A comparison of the outcomes of one-stage and
two-stage brachiobasilic arteriovenous fistulas
Georgios Vrakas, MD, MSc,a,b Fatima Defigueiredo,a Sam Turner, MBBS, MRCS,a,b Chris Jones, PhD,a
John Taylor, MBBS, FRCS,a,b and Francis Calder, MB, FRCS,a,b London, United Kingdom
Objective: The brachiobasilic arteriovenous fistula (BBAVF) can be formed in one or two stages. This study examined the
failure rates and functional patencies of one-stage vs two-stage brachiobasilic transposition fistulas to compare the two
surgical techniques.
Methods: We retrospectively identified all the patients who underwent BBAVF access surgery at King’s College Hospital
between January 1, 2009, and December 31, 2011 (3 years). Patients were divided into two groups according to onestage or two-stage procedure. All patients were seen in the access clinic 4 to 6 weeks postoperatively, and their fistulas
were scanned (duplex). The surveillance of fistulas consists of duplex scans every 6 months to assess volume flow.
Results: During the study interval, 149 brachiobasilic transpositions (65 one-stage and 84 two-stage) were performed in
141 patients. Patients undergoing the two-stage procedure had a smaller mean preoperative vein diameter (4.0 6 1.1 vs
3.6 6 1.3 mm; P [ .041) and tended to be older (58 6 15 vs 63 6 15 years; P [ .062). Mean overall follow-up was
559 6 333 days. There was no difference in primary failure between the two groups (45% vs 42%; P [ .718). At 1 year,
the two-stage BBAVFs had significantly better primary (71% vs 87%; P [ .034), assisted primary (77% vs 95%; P [ .017),
and secondary functional (79% vs 95%; P [ .026) patencies. The same applied to 2-year primary (53% vs 75%; P [ .034),
assisted primary (57% vs 77%; P [ .017), and secondary functional (57% vs 77%; P [ .026) patencies. Multivariate Cox
regression showed that the one-stage procedure was 3.2 times more likely to fail (P [ .028). Men were 2.7 times more
likely to lose their access (P [ .054).
Conclusions: This study describes a large series of BBAVFs and makes an extensive comparison between the one-stage
and two-stage operations. Significantly improved overall functional patency is demonstrated for the two-stage
operation. (J Vasc Surg 2013;58:1300-4.)
The use of the basilic vein for an autogenous fistula
creation is often considered a complex vascular access
procedure, usually involving a general anesthetic and significant surgical dissection. However, when other simple
fistula options are exhausted, the basilic vein, lying deep
and protected from damage by venipuncture, makes an
excellent hemodialysis conduit.
The brachiobasilic arteriovenous fistula (BBAVF) was
first described by Dagher1 in 1976. Several modifications
of the initial operation have been developed in the years
since then.2,3 However, the basic principle is to superficialize
the basilic vein and make it amenable to needle puncture.
The BBAVF can be formed in one stage or two stages.
To date, limited and conflicting data exist regarding
primary failure and the patency rates of one-stage and
two-stage procedures.4-12 Each procedure has advantages
and disadvantages. The one-stage procedure offers the
benefits of a single operation with earlier functional patency
From the Renal Department, King’s College Hospitala; and the Department
of Nephrology and Transplantation, Guy’s Hospital.b
Author conflict of interest: none.
Reprint requests: Georgios Vrakas, MD, MSc, Guy’s Hospital, Renal
Offices, 6th Flr, Borough Wing, Great Maze Pond, London, SE1 9RT,
UK (e-mail: [email protected]).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214/$36.00
Copyright Ó 2013 by the Society for Vascular Surgery.
http://dx.doi.org/10.1016/j.jvs.2013.05.030
1300
and possible shorter duration with a central venous catheter. The advantage of a two-stage procedure is the ease
of mobilization of a larger “arterialized” vein, rendering
it less susceptible to torque and devascularization during
mobilization.13 If surgical revision for postanastomotic
stenosis is required, this is easily performed at the second
stage. In case of early failure, the patient is spared a general
anesthetic and significant surgical dissection. However, the
two-stage procedure necessitates two operations, which
may affect operating theater capacity and delay acquisition
of permanent access.
In this study, we examined primary failure rates and
the primary, primary assisted, and secondary functional
patencies of one-stage vs two-stage brachiobasilic transposition fistulas to compare the two surgical techniques. The
hypothesis is that two-stage BBAVFs provide longer
patency. In addition, we examined the effect of patient
variables on the final outcome.
METHODS
Design and patients. We retrospectively identified all
patients who underwent BBAVF at King’s College
Hospital between January 1, 2009, and December 31,
2011 (3 years). Patients who underwent creation of a
brachiobasilic transposition fistula were divided into groups
according to one-stage or two-stage procedures. During
this 3-year period, 149 BBAVFs were formed in
141 patients. The patients were consecutive, and two
experienced surgeons performed the operations. One of
JOURNAL OF VASCULAR SURGERY
Volume 58, Number 5
the surgeons usually performs the one-stage operation,
whereas the other usually performs the two-stage one. In
patients with small-sized veins, both surgeons would
mostly perform the procedure in two stages. Minimum
vein threshold for AVF is 2 mm, as determined by preoperative vein mapping, which was performed without the
use of tourniquet on all patients.
All patients were seen in the access clinic 4 to 6 weeks
postoperatively, and their AVFs underwent duplex scanning to assess maturation. Once in use, the fistulas entered
the surveillance program of 6-month duplex scanning of
volume flow. Prolonged bleeding, raised static venous pressure (>170 mm Hg), inability to achieve blood pump
speed of 300 mL/min, urea reduction ratio <65%, and
dialyzer clearance of urea (K) dialysis time (t)/volume of
distribution of urea (V) <1.2 prompted referral for
fistuloplasty. Stenotic areas on duplex imaging were considered for fistuloplasty if they affected the quality of
hemodialysis.
Definition of variables. Primary patency (intervention-free access survival) was defined as the interval from
time of access placement to any intervention designed
to maintain or re-establish patency.14 Assisted primary
patency (thrombosis-free access survival) was defined as the
interval from time of access placement to access thrombosis.14 Secondary patency (access survival until abandonment) was defined as the interval from time of access
placement to access abandonment. A functional AVF is an
access that is able to deliver a flow rate of 350 to 400 mL/
min without recirculation for the total duration of dialysis.
A nonfunctional AVF is an access that is not being successfully used for hemodialysis, regardless of whether it is
patent.14
Primary failure was defined as an AVF that was never
used for dialysis. This definition includes (1) inadequate
maturation, (2) early thrombosis, (3) failure of first cannulation, and (4) other complications, such as ischemia or
infection, which made it unusable.
This study refers to primary functional, assisted primary
functional, and secondary functional patency. Therefore
AVFs that were not used for dialysis were not included in
the survival models.
All complications were extracted from the electronic
patient records. Early complications are defined as occurring #30 days from the operation date.
Description of surgical technique. The one-stage
operation is performed under general anesthesia. A 5-cm
incision at the antecubital fossa identifies the basilic vein.
Brachial vein fistulas were not included in this series.
Intraoperative ultrasound imaging was not used. The
incision is extended proximally, and the underlying deep
fascia is opened. The basilic vein is mobilized up to its
junction with the brachial vein. The median cutaneous
nerve of the forearm is carefully dissected and preserved.
After side branches are ligated, the basilic vein is tunnelled
subcutaneously, with a Roberts’ forceps maintaining its
axial orientation. An end-to-side arteriovenous anastomosis
to the brachial artery is performed.
Vrakas et al 1301
The first stage of the two-stage operation is performed
under local anesthesia by formation of the arteriovenous
anastomosis with minimal disturbance of the basilic vein.
After 4 to 6 weeks, a flow assessment of the AVF by duplex
scanning is made to determine if revision of the anastomosis is necessary at the second stage. The second stage
is performed under general anesthesia. The entire length
of the basilic vein is mobilized, a “subcutaneous flap” is
created, and the vein is positioned anterolaterally. Usually,
a further 4 weeks is required before the AVF can be used.
Statistical analysis. Analyses were conducted using
SPSS 20.0 software (SPSS Inc, Chicago, Ill). Descriptive
statistics were calculated for all variables. Results are shown
as means 6 standard deviation, unless otherwise described.
Categoric variables were compared using Pearson c2 and
Fisher exact tests. The Kolmogorov-Smirnov test was
used to test continuous variables for normal distribution.
Normally distributed data were compared with the t-test
and are expressed as mean 6 standard deviation; otherwise,
the Mann-Whitney test was used and they are expressed as
median and interquartile range. Primary, assisted primary,
and secondary functional patencies were estimated with the
use of the Kaplan-Meier method and were compared with
the log-rank test.
Multivariate Cox proportional hazard models were used
to assess the independent effects of one-stage or two-stage
procedure and other factors on patency and failure rates,
including age >65 years, sex, ethnic origin (white, black,
other), diabetes, body mass index (BMI) >30 kg/m2, and
size of vein <3 mm on preoperative vein mapping. The
selection of the factors was based on previously published
studies. Data from patients who had patent fistulas at the
last follow-up (August 31, 2012) were censored on that
date. Patient deaths unrelated to fistula failure, patients
who had successful kidney transplantation, or those who
were transferred to other dialysis units were censored.
All reported P values are two-sided, and a P value
of <.05 was considered statistically significant.
RESULTS
From January 1, 2009, to December 31, 2011, 149
brachiobasilic transpositions (65 one-stage and 84 twostage) were performed in 141 patients (1.06 operations/
patient). The left arm was used in 99 and the right in
50. Mean follow up was 559 6 33 days (range, 1-1261
days). Median interval between the first and second operation for the two-stage BBAVFs was 90 days (interquartile
range, 68-129 days).
Patients undergoing the two-stage procedure had
a smaller mean preoperative vein diameter (4.0 6 1.1 vs
3.6 6 1.3 mm; P ¼ .041). There was also a trend to use
the two-stage procedure on older patients (58 6 15 vs
63 6 15 years; P ¼ .062; Table I).
The BBAVF was the first access in 64 patients (43%),
second in 50 (34%), third in 23 (15%), fourth in six (4%),
fifth in three (2%), and sixth in two (1%). The number of
previous fistulas is not mentioned in two patients (1%).
JOURNAL OF VASCULAR SURGERY
November 2013
1302 Vrakas et al
Table I. Patient demographics
Variables
One-stage
(n ¼ 65)
Two-stage
(n ¼ 84)
P
Age, mean 6 SD, years
Female sex, %
Diabetes, %
Hypertension, %
BMI, mean 6 SD, kg/m2
Black race, %
Vein size, mean 6 SD, mm
58 6 15
49
38
81
29 6 6
45
4.0 6 1.1
63 6 15
52
39
80
27 6 7
46
3.6 6 1.3
.062
.703
.825
.821
.221
.958
.041
BMI, Body mass index; SD, standard deviation.
Table II. Primary failure
One-stage (n ¼ 65)
45%
Two-stage (n ¼ 84)
P
42%
.718
Of the fistulas created, 93 (62%) were used for hemodialysis (66% one-stage vs 60% two-stage; P ¼ .407), and
56 (38%) were not used, of which 19 (34%) failed before
needling, two patients (4%) received a renal transplant,
seven (13%) died, and 28 (50%) BBAVFs remain patent
in predialysis patients (equally distributed between the
two groups).
Primary failure was similar between the two groups
(45% vs 42%; P ¼ .718; Table II). Intervention before first
dialysis was similar in the two groups (21% vs 11%; P ¼
.201). Most preemptive interventions were endovascular,
whereas open surgery was reserved for two one-stage
patients. The mean flows at 6 weeks postoperatively were
1256 6 471 mL/min for the one-stage group and
1167 6 439 mL/min for the two-stage group (P ¼ .313).
Primary functional patency, assisted primary functional
patency, and secondary functional patency for both groups
are depicted in Kaplan-Meier graphs seen in Figs 1, 2, and
3, respectively. In the one-stage vs two-stage groups, the
mean primary functional patency was 753 6 88 days and
853 6 59 days (P ¼ .045), mean assisted primary
functional patency was 795 6 79 and 987 6 54 days
(P ¼ .026), and mean secondary functional patency was
803 6 77 and 992 6 52 days (P ¼ .027), respectively.
At 1 and 2 years, the primary, assisted primary, and
secondary functional patency rates were significantly better
for the two-stage BBAVFs (Table III).
Risk factors associated with the BBAVF outcome, such
as age >65 years, sex, diabetes, BMI >30 kg/m2, ethnic
origin, and size of the vein (<3 mm) preoperatively were
analyzed in a multivariate Cox proportional hazard model
(Table IV). The overall model was statistically significant
(P ¼ .040) and showed that the one-stage procedure was
3.2 times more likely to fail (P ¼ .028) and that men
were 2.7 times more likely to lose their access (P ¼ .054).
There were 27 deaths during the 3-year study period:
10 one-stage patients and 17 two-stage patients (c2
P ¼ .446)
Fig 1. Kaplan-Meier curve depicts primary functional patency
for one-stage and two-stage brachiobasilic arteriovenous fistulas
(BBAVFs). P ¼ .045.
Early complications (<30 days) occurred in six patients
(9%). Five patients (two thrombosis, two hematoma, one
steal; 16%) belonged to the one-stage group and one
(hematoma, 2%) was in the two-stage group (Fisher exact
test, P ¼ .078). One early death occurred in the onestage stage group, not related to the AVF.
Overall, there was no statistical significance comparing
the total complication rate between the two groups (c2,
P ¼ .715). Table V reports the complications encountered
with the respective probability scores.
DISCUSSION
This is the largest single-center study to compare the
functional patencies of one-stage vs two-stage brachiobasilic transposition fistula. Several previous studies4-12 have
compared the two operations. However, which technique
is superior in long-term patency and complications remains
unclear.
This study adds significant data on the functional
patencies, complications, and risk factors associated with
one-stage and two-stage BBAVFs. The primary functional
patency of BBAVFs in this study at 1 year is comparable
to reports published within the last 10 years.12,15-19 Our
data suggest that at 1 year, the two-stage BBAVFs have
significantly better primary (71% vs 87%; P ¼ .034), assisted primary (77% vs 95%; P ¼ .017), and secondary (79%
vs 95%; P ¼ .026) functional patencies. A similar trend is
seen for 2-year primary (53% vs 75%; P ¼ .034), assisted
primary (57% vs 77%; P ¼ .017), and secondary functional
(57% vs 77%; P ¼ .026) patencies. These data are in accord
with work by El Mallah,4 who randomized 40 patients to
JOURNAL OF VASCULAR SURGERY
Volume 58, Number 5
Fig 2. Kaplan-Meier curve depicts assisted primary functional
patency for one-stage and two-stage brachiobasilic arteriovenous
fistulas (BBAVFs). The dashed line indicates standard error >10%.
P ¼ .026.
Vrakas et al 1303
Fig 3. Kaplan-Meier curve depicts secondary functional patency
for one-stage and two-stage brachiobasilic arteriovenous
fistulas (BBAVFs). The dashed line indicates standard error >10%.
P ¼ .027.
Table III. Patency rates at 1 and 2 years
a one-stage or a two-stage procedure, with primary patency
rates 50% and 80%, respectively, at a median follow-up of
15 months, indicating a benefit for the two-stage procedure. However, the retrospective study of 70 patients (30
transposed/20 elevated in one-stage and 20 elevated in
two-stages) by Hossny5 showed no significant difference
in secondary patency rates at 12 and 24 months between
one-stage and two-stage procedures, at 90% and 84.2% vs
70% and 68.4%, respectively.
Several studies have shown older age is a significant factor in access failure, as well as obesity.15,20,21 Our study did
not show that BMI >30 kg/m2 (P ¼ .139) or older age
(P ¼ .748) had a clear link with access failure. In addition,
our study did not show that diabetic individuals have a worse
fistula outcome, as seen in another study.20 Why men would
be at a higher risk for losing their access is unclear.
The reported complication rate for BBAVF remains
high, between 43% and 71%.5,9,22-24 The 53.7% overall
complication rate in this study is in agreement with such
findings. Hossny5 showed the complication rate was significantly higher in the two-stage elevation group compared
with the one-stage transposition group (71.4% vs 28.6%;
P > .001). Kakkos et al,24 however, found the complication rate was significantly higher in the one-stage operation
(43% vs 11%; P < .001). Our study did not show any significant difference in the complication rates between the two
procedures (P ¼ .715). However, there was a trend toward
more thrombosis in the one-stage operation (4% vs 1%;
Interval
1 year
2 years
Functional
patency
One-stage,
%
Two-stage,
%
P
Primary
Assisted
Secondary
Primary
Assisted
Secondary
71
77
79
53
57
57
87
95
95
75
77
77
.034
.017
.026
.034
.017
.026
Table IV. Multivariate Cox proportional hazard model
Variable
Male sex
Race
White
Black
Other
Diabetic
BMI >30 kg/m2
One-stage operation
Age >65 years
Vein <3 mm
Significance
b (95% CI)
.054
2.672 (0.985-7.250)
.540
.268
.806
.342
.139
.028
.748
.100
1.820
1.228
1.604
2.245
3.180
1.170
2.343
(0.631-5.247)
(0.238-6.349)
(0.606-4.247)
(0.770-6.548)
(1.133-8.927)
(0.448-3.061)
(0.848-6.470)
BMI, Body mass index; CI, confidence interval.
P ¼ .079) and for more stenosis in the two-stage group
(9% vs 20%; P ¼ .06). Why the two-stage procedure would
present with a higher stenosis rate is unclear, although
JOURNAL OF VASCULAR SURGERY
November 2013
1304 Vrakas et al
Table V. Complications
Variable
Overall
Infection
Hematoma
Thrombosis
Steal syndrome
Venous hypertension
Stenosis
One-stage
(n ¼ 65), %
Two-stage
(n ¼ 84), %
P
24
3
3
4
2
2
9
30
2
3
1
3
1
20
.715
.297
.504
.079
.1
.318
.06
a possible explanation could relate to the smaller vein diameter (4.0 6 1.1 vs 3.6 6 1.3 mm; P ¼ .041).
This study has several limitations. It is a retrospective,
nonrandomized study, therefore allowing for selection
bias. Personal preference of the two operating surgeons
affected the type of the operation, and patients with smaller
veins would mostly be allocated to the two-stage group.
Another limitation is that our survival analysis is based
only on functional BBAVFs (43 one-stage and 50 twostage cases).
CONCLUSIONS
This study demonstrates significantly improved primary, assisted primary and secondary functional patency
for the two-stage operation, with a similar complication
rate to the one-stage procedure. The superior functional
patency of the two-stage procedure noted in this study
suggests that the two-stage approach should be the operation of choice for BBAVFs. However, our results should be
confirmed by a prospective, randomized multicenter trial.
AUTHOR CONTRIBUTIONS
Conception and design: GV, ST
Analysis and interpretation: GV
Data collection: GV, ST, FD
Writing the article: GV, FC
Critical revision of the article: CJ, JT, FC
Final approval of the article: FC
Statistical analysis: GV, CJ
Obtained funding: Not applicable
Overall responsibility: GV
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Submitted Jan 31, 2013; accepted May 10, 2013.