 1 (11.1) Congestive heart failure 2 (22.2) Hyperlipidemia 2 (22.2) Hypercoagulability 0 (0) Smoking history 4 (44.4) Manifestation Venous hypertension 6 (66.7) Thrombosis 3 (33.3) Preoperative VP HD * , mmHg 166.78 ± 48.22 non-tunneled CVC 1 (11.1) Statin 1 (11.1) Aspirin 0 (0) Warfarin 0 (0) Preoperative basilic vein diameter, mm 2.0 ± 0.28 VP HD: venous pressure during hemodialysis The average follow-up time was 16.20 ± 7.34 months. One patient died 3 months postoperatively due to diseases unrelated to surgery or surgical complications. No wound infection or clinically significant access-related steal was observed (Table 3 ). The primary patency, primary assisted patency, and secondary patency rates in our cohort were 88.9%, 100%, 100% respectively at 3 months, and 76.2%, 87.5%, 100% at 6 months. The 1-year primary patency, primary assisted patency, and secondary patency rates were 63.5%, 87.5% and 100%, respectively (Fig. 3 ). Re-stenosis of the AVF emerged as the most common postoperative complication during follow-up. Table 2 Surgical events and early complications Events Value (n = 9) Primary failure 0 (0) Operative time, min 129.67 ± 37.55 Basilic vein pedicle length, cm 8.56 ± 3.25 Anastomotic diameter, mm 6.89 ± 0.93 Venous pulsation diminished 7 (77.8) Postoperative VP HD * , mmHg 90.00 ± 35.21 Perioperative complications Hemorrhage 2 (22.2) Hematoma 0 (0) Thrombosis 0 (0) Nerve injury 0 (0) VP HD: venous pressure during hemodialysis Table 3 Early and 12-month outcomes Outcomes Value (n = 9) Follow-up, months 16.20 ± 7.34 At 1 months Primary patency, % 100 Secondary patency, % 100 Wound infection 0 (0) Steal 0 (0) Swealing 0 (0) Mean basilic vein diameter, mm 5.36 ± 0.95 At 3 months Primary patency, % 88.9 Secondary patency, % 100 At 6 months Primary patency, % 76.2 Secondary patency, % 100 At 12 months Primary patency, % 63.5 Secondary patency, % 100 Reintervention rate, events per access-year PTA * 0.92 Open thrombectomy 0.17 Stent placement 0 PTA: percutaneous transluminal angioplasty. Discussion Current international consensus emphasizes that vascular access salvage should be prioritized whenever feasible before abandonment, particularly in patients with limited remaining venous options[ 4 ]. In certain patients with forearm AVFs, superficial venous outflow may become exhausted, manifesting as cephalic vein occlusion or refractory stenosis, accompanied by occlusion of communicating branches with the basilic vein, resulting in reliance on a single deep venous outflow pathway. These patients typically exhibit elevated venous pressure within the fistula, augmented fistula pulsation, and, in severe cases, thrombotic occlusion of the fistula. Although endovascular interventions remain essential in contemporary vascular access maintenance, they are associated with notable limitations, including suboptimal recanalization rates for occlusions and high restenosis recurrence[ 6 ]. Stent deployment may reduce the need for frequent reinterventions; however, its effectiveness in improving patency across joint-related or complex anatomical lesions remains suboptimal. In patients in whom arterial inflow to the fistula is preserved, surgical redirection of venous outflow represents a rational salvage strategy. Previous studies have confirmed that utilization of the basilic vein is feasible and clinically practical in scenarios where the cephalic vein or other forearm veins are unsuitable. Traditional basilic vein transposition fistulas (BVTs) involve mobilizing the basilic vein from its native anatomical position to a more superficial location, and anastomosing it with the brachial artery or its branches. Although the technique demonstrates favorable primary and secondary patency rates, controversy persists regarding the technical choice between one-stage and two-stage procedures and the role of adjunctive endovascular therapy[ 7 ]. Tan et al. observed a higher 12-month primary patency rate for the one-stage approach (49.1% vs 40.4%, P = 0.005) and a comparable secondary patency rate between two approaches (80.0% vs 77.9%, P = 0.538)[ 8 ]. Furthermore, BVT construction creates a new arterialized conduit, which entails risks such as additional arterial anastomosis and prolonged maturation time. Our study differs in anatomic intent and operative design: rather than creating a new inflow-outflow circuit off the brachial artery, we retain the functioning arterial inflow of the index AVF and add a new, superficialized basilic outflow pathway. The approach eliminated the need for fistula maturation time, reduced dependence on central venous catheters and achieved early cannulation of the AVF. The observed functional patency and low access-threatening complication rate are directionally consistent with published outcomes of upper-arm transposition series[ 9 ]. Similar strategies based on grafts were reported for the salvage of failing autogenous arteriovenous fistulas. Short-segment interposition grafting or ‘jump’ graft bypass has been employed to replace or circumvent refractory stenosis or complex anatomical segments in order to re-establish adequate venous outflow[ 10 , 11 ]. Hybrid constructs, such as the HeRO graft, are utilized to circumvent severe central venous stenoses[ 12 ]. When superficial venous options are inadequate, prosthetic arteriovenous grafts (AVGs) are regarded as secondary vascular access alternatives[ 5 ]. However, relative to autogenous vessels, prosthetic grafts are associated with a higher risk of thrombosis, greater susceptibility to anastomotic or bridging segment stenosis, and elevated infection rates. Previous evidences for ePTFE grafts reported a mean 1-year primary patency of 41% (95% CI, 35% to 47%), while a 1-year secondary patency of 70% (95% CI, 64% to 75%). The infection risk was reported to be 9% per patient-year (95% CI, 6% to 12%), which was suggested as a significant contributor to graft failure[ 13 ]. Basilic vein is located on the medial side of the upper arm and is almost free from iatrogenic damage. The anatomical features of the basilic vein make it a reliable autogenous vascular alternative. In the present study, the basilic vein was utilized as an autogenous transposition conduit, thereby avoiding the use of prosthetic material. During the follow-up period, no infectious events were observed in our cohort, and the primary and secondary patency rates remained competitive in comparison with the reported outcomes of AVGs. The approach not only reduces the risk of infection and the economic burden to patients, but also preserves favorable long-term patency of the AVF while minimizing the need for frequent reinterventions. Vein-to-vein anastomosis as a salvage intervention for arteriovenous fistula occlusion remains understudied in large cohorts. Chen et al. reported veno-venostomy in 11 patients following unsuccessful endovascular therapy, including two cases utilizing the basilic vein as the transposed conduit, with assisted primary patency rates approaching 90% over a follow-up period of up to 39 months[ 14 ]. More recent data were provided by Jeong et al., who described cephalic vein transposition to the basilic or axillary vein for refractory cephalic arch stenosis. Technical success exceeded 90%, with 1-year primary patency of 60–65% and primary-assisted patency of 75–80%; restenosis necessitating percutaneous transluminal angioplasty emerged as the most common complication[ 15 ]. The outcomes of these studies align broadly with those of our investigation, underscoring the feasibility of vein-to-vein transposition in alleviating obstructed venous outflow. The ESVS guidelines emphasize the importance of venous caliber and wall quality for fistula maturation, with small diameters (< 2 mm) portending adverse outcomes[ 4 ]. In addition to preserving arterial inflow to the AVF and maintaining patency of central venous outflow, the anatomical characteristics of the basilic vein are pivotal to the success of this procedure and favorable long-term prognosis. Candidates for this surgery require the basilic vein with sufficient diameter and adequate wall quality to fulfill criteria for transposition and superficialization. In our study, the mean preoperative diameter of the forearm basilic vein was 2.0 ± 0.28 mm, and further intraoperative dilation was achieved using saline infusion. The basilic vein should be separated to an adequate length to allow creation of a tension-free subcutaneous tunnel. Concurrently, given the frequently suboptimal wall quality of the original fistula vein, the anastomosis should be appropriately enlarged to mitigate the risk of anastomotic stenosis. Meticulous attention should be paid to confirming that the basilic vein is free of torsion within the tunnel, thereby minimizing swing-segment stenosis. The intraoperative strategies contributed to the early patency we observed. Postoperative physical examination and Doppler ultrasound evaluation at 1 month are imperative. Furthermore, follow-up assessments should be conducted at intervals of 3 to 6 months to enable preemptive angioplasty for focal restenosis. Clinical signs such as elevated venous pressure on dialysis or fistula pulsation require timely ultrasonographic evaluation. Confirmed stenotic lesions or thrombotic events should receive targeted intervention. These pragmatic steps are reproducible and consistent with surveillance principles described in prior transposition series. The overall complication rate was acceptable. Early postoperative wound oozing occurred in two patients and was effectively managed with conservative measures or bedside evacuation. No instances of early thrombosis, infection, or neurological deficits associated with medial upper arm dissection were observed. Clinically significant access-related steal syndrome was absent, consistent with the strategy of preserving the original inflow and eschewing the creation of a new high-flow inflow anastomosis. The time to first cannulation (within 48 hours) compares favorably with literature reports for newly constructed upper arm autogenous or prosthetic accesses, aligning with KDOQI objectives to minimize catheter exposure[ 2 ]. The more superficial and extended venous cannulation segment mitigates hemodynamic bottlenecks, broadens the cannulation window, and diminishes cannulation-related complications stemming from deep, short, or tortuous segments. These practical advantages, combined with reduced implantation costs and shorter operative durations, indicate potential cost-effectiveness compared with BVTs or AVGs, notwithstanding the absence of a formal economic assessment in this study. Furthermore, targeted reinterventions sustained high assisted patency rates for the AVF (100% at 1 year), mitigating the risk of access loss. Our study has important limitations. The modest sample size of patients restricts the generalizability of the findings, and the limited follow-up duration further diminishes the ability to assess long-term outcomes and complications. Additionally, the absence of a control group hinders direct comparisons with alternative surgical strategies or access techniques. Furthermore, selection bias is inherent in the study design, as eligibility criteria required both an adequate basilic vein and preserved arterial inflow, which may not be representative of the broader patient population. These factors collectively temper the interpretability of the results and suggest that larger, multi-center studies with longer follow-up are needed to confirm the findings. Conclusion In patients with forearm AVFs complicated by outflow venous obstruction refractory to endovascular therapy, particularly those reliant on a single deep venous pathway, basilic-to-fistula venovenous transposition effectively redirects a functional autogenous venous outflow route. This procedure broadens the treatment options available for complex ESKD access, enables early postoperative cannulation, sustains favorable long-term patency rates with low complication profiles, and reduces the burden of subsequent reinterventions. Further validation through larger-scale comparative cohorts with extended follow-up is warranted to confirm these findings in salvage strategies for complex outflow-compromised forearm AVFs. Declarations Author Contributions LZJ and YS were responsible for the study conception and design. XJL performed the data analysis and drafted the manuscript. DW, XWS, BY, LZJ and XJL participated in the surgical procedures. QLL and CY were responsible for data collection. All authors reviewed and approved the final manuscript. Ethical considerations Ethical approval for this study was waived by the Ethics Committee of Chengdu Third People's Hospital, because this was a retrospective study based on existing clinical data and images, with no additional intervention or contact with patients. The study was conducted in accordance with the Declaration of Helsinki and its later amendments. Clinical trial number Not applicable. Consent to participate The requirement for informed consent to participate was waived by the Ethics Committee of Chengdu Third People's Hospital because of the retrospective nature of the study. Consent for publication Written informed consent for publication of the representative patient images in this article was obtained from the patient. Declaration of conflicting interest The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding statement The authors received no financial support for the research, authorship, and publication of this article. Data availability The datasets analyzed during the current study are not publicly available because they contain information that could compromise patient privacy, but are available from the corresponding author on reasonable request. References Bello AK, Okpechi IG, Levin A, Ye F, Damster S, Arruebo S, Donner J-A, Caskey FJ, Cho Y, Davids MRJTLGH. An update on the global disparities in kidney disease burden and care across world countries and regions. 2024, 12(3):e382–95. Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, Herrington WG, Hill G, Inker LA. Kazancıoğlu RJKi: KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. 2024, 105(4):S117–314. Lok CE, Yuo T, Lee TJAJKD. Hemodialysis vascular access: core curriculum 2025. 2025, 85(2):236–52. Wilmink TJEJV, Surgery E. Vascular access: clinical practice guidelines of the european society for vascular surgery. In., vol. 55: Elsevier; 2018: 753–754. Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC. Glickman MHJAJoKD: KDOQI clinical practice guideline for vascular access: 2019 update. 2020, 75(4):S1-S164. Ratnam L, Karunanithy N, Mailli L, Diamantopoulos A, Morgan RAJC, Radiology I, Ratnam, et al. Dialysis Access Maintenance: Plain Balloon Angioplasty…. 2023;46(9):1136–43. Wee IJY, Mohamed IH, Patel A, Choong AMJJVS. A systematic review and meta-analysis of one-stage versus two-stage brachiobasilic arteriovenous fistula creation. 2018, 68(1):285–97. Tan T-W, Siracuse JJ, Brooke BS, Baril DT, Woo K, Rybin D, Doros G, Farber AJJVS. Comparison of one-stage and two-stage upper arm brachiobasilic arteriovenous fistula in the Vascular Quality Initiative. 2019, 69(4):1187–95. e1182. Welander G, Lundin F, Palanjafi H, Sigvant BJEJV, Surgery E: 's Choice–Outcomes of single or two stage brachiobasilic arteriovenous fistula, editors. a nationwide Swedish registry study. 2025, 69(6):889–896. Naazie IN, Janssen C, Perez S, Mathlouthi A, Cajas-Monson L, Malas M, Al-Nouri OJAVS. Revision of Aneurysmal Arteriovenous Access with Immediate Use Graft Is Safe and Avoids Prolonged Use of Tunneled Hemodialysis Catheters. 2022, 87:295–301. Hingorani A, Ascher E, Kallakuri S, Greenberg S, Khanimov YJJ. Impact of reintervention for failing upper-extremity arteriovenous autogenous access for hemodialysis. 2001, 34(6):1004–9. Prescott AT, Allan BJ, Bornak A, Tabbara M. Goldstein LJJJoVS: Modified Use of the HeRO Device for Immediate Salvage of a Threatened Dialysis Graft. 2011, 54(6):1865. Halbert RJ, Nicholson G, Nordyke RJ, Pilgrim A, Niklason LJK. Patency of ePTFE arteriovenous graft placements in hemodialysis patients: systematic literature review and meta-analysis. 2020, 1(12):1437–46. Chen JC, Kamal DM, Jastrzebski J, Taylor, DCJAovs. Venovenostomy for outflow venous obstruction in patients with upper extremity autogenous hemodialysis arteriovenous access. 2005, 19(5):629–35. Sheng N, Chivukula SV, Xu TQ, Farlow E, Keen RJJVS. IP161. Strategies for Surgical Salvage of Cephalic Vein-Based Arteriovenous Fistulas. 2019, 69(6):e155. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9324147","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626492881,"identity":"b1cda041-9dba-4efa-802e-7928e7dbc460","order_by":0,"name":"Xingjian Li","email":"","orcid":"","institution":"Chengdu Third People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xingjian","middleName":"","lastName":"Li","suffix":""},{"id":626492882,"identity":"10896632-82b1-4001-b661-a48d508ab4f6","order_by":1,"name":"Dan Wu","email":"","orcid":"","institution":"Chengdu Third People's 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Jin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBACfmb+jw8SDGx4+NkbiNQi2d5gbPChIE1GsucAkVoMzhwwk5zx4bCNwYwEYm2ZkZAmzWNwmMdA8vHGGww1NtEEtfBLJBy25jFI5zGXTiu2YDiWlttA2JbExts8BtY8lrNzzCQYGw4T1mJwI5kB6DBmHoObZ4jVcuYYk+QMA2cegxs8RGqRbO9hNvhgkMYj2QP0SwIxfuFn5mF8kPDHxp6f/fDGGx9qbAhrQXGkRAIpyiFaSNUxCkbBKBgFIwMAAKLUPTOM3Q/lAAAAAElFTkSuQmCC","orcid":"","institution":"Chengdu Third People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Lizhu","middleName":"","lastName":"Jin","suffix":""}],"badges":[],"createdAt":"2026-04-05 05:08:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9324147/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9324147/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107450507,"identity":"a14b05a9-468e-4b0f-924f-a7ae33433dd7","added_by":"auto","created_at":"2026-04-21 15:12:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":210845,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic drawing of the surgery. \u003cstrong\u003e(a) \u003c/strong\u003eThe lesion segments of AVF. \u003cstrong\u003e(b) \u003c/strong\u003eThe basilic vein transposition of to the fistula vein.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9324147/v1/d350fcdc7c4ef6b24a0d5bc9.png"},{"id":107450508,"identity":"02f00b1c-319b-42d0-b215-a2c6fa7df7bd","added_by":"auto","created_at":"2026-04-21 15:12:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":6395300,"visible":true,"origin":"","legend":"\u003cp\u003eA representative case of basilic-to-fistula venovenous transposition. \u003cstrong\u003e(a)\u003c/strong\u003e Preoperative view of the occluded venous segment (white dashed line). \u003cstrong\u003e(b)\u003c/strong\u003e Intraoperative dissection and mobilization of the basilic vein.\u003cstrong\u003e (c)\u003c/strong\u003e The forearm basilic vein was transposed through a subcutaneous tunnel and anastomosed to the native fistula vein. \u003cstrong\u003e(d) \u003c/strong\u003ePostoperative schematic showing the original AV anastomosis (blue arrow) and the venovenous anastomosis (red arrow). \u003cstrong\u003e(e-f) \u003c/strong\u003ePostoperative Doppler ultrasound images demonstrating transverse and longitudinal views of the venovenous anastomosis (yellow arrows). \u003cstrong\u003e(g)\u003c/strong\u003e Doppler ultrasound image of the basilic vein 2 weeks after surgery.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9324147/v1/f026efb59f03efa74a97f871.png"},{"id":107450509,"identity":"89792831-7052-4e3c-8030-a465a13809f3","added_by":"auto","created_at":"2026-04-21 15:12:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":32587,"visible":true,"origin":"","legend":"\u003cp\u003eThe Kaplan-Meier curves for postoperative patency. \u003cstrong\u003e(a) \u003c/strong\u003ePrimary patency. \u0026nbsp;\u003cstrong\u003e(b) \u003c/strong\u003ePrimary assisted patency and secondary patency.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9324147/v1/be10fe4d5e1ac9ac59171b92.png"},{"id":107490434,"identity":"9d384bbd-1cdf-4683-98c2-94590292cd22","added_by":"auto","created_at":"2026-04-22 02:52:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7148936,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9324147/v1/f7f344c4-5bb9-4373-9176-732bdfaa4880.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Basilic Vein Transposition to Fistula Vein for Hemodialysis Access: A Single-Center Experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEnd-Stage Kidney Disease (ESKD) represents a significant global public health burden. It is estimated that by 2023, 4.59\u0026nbsp;million people worldwide will suffer from kidney failure requiring kidney replacement therapy (KFRT), with approximately 3.57\u0026nbsp;million individuals undergoing maintenance dialysis[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The maintenance of dialysis access is a critical factor influencing the survival rate and quality of life of dialysis patients. Autologous arteriovenous fistula (AVF) is widely regarded as the preferred vascular access[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite a lower overall complication rate of AVF compared to other access, complications such as fistula stenosis remain a significant clinical concern, particularly in elderly patients and those with multiple comorbidities. Percutaneous transluminal angioplasty (PTA), due to its minimally invasive nature, lower complication rates, faster recovery, and repeatability, is widely considered the first-line treatment for AVF stenosis or occlusion in hemodialysis patients. Other treatment strategies include stent placement, AVF reconstruction, and arteriovenous grafts (AVG)[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor patients with long-standing and severe stenosis or occlusion of the venous limb of the fistula, particularly those relying on a single deep venous compensatory return, conventional endovenous treatments may not yield satisfactory results. In such cases, autologous vein bypass surgery can serve as a crucial salvage strategy. We performed venovenous anastomosis between the basilic vein and the fistula vein to establish effective venous return and improve the patency of the AVF. In this study, we describe patient selection, surgical techniques, access maturation, and patency outcomes associated with this strategy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003ePatients.\u003c/b\u003e This was a descriptive case series based on electronic medical records supplemented by telephone follow-up. We identified 9 patients who underwent basilic-to-fistula venous venovenous transposition at our institution between December 2023 and March 2026 and abstracted demographic characteristics, postoperative complications, and patency outcomes. Consent was waived because patients were not directly studied and the data collection was retrospective. All data were extracted from routine care documentation and analyzed in de-identified form in accordance with institutional policy. All candidates met the indications for surgical intervention included outflow venous total occlusion with single deep venous compensatory return, frequently recurrent stenosis (requiring angioplasty in \u0026lt;\u0026thinsp;3-month intervals), highgrade elastic stenosis (residual stenosis\u0026thinsp;\u0026gt;\u0026thinsp;50% after angioplasty), and other lesions not amenable to endovascular interventions. During the study period, five nephrologists performed the reconstructions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eManagement.\u003c/b\u003e All patients underwent preoperative ultrasound assessment to evaluate the diameter, wall quality, and feasibility of forming a tension-free tunnel in the basilic vein, and to mark its anatomical course. The procedure was performed under local anesthesia. After preparing and draping the entire arm, a single longitudinal incision was made at the site of the marked basilic vein on the forearm. The subcutaneous tissue was dissected to expose the basilic vein. The tributaries of the basilic vein and its communication with the brachial vein were ligated or divided. The distal end of the basilic vein was then ligated with non-absorbable sutures, and the vein was dilated with saline. A second skin incision was made to expose the distal end of the fistula vein at the site of the lesion. A subcutaneous tunnel was created, through which the basilic vein was passed, and an end-to-side anastomosis was performed using non-absorbable sutures to connect the basilic vein to the fistula vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Finally, the vascular clamps were removed, and the patency of the basilic vein was checked. The subcutaneous tissue and skin were closed with non-absorbable sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). We marked the v-v anastomosis on the skin to reduce juxta-anastomotic stenosis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFollow-up.\u003c/b\u003e On postoperative day 1, the reconstructed segment was examined for a palpable continuous thrill and an audible bruit. On postoperative day 7, patients were reassessed for early complications, including bleeding/hematoma, surgical-site infection, and nerve injury. At Between 30 to 45 days after basilic-to-fistula reconstruction, Doppler ultrasonography was performed to assess venous diameter, depth, flow rates, and to identify any significant stenosis or aneurysms in the reconstructed segment. Subsequent follow-up assessments were conducted every 3 to 6 months. These follow-up evaluations involved a combination of history-taking, physical examination, and ultrasound assessment focused on the fistula. if any issues were identified, biplane Doppler ultrasonography was performed, including assessment of inflow arterial, venous outflow anatomy, and the flow rates and hemodynamics within the fistula.\u003c/p\u003e \u003cp\u003e\u003cb\u003eClinical Outcomes.\u003c/b\u003e Complications and patency rates were evaluated as clinical outcomes. Each patient was examined during outpatient visits, and if an outpatient visit was not possible, follow-up was conducted via telephone. According to the K/DOQI guidelines, primary failure was defined as when AVF could not be used, leading to the creation of a new AVF or requiring radiological or surgical intervention within 30 days. Primary patency was defined as the time from surgery until thrombosis or any intervention aimed at maintaining or restoring patency. Assisted patency was defined as the time from surgery to the need for endovascular or surgical intervention due to stenosis to maintain patency. Secondary patency was defined as the time from access creation to the abandonment of the access[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical Analysis.\u003c/b\u003e Statistical analyses were conducted using IBM SPSS Statistics (version 26.0; Armonk, NY) and R 4.3.2. Kaplan-Meier survival analysis was used to estimate the primary, assisted primary, and secondary patency rates. Data are presented as either percentages or as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic and baseline characteristics of the 9 patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the patients, 7 were male and 2 were female. All patients had hypertension, and 2 patients (22.2%) had diabetes mellitus. The mean age was 67.78\u0026thinsp;\u0026plusmn;\u0026thinsp;7.17 years. 7 patients manifested enhanced pulsation of the fistula vein and elevated venous pressures during hemodialysis sessions, whereas 2 patients developed thrombotic occlusion of the cephalic vein. Preoperative Doppler ultrasound demonstrated a mean basilic vein diameter of 2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28 mm in our cohort.\u003c/p\u003e \u003cp\u003eAmong all patients, the average surgical time was 158\u0026thinsp;\u0026plusmn;\u0026thinsp;41.80 minutes, and the mean length of hospital stay was 5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94 days. All patients received an end-to-side anastomosis between the fistula vein and the intraoperatively dilated basilic vein. Most patients also underwent fistula outflow vein angioplasty, and 1 patient had resection of the infected segment of the fistula vein. In the postoperative period, palpable thrill returned in the fistula vein of every patient, while venous pulsation was markedly attenuated. All patients were able to successfully complete dialysis via the fistula within 48 hours postoperatively, with 1 patient having his central venous catheter removed on postoperative day 2. Mean intrafistular venous pressure during dialysis decreased significantly relative to preoperative values (166.78\u0026thinsp;\u0026plusmn;\u0026thinsp;48.22 vs 90.00\u0026thinsp;\u0026plusmn;\u0026thinsp;35.21, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.005). Early postoperative complications were confined to wound hemorrhage in two patients, which resolved uneventfully after bedside intervention. No instances of hematoma, early access thrombosis, or nerve injury were encountered (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics and baseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at access placement, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.78\u0026thinsp;\u0026plusmn;\u0026thinsp;7.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (77.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, kg/m\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongestive heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypercoagulability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eManifestation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative VP HD\u003csup\u003e*\u003c/sup\u003e, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e166.78\u0026thinsp;\u0026plusmn;\u0026thinsp;48.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-tunneled CVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspirin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative basilic vein diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eVP HD: venous pressure during hemodialysis\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average follow-up time was 16.20\u0026thinsp;\u0026plusmn;\u0026thinsp;7.34 months. One patient died 3 months postoperatively due to diseases unrelated to surgery or surgical complications. No wound infection or clinically significant access-related steal was observed (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The primary patency, primary assisted patency, and secondary patency rates in our cohort were 88.9%, 100%, 100% respectively at 3 months, and 76.2%, 87.5%, 100% at 6 months. The 1-year primary patency, primary assisted patency, and secondary patency rates were 63.5%, 87.5% and 100%, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Re-stenosis of the AVF emerged as the most common postoperative complication during follow-up.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical events and early complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129.67\u0026thinsp;\u0026plusmn;\u0026thinsp;37.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasilic vein pedicle length, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.56\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic\u0026nbsp;diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous pulsation diminished\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (77.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative VP HD\u003csup\u003e*\u003c/sup\u003e, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.00\u0026thinsp;\u0026plusmn;\u0026thinsp;35.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePerioperative complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNerve injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eVP HD: venous pressure during hemodialysis\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEarly and 12-month outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up, months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.20\u0026thinsp;\u0026plusmn;\u0026thinsp;7.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAt 1 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSteal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwealing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean basilic vein diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAt 3 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAt 6 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAt 12 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary patency, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eReintervention rate, events per access-year\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTA\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen thrombectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent placement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePTA: percutaneous transluminal angioplasty.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCurrent international consensus emphasizes that vascular access salvage should be prioritized whenever feasible before abandonment, particularly in patients with limited remaining venous options[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In certain patients with forearm AVFs, superficial venous outflow may become exhausted, manifesting as cephalic vein occlusion or refractory stenosis, accompanied by occlusion of communicating branches with the basilic vein, resulting in reliance on a single deep venous outflow pathway. These patients typically exhibit elevated venous pressure within the fistula, augmented fistula pulsation, and, in severe cases, thrombotic occlusion of the fistula. Although endovascular interventions remain essential in contemporary vascular access maintenance, they are associated with notable limitations, including suboptimal recanalization rates for occlusions and high restenosis recurrence[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Stent deployment may reduce the need for frequent reinterventions; however, its effectiveness in improving patency across joint-related or complex anatomical lesions remains suboptimal. In patients in whom arterial inflow to the fistula is preserved, surgical redirection of venous outflow represents a rational salvage strategy.\u003c/p\u003e \u003cp\u003ePrevious studies have confirmed that utilization of the basilic vein is feasible and clinically practical in scenarios where the cephalic vein or other forearm veins are unsuitable. Traditional basilic vein transposition fistulas (BVTs) involve mobilizing the basilic vein from its native anatomical position to a more superficial location, and anastomosing it with the brachial artery or its branches. Although the technique demonstrates favorable primary and secondary patency rates, controversy persists regarding the technical choice between one-stage and two-stage procedures and the role of adjunctive endovascular therapy[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Tan et al. observed a higher 12-month primary patency rate for the one-stage approach (49.1% vs 40.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005) and a comparable secondary patency rate between two approaches (80.0% vs 77.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.538)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, BVT construction creates a new arterialized conduit, which entails risks such as additional arterial anastomosis and prolonged maturation time. Our study differs in anatomic intent and operative design: rather than creating a new inflow-outflow circuit off the brachial artery, we retain the functioning arterial inflow of the index AVF and add a new, superficialized basilic outflow pathway. The approach eliminated the need for fistula maturation time, reduced dependence on central venous catheters and achieved early cannulation of the AVF. The observed functional patency and low access-threatening complication rate are directionally consistent with published outcomes of upper-arm transposition series[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilar strategies based on grafts were reported for the salvage of failing autogenous arteriovenous fistulas. Short-segment interposition grafting or \u0026lsquo;jump\u0026rsquo; graft bypass has been employed to replace or circumvent refractory stenosis or complex anatomical segments in order to re-establish adequate venous outflow[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Hybrid constructs, such as the HeRO graft, are utilized to circumvent severe central venous stenoses[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. When superficial venous options are inadequate, prosthetic arteriovenous grafts (AVGs) are regarded as secondary vascular access alternatives[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, relative to autogenous vessels, prosthetic grafts are associated with a higher risk of thrombosis, greater susceptibility to anastomotic or bridging segment stenosis, and elevated infection rates. Previous evidences for ePTFE grafts reported a mean 1-year primary patency of 41% (95% CI, 35% to 47%), while a 1-year secondary patency of 70% (95% CI, 64% to 75%). The infection risk was reported to be 9% per patient-year (95% CI, 6% to 12%), which was suggested as a significant contributor to graft failure[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Basilic vein is located on the medial side of the upper arm and is almost free from iatrogenic damage. The anatomical features of the basilic vein make it a reliable autogenous vascular alternative. In the present study, the basilic vein was utilized as an autogenous transposition conduit, thereby avoiding the use of prosthetic material. During the follow-up period, no infectious events were observed in our cohort, and the primary and secondary patency rates remained competitive in comparison with the reported outcomes of AVGs. The approach not only reduces the risk of infection and the economic burden to patients, but also preserves favorable long-term patency of the AVF while minimizing the need for frequent reinterventions.\u003c/p\u003e \u003cp\u003eVein-to-vein anastomosis as a salvage intervention for arteriovenous fistula occlusion remains understudied in large cohorts. Chen et al. reported veno-venostomy in 11 patients following unsuccessful endovascular therapy, including two cases utilizing the basilic vein as the transposed conduit, with assisted primary patency rates approaching 90% over a follow-up period of up to 39 months[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. More recent data were provided by Jeong et al., who described cephalic vein transposition to the basilic or axillary vein for refractory cephalic arch stenosis. Technical success exceeded 90%, with 1-year primary patency of 60\u0026ndash;65% and primary-assisted patency of 75\u0026ndash;80%; restenosis necessitating percutaneous transluminal angioplasty emerged as the most common complication[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The outcomes of these studies align broadly with those of our investigation, underscoring the feasibility of vein-to-vein transposition in alleviating obstructed venous outflow.\u003c/p\u003e \u003cp\u003eThe ESVS guidelines emphasize the importance of venous caliber and wall quality for fistula maturation, with small diameters (\u0026lt;\u0026thinsp;2 mm) portending adverse outcomes[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In addition to preserving arterial inflow to the AVF and maintaining patency of central venous outflow, the anatomical characteristics of the basilic vein are pivotal to the success of this procedure and favorable long-term prognosis. Candidates for this surgery require the basilic vein with sufficient diameter and adequate wall quality to fulfill criteria for transposition and superficialization. In our study, the mean preoperative diameter of the forearm basilic vein was 2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28 mm, and further intraoperative dilation was achieved using saline infusion. The basilic vein should be separated to an adequate length to allow creation of a tension-free subcutaneous tunnel. Concurrently, given the frequently suboptimal wall quality of the original fistula vein, the anastomosis should be appropriately enlarged to mitigate the risk of anastomotic stenosis. Meticulous attention should be paid to confirming that the basilic vein is free of torsion within the tunnel, thereby minimizing swing-segment stenosis. The intraoperative strategies contributed to the early patency we observed. Postoperative physical examination and Doppler ultrasound evaluation at 1 month are imperative. Furthermore, follow-up assessments should be conducted at intervals of 3 to 6 months to enable preemptive angioplasty for focal restenosis. Clinical signs such as elevated venous pressure on dialysis or fistula pulsation require timely ultrasonographic evaluation. Confirmed stenotic lesions or thrombotic events should receive targeted intervention. These pragmatic steps are reproducible and consistent with surveillance principles described in prior transposition series.\u003c/p\u003e \u003cp\u003eThe overall complication rate was acceptable. Early postoperative wound oozing occurred in two patients and was effectively managed with conservative measures or bedside evacuation. No instances of early thrombosis, infection, or neurological deficits associated with medial upper arm dissection were observed. Clinically significant access-related steal syndrome was absent, consistent with the strategy of preserving the original inflow and eschewing the creation of a new high-flow inflow anastomosis. The time to first cannulation (within 48 hours) compares favorably with literature reports for newly constructed upper arm autogenous or prosthetic accesses, aligning with KDOQI objectives to minimize catheter exposure[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The more superficial and extended venous cannulation segment mitigates hemodynamic bottlenecks, broadens the cannulation window, and diminishes cannulation-related complications stemming from deep, short, or tortuous segments. These practical advantages, combined with reduced implantation costs and shorter operative durations, indicate potential cost-effectiveness compared with BVTs or AVGs, notwithstanding the absence of a formal economic assessment in this study. Furthermore, targeted reinterventions sustained high assisted patency rates for the AVF (100% at 1 year), mitigating the risk of access loss.\u003c/p\u003e \u003cp\u003eOur study has important limitations. The modest sample size of patients restricts the generalizability of the findings, and the limited follow-up duration further diminishes the ability to assess long-term outcomes and complications. Additionally, the absence of a control group hinders direct comparisons with alternative surgical strategies or access techniques. Furthermore, selection bias is inherent in the study design, as eligibility criteria required both an adequate basilic vein and preserved arterial inflow, which may not be representative of the broader patient population. These factors collectively temper the interpretability of the results and suggest that larger, multi-center studies with longer follow-up are needed to confirm the findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn patients with forearm AVFs complicated by outflow venous obstruction refractory to endovascular therapy, particularly those reliant on a single deep venous pathway, basilic-to-fistula venovenous transposition effectively redirects a functional autogenous venous outflow route. This procedure broadens the treatment options available for complex ESKD access, enables early postoperative cannulation, sustains favorable long-term patency rates with low complication profiles, and reduces the burden of subsequent reinterventions. Further validation through larger-scale comparative cohorts with extended follow-up is warranted to confirm these findings in salvage strategies for complex outflow-compromised forearm AVFs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLZJ and YS were responsible for the study conception and design. XJL performed the data analysis and drafted the manuscript. DW, XWS, BY, LZJ and XJL participated in the surgical procedures. QLL and CY were responsible for data collection. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was waived by the Ethics Committee of Chengdu Third People\u0026apos;s Hospital, because this was a retrospective study based on existing clinical data and images, with no additional intervention or contact with patients. The study was conducted in accordance with the Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe requirement for informed consent to participate was waived by the Ethics Committee of Chengdu Third People\u0026apos;s Hospital because of the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of the representative patient images in this article was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are not publicly available because they contain information that could compromise patient privacy, but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBello AK, Okpechi IG, Levin A, Ye F, Damster S, Arruebo S, Donner J-A, Caskey FJ, Cho Y, Davids MRJTLGH. An update on the global disparities in kidney disease burden and care across world countries and regions. 2024, 12(3):e382\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, Herrington WG, Hill G, Inker LA. Kazancıoğlu RJKi: KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. 2024, 105(4):S117\u0026ndash;314.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLok CE, Yuo T, Lee TJAJKD. Hemodialysis vascular access: core curriculum 2025. 2025, 85(2):236\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilmink TJEJV, Surgery E. Vascular access: clinical practice guidelines of the european society for vascular surgery. In., vol. 55: Elsevier; 2018: 753\u0026ndash;754.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC. Glickman MHJAJoKD: KDOQI clinical practice guideline for vascular access: 2019 update. 2020, 75(4):S1-S164.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRatnam L, Karunanithy N, Mailli L, Diamantopoulos A, Morgan RAJC, Radiology I, Ratnam, et al. Dialysis Access Maintenance: Plain Balloon Angioplasty\u0026hellip;. 2023;46(9):1136\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWee IJY, Mohamed IH, Patel A, Choong AMJJVS. A systematic review and meta-analysis of one-stage versus two-stage brachiobasilic arteriovenous fistula creation. 2018, 68(1):285\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan T-W, Siracuse JJ, Brooke BS, Baril DT, Woo K, Rybin D, Doros G, Farber AJJVS. Comparison of one-stage and two-stage upper arm brachiobasilic arteriovenous fistula in the Vascular Quality Initiative. 2019, 69(4):1187\u0026ndash;95. e1182.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWelander G, Lundin F, Palanjafi H, Sigvant BJEJV, Surgery E: 's Choice\u0026ndash;Outcomes of single or two stage brachiobasilic arteriovenous fistula, editors. a nationwide Swedish registry study. 2025, 69(6):889\u0026ndash;896.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaazie IN, Janssen C, Perez S, Mathlouthi A, Cajas-Monson L, Malas M, Al-Nouri OJAVS. Revision of Aneurysmal Arteriovenous Access with Immediate Use Graft Is Safe and Avoids Prolonged Use of Tunneled Hemodialysis Catheters. 2022, 87:295\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHingorani A, Ascher E, Kallakuri S, Greenberg S, Khanimov YJJ. Impact of reintervention for failing upper-extremity arteriovenous autogenous access for hemodialysis. 2001, 34(6):1004\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrescott AT, Allan BJ, Bornak A, Tabbara M. Goldstein LJJJoVS: Modified Use of the HeRO Device for Immediate Salvage of a Threatened Dialysis Graft. 2011, 54(6):1865.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalbert RJ, Nicholson G, Nordyke RJ, Pilgrim A, Niklason LJK. Patency of ePTFE arteriovenous graft placements in hemodialysis patients: systematic literature review and meta-analysis. 2020, 1(12):1437\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen JC, Kamal DM, Jastrzebski J, Taylor, DCJAovs. Venovenostomy for outflow venous obstruction in patients with upper extremity autogenous hemodialysis arteriovenous access. 2005, 19(5):629\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheng N, Chivukula SV, Xu TQ, Farlow E, Keen RJJVS. IP161. Strategies for Surgical Salvage of Cephalic Vein-Based Arteriovenous Fistulas. 2019, 69(6):e155.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Basilic-to-fistula venovenous transposition, Outflow venous obstruction, Hemodialysis access, Outcomes, Patency","lastPublishedDoi":"10.21203/rs.3.rs-9324147/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9324147/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the outcomes of basilic-to-fistula venovenous transposition as a salvage strategy for refractory outflow venous stenosis or occlusion in patients with end-stage kidney disease (ESKD). The study focused on assessing the technical feasibility, patency rates, and complication profiles associated with this procedure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e9 cases of basilic-to-fistula venovenous transposition at a single center between December 2023 and March 2026 were reviewed retrospectively. Data including demographics and postoperative complications were collected. Primary and secondary patency rates were determined by using Kaplan-Meier methods.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age of the cohort was 67.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 years, with 7 males and 2 females. Renal failure was complicated with hypertension in 100%, and with diabetes in 22.2%. The average follow-up time was 16.20\u0026thinsp;\u0026plusmn;\u0026thinsp;7.34 months. All fistulas were successfully used for dialysis within 48 hours postoperatively. The primary patency rate, primary assisted patency rate and secondary patency rate was 88.9%, 100%, 100% at 3 months, 76.2%, 87.5%, 100% at 6 months, and 63.5%, 87.5%, 100% at 1 year. 2 patients experiencing wound hemorrhage at the surgical site, and no patients developed early thrombosis, hematoma, nerve injury, wound infection, or clinically significant access-related steal.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBasilic-to-fistula venovenous transposition provides an effective autogenous solution for patients with complex ESKD access obstruction refractory to endovascular therapy. This procedure offers early functional usability, a favorable safety profile, and reduces the reintervention burden.\u003c/p\u003e","manuscriptTitle":"Basilic Vein Transposition to Fistula Vein for Hemodialysis Access: A Single-Center Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 15:12:55","doi":"10.21203/rs.3.rs-9324147/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-20T16:50:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T09:12:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T03:44:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23849631926196825211423847129114459220","date":"2026-04-19T18:14:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83602245247176290090263921248362602669","date":"2026-04-19T12:58:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187613363264937613346025344459688867688","date":"2026-04-16T04:12:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"269440128735154823925276274923276852501","date":"2026-04-14T17:24:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6186060061707499999724915392683539647","date":"2026-04-14T10:51:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112433166973549975310645152714659204648","date":"2026-04-14T08:37:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19507760225147097878106001742492167071","date":"2026-04-14T05:21:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-14T03:46:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-08T20:03:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-08T04:36:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-08T04:35:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-04-05T04:55:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd4ada8c-de7b-4df7-b07c-f091c359c64c","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T06:10:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 15:12:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9324147","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9324147","identity":"rs-9324147","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}