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Abstract
Background and Aims Transposed brachiobasilic arteriovenous fistula (TBBAVF) is often used as an alternative for difficult AVF creation in the forearm or cubital fossa. The proximal site surgical incision close to the axilla frequently extends beyond coverage by a brachial plexus block (BPB) and often requires either rescue local anaesthetic (LA) supplementation or general anaesthesia. We report two cases that were successfully managed with an intercostal nerve block (ICB) and axillary brachial plexus block under ultrasound guidance.
Methods The Institutional Review Board’s approval was obtained for these case reports. Two ASA III patients with similar comorbidities of hypertension, hyperlipidemia, diabetes mellitus and end-stage-renal failure, required TBBAVF due to their previous non-functioning AVFs.
An ICB nerve block (figure 1) and axillary BPB (figure 2) were performed under ultrasound guidance in both patients with Ropivacaine 0.25% 10 mL and 0.5% Ropivacaine 25 mL respectively with a BBraun Stimuplex 21G 100 mm insulated needle.
The surgery involved a continuous longitudinal incision over the basilic vein from the axilla to the medial epicondyle of the humerus for brachial artery to basilic vein anastomosis and anterior and superficial relocation of basilica vein (figure 3). Surgical duration was two hours.
Results The patients remained pain free intraoperatively with no supplemental LA required and completed uneventfully. Patients were discharged on the same day and the numbness resolved within 24 hours.
Ultrasound guided of axillary brachial plexus nerver block (AXB) and Ultrasound guided Intercostobrachial nerve block (ICBN). MN (Median nerve), UN (Ulnar nerve), McN (Musculocutaneous nerve), RN (radial nerve), TM (Teres Major muscle), AA (axillary artery), AV (axillary vein)
A continuous longitudinal incision over the basilic vein from the axilla to the medial epicondyle of the humerus for brachial artery to basilic vein anastomosis and anterior and superficial relocation of basilica vein
Conclusions We demonstrated how TBBAVF surgery is successfully managed by an ICB nerve block and axillary BPB under ultrasound guidance. Future studies are required to explore this technique, including dosage-finding study.