Abstract
Introduction: End Stage Renal Disease (ESRD) is a clinical situation of irreversible decline in renal function in a way that can cause permanent dependence on alternatives like dialysis (Haemo or peritoneal dialysis) or kidney transplant. In the present study, we aimed at evaluating the anatomical variations of the veins in cubital region to have a better venous access. Material & Methods: In this descriptive cross-sectional study, 699 patients visiting the Vascular Surgery Department of Razi Hospital (in Rasht) for applying dialysis were evaluated by means of color Doppler sonography to show the exact cubital anatomy. Results: According to this research, 4 anatomical variations were described around the cubital region: Type A (438 cases - 62.7%): presence of cephalic and basilic veins joining through a perforating vein, Type B (13 cases-1.9%): presence of cephalic and basilic veins without any perforans, Type C (41 cases-5.9%): presence of the basilic vein and no cephalic vein, Type C (27 cases -29.6%): presence of cephalic vein and no basilic vein.Discussion: With perforating veins in 92.55% of patients in our study, the fistulation process is an appropriate and long-lasting method which can be used for patients with inappropriate distal veins due to any underlying reason.
Key words: ESRD, Anatomical Variations, Cubital Region
Introduction:
End Stage Renal Disease (ESRD) is a clinical situation of irreversible decline in renal function in a way that can cause permanent dependence on alternatives such as dialysis (Haemo or peritoneal dialysis) or kidney transplant (1). The total incidence rate of ESRD is about 260 cases in one million people and the number of patients has a 6% increase annually (2). It is estimated that 24 million people will have ESRD by 2030 (3). Over 15,000 people suffer from ESRD in Iran and the number of new cases is said to be 3175 patients per year. Over the past 40 years, alternative treatments like dialysis and kidney transplant saved hundreds of lives of people with ESRD (1). Although the dialysis device was firstly invented in 1940 but due to lack of appropriate vascular access until late 60s, there was no hope for patients (4). However, nowadays haemo dialysis is absolutely the most common way to treat the patients (2). This could be somehow due to the progress in having better vascular access for patients over time. The most common type of this access is achieved through arteriovenous fistulas (AVFs) and if not possible, vascular prosthesis might help (4, 5). The significance and effect of surgeries for vascular access might light out if we consider that over 200,000 of American ESRD patients are dependent on dialysis and also about 9.5 billion dollars are paid for burden of the disease (6). There are some problems surgeons may face when performing (Performing what?) to get vascular access like congenital lack of appropriate superficial veins, losing the vessels due to frequent venous canulation and not using the AVFs by the right method. It seems ligating the perforating vein which connects superficial veins of the cubital region to the deep veins is extremely necessary to improve the preparation of the arteriovenous fistulas even it might help treat the steal syndrome in patients (7), thus knowing the exact anatomical characteristics of the veins in cubital region and their variations could help improve the surgical techniques to achieve optimal results from the surgeries (8). In the present study, we aimed at evaluating the anatomical variations of the veins in cubital region.
Material & Method:
In this cross-sectional descriptive study, patients visiting the Vascular Surgery Department of Razi Hospital in Rasht city for applying dialysis fistulation since January to June were evaluated by means of color Doppler sonography. Among patients those without appropriate distal vascular access became candidates for cubital region fistulation. The cubital region was explored in these patients only by one surgeon and after the surgery the anatomies of the veins of the area were documented. A total number of 699 patients were totally evaluated. After collecting data from all patients based on the assessing variables, they were analyzed by means of Chi-square and SPSS version 16.
Result:
699 patients who visited Vascular Department of Razi Hospital in Rasht for placing arteriovenous fistula in cubital region for dialysis underwent surgery by the same surgeon and were enrolled in the study. According to this research, 4 anatomical variations were described around the cubital region:
Type A: (438 cases - 62.7%): Presence of cephalic basilica veins joining through a perforating vein.
Type B: (13 cases-1.9%): Presence of cephalic and basilica vein without any perforants.
Type C: (41 cases-5.9%): Presence of the basilic vein and no cephalic vein.
Type C: (27 cases -29.6%): Presence of cephalic vein and no basilica vein.( Table 1)
There was no significant statistical relationship between the anatomical variation of the veins and the gender of the patients (P=0.066). There was no significant statistical difference in frequency distribution of the different anatomical variations of veins among the left and right hand (P=0.21). Perforating veins were observed in 647 patients (92.6%) during the survey while 52 patients had no perforating veins. The distribution frequency of the presence of perforating vein was the same for both hands.
Discussion:
Over 15000 patients suffer from ESRD in Iran and numerous new cases are increasingly adding to this figure. It seems all of these patients need vascular access for dialysis; however, wrist region is counted as the most appropriate area for placing AVF in most patients. Applying AVF is sometimes not effective due to reasons including age, obesity, diabetics, and frequent vascular access, thus using cubital region veins can be helpful in seriously ill patients (7).(Table 1) To better apply the appropriate technique for placing the effective AVF, knowing about the anatomical variations of superficial veins of cubital region is necessary for the operating surgeon (8). (Table 1) In ongoing study, we evaluated the anatomical variations of the superficial veins of the cubital region in ESRD patients visiting to place fistulas for haemo dialysis. The total 4 variations were observed. The most common form of variation was type A (62.7%) which was seen in 60.4% of men and 65% of women, followed by type D (29.6%) while type B (1.9%) seems to be the most uncommon one. In a study performed by Jay Datta Singh et al in 1982, Nigeria, 5 different variations of anatomical veins of the cubital region were observed. In the most common pattern, the median cubital vein originates a few centimeters below the elbow and it is then poured into the basilic vein just a few centimeters above the elbow. The frequency rate of this type is estimated to be more common in men (62%) than women (49%). In the second common type, the middle forearm vein bifurcates in the cubital region and makes basilic and cephalic vein. Unlike the former type, this pattern is likely to be more seen in women (30%) than men (24%) and in 3-5% of cases, the basilic and cephalic veins are joined together through an archoid vein (9). (Table 1) The variation above is compatible with type A pattern in our study. In 7-10 % of cases there was no connecting vein between basilic and cephalic vein which is referred as type B (1.9%) in our study. Another similar research was performed by Del Sol in 2007 In South America in which 5 anatomical variations were found for superficial veins of the cubital region are as followed: Type I (38.7 %): the cephalic vein is divided into middle basillic and middle cephalic vein which are finally poured into accessory cephalic vein. Type II (28.30 %): known as the middle cephalic vein and is then connected to basilic vein. Type III (24 %): there is no commisuring vein between basilic and cephalic veins. This pattern is like the type B in our study; however, 1.9 % of cases have this pattern, thus the statistics are not the same. Type IV (4.3 %): the cephalic vein is poured into basilic vein while the middle vein of forearm is poured into the cephalic vein. Type V: includes the rest of variations. Type I / II is compatible with the type A in our study and it is also considered as the most common type in both studies. Type IV is like type C in our study allocates 5.9 % of cases and it is also statistically compatible(10). (Table 1) Moreover, in a study presented by Halim A in India in 2005, three variations were observed. Type I: presence of median cubital vein connecting basillic and cephalic vein (the most common type: 67.5 %) and it is compatible with the A pattern in our study. Type II: cephalic vein pours into the basilic vein (19.5 %). Type III: there is no vein connecting cephalic and basilic vein. This type divides into two subtypes: type III (A) (6%) the median vein of forearm pours into either cephalic or basilic vein and type III (B) (6.5 %): the median vein of forearm is divided to median basilic or median cephalic vein which pours into median basilic or median cephalic veins, respectively(11). (Table 1) This last type of variation is compatible with type B in our study. In a research presented in an article by Alamshah in Iran (Ahvaz) in 2003, the anatomical variations of the cephalic vein in the cubital region were assessed in which 5 patterns were observed:
Type A: the cephalic-median cephalic (44.66%). Type B: the cephalic vein-median cephalic vein-antebrachial vein (30.1%). Type C: One-branch cephalic vein (18.44%). Type D: cephalic vein-median cubital vein (3.88%). Type E: Cephalic vein-median vein-basilic vein (2.29%). The A, C, D patterns in this study were named dependant from the lateral branches which could help surgeons for better anastomosis. The B, D, E types are compatible with the A type in our study but not statistically, as the type A (the most common type) in our study is mostly compatible with type D of the Alamshah, et al. In patients with inappropriate distal veins for fistulisation, due to any underlying reason, the side-side fistula is used in the cubital region. This process can be accompanied with complications such as arm swelling and ischemic symptoms arised from the possible steal syndrome(8). In a study by Moini, et al in Iran (Tehran) in 2008 by means of Doppler sonography, there was a high flow in the great perforating vein of the cubital region in patients with the inappropriate distal veins, thus in one-step surgery procedure and ligating, the perforating vein of the cubital region, the blood flow pressure and distention of superficial forearm veins increased. This procedure, on the other hand, prevented the steal syndrome by decreasing the blood flow of the deep veins. The success rate of the procedure was 89.7%±2.66% and 83.7±3.5% for the first and second year after surgery, respectively. There were no reports of steal syndrome or venous hypertension(7). (Table 1) In this research study, we found out the perforating veins are present in 92.6% of population, thus this could mean that by means of ligators of perforating veins longer application of the fistula could be insured. In a study by Waclow W, in Netherlands in 2007 radial artery was used for making anastamosis with the perforating veins in the cubital region in patients without appropriate distal vessels. The above procedure was performed with the Gracz et al, fistulization method (Anastomosis of perforation vein and brachial artery). At the end, the process was successful in 73 % of patients and the primary surveillance rate was 47%, 43% and 39% for the first, second and third year after surgery, respectively. There were no reports of complications such as Steal syndrome. The above procedure is useful for patients not having appropriate distal veins, the ones with vascular malformation or the patients who have insufficient fistulas due to clot formation. It is best recommended for patients with peripheral artery diseases like elderly diabetics. As we have seen perforating veins in 92.55 of patients in our study, the fisulization process is an appropriate and long-lasting method that could be used for patients with inappropriate distal veins due to any underlying reason. Regarding previous studies, the A pattern was the most common pattern of anatomical variations in the patients. Due to the numerous benefits of ligating the perforating veins in fistulization of the cubital region for most patients, exploring the vein and its ligation is recommended.
