December 12, 2008

FREQUENCY AND IMPORTANCE OF VARIANT BRACHIAL-BASILIC VEIN ANATOMY: AN OBSERVATIONAL STUDY USING DOPPLER ULTRASOUND VEIN MAPPING

Houssam K. Younes, MD¹, Christy L. Kaiser, BS², Debra L. Canter, BA², Kristofer Charlton-Ouw, MD¹, Mark G. Davies, MD,PhD¹, Alan B. Lumsden, MD¹, Eric K. Peden, MD¹.
¹Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX, USA, ²The Methodist Hospital Research Institute, The Methodist Hospital, Houston, TX, USA.

OBJECTIVES:
Increased understanding of the upper extremity venous anatomy can heighten awareness of a previously undescribed variation that could impact planning of permanent hemodialysis (HD) access procedures.
METHODS:
We conducted a cross-sectional, observational study of the anatomy of upper extremity veins in End Stage Renal Disease patients seeking permanent HD access between August 2005 and August 2008. Pre-operative vein mapping was conducted by vascular surgeons and registered vascular technologist. If the basilic-brachial junction was observed in the upper arm we classified this as “Type 1”. Junctions observed at the mid and lower portions of the arm with a duplication of the brachial vein above that level were classified as a “Type 2”. Junctions observed at the mid and lower portions of the arm with no duplication of the brachial vein above that level were classified as a “Type 3” (see figure)
RESULTS:
169 patients (age 54.5 ± 1.4 years, 49.7% male) were observed and 244 arms were mapped (125 right, 119 left). The prevalence of variations in venous arm anatomy was: Type 1 60.5%, Type 2 18.4%, Type 3 21.1%. Of the 92 patients who had both arms mapped, the agreement in anatomy between the two arms was 65 %.
CONCLUSIONS:
Although, the well described type 1 is still the most frequent variation, type 3 is not infrequent. This has not been previously described in textbooks or widely available literature. If these variations are not recognized prior to HD access surgery, mobilization and ligation of the brachial vein can result. Subsequently, upper extremity venous hypertension and future access options in the arm may be compromised. This study underscores the need for heightened awareness of upper arm venous anomalies and for the regular use of preoperative ultrasound imaging to identify these variations while planning the creation of a permanent HD access.

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