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accessory veins

Posted By Jeffrey Hoggard, Monday, March 16, 2015

Dear all,


A surgeon told me that as a fistula enlarges there will be more accessory vein flow. Not sure what his point was.  Certainly we think that fistulas will not clot at lower  access flow rates  as compared to grafts  because of these accessory ( “ collateral”)  veins maintaining outflow.   I am perplexed how frequently the accessory veins  involute  in larger fistulas.   Classic example is a well -developed BC avf that presents with  subtotal  occlusion of the cephalic arch and there are no longer any accessory/collateral veins draining to the basilic/brachial  veins.   What caused the attrition of these collateral pathways that were present when the fistula was created?   The fistula  vein became the pathway of least resistance  to flow  as the fistula matured.   Early in the maturation of the fistula, one could still demonstrate that  the accessory veins were still there if a  reflux study  was done with outflow compression.   But  later as the fistula became much larger and one discovers  an outflow occlusion  or  development of  high inflow  the accessory/collateral veins  did not enlarge to accommodate the outflow.  What causes this attrition; thrombosis in the  much smaller veins?


  I guess the other  question is why don’t some accessory veins involute when there is no longer an outflow  restriction in a developing immature fistula.   I see this more commonly in an immature forearm RC avf that has now been dilated to 8 mm and  multiple  accessory veins  remain even a year later.     Seems like the physics of  flow don’t   explain all the findings of the shunts that are man- made.


Does anyone know of any anatomy/pathology studies that document the presence of valves in these small  accessory  veins. I would assume they have valves but I don’t know.


Thank you for any thoughts or feedback about accessory veins.




Jeffrey Hoggard MD

Capital Nephrology Assoc

3031 New Bern Ave

Suite 100

Raleigh, NC  27610

Office: 919-747-7820

Cell:  252 -531-9556



Tags:  accessory veins 

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Comments on this post...

Thierry M. POURCHEZ says...
Posted Wednesday, March 25, 2015
Dear all,

The arm cephalic vein has few side branches, and it is frequent to see that in case of cephalic arch stenosis.

The forearm cephalic vein has more side branches, and particularly the external accessory cephalic.

The blood flow goes where the pressure would be the lower. It takes the biggest veins going directly to the heart, and it is mainly the arm basilic vein. But we see frequently side branches who are filled during a procedure. There are less side branches after treatment of a stenosis, and it is a way to know the efficacy of the balloon. These side branches are not the so called "competing veins", and their flow is low. They are going to enlarge in case of recurrence of the stenosis and it is a good signal to recognize the recurrence of that stenosis.

With the time, we see a disappearing of side branches, mainly close to the place of dilatation, and I think because of the injury of the wall of the vein, giving a thickening of the vein wall. Some of this side branches expect also stenosis giving a thrombosis with the time.

I think globally we might create fistulas with low flow with healthy veins to avoid high shear stress and hyperplasia on the vessels. The main goal is always to protect the upper limbs veins.

Kind regards.

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Marc Webb says...
Posted Tuesday, October 20, 2015
Regarding the specific question on valves - I do a large number of transpositions and superficializations and have an opportunity to examine cephalic and basilic veins directly - there are a significant number of valves in these "trunk" veins and generally at most but not all tributary orifices.
My two cents: the presence of a branch is not an indication for a procedure - I interrupt branches when early diverting flow near the origin of a fistula (1) interferes with maturation of the fistula above the diversion; (2) contributes to steal by lowering resistance and increasing flow in the dialysis circuit to the detriment of the hand; or (3) contributes to venous hypertension and swelling in the extremity.
And greetings to Thierry ....
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Jeffrey Hoggard says...
Posted Wednesday, October 21, 2015
Thierry and Marc,
Thank you for your expert commentary. i always learn from my surgical colleagues.

Jeff Hoggard
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