Didactic discussion focusing on common variation of perforating veins connecting the deep and superficial veinous system pertinent to endoAVF creation.
Hello, I'm Steven Holman vascular surgeon from Dallas Texas. Hi, I'm Ngai Mala. I'm an interventional nephrologist from Dallas Texas. Well, this is a fitting topic because the perforator is the key to the wavelength procedure. So the perforator is the connection between the deep system and the superficial system. Um I think we've dubbed it the escalator, the elevator. I'm not sure what else. Elevator have we called it? The elevator? I, I think I have. Yeah. Well, anything that connects the deep to the superficial. So come up with your own and let us know we'd love to include it in future topics. So think about it. The perforator communicates your superficial vessels, your cephalic and your median cubital down to your radial veins and typically it's the lateral radial vein and then it goes down to the lateral ulnar vein almost exclusively. Yeah, this is a great shot of that. What you just explained here, Doctor Mala. So here's the cephalic vein, then the median cubital, which of course joins the basilic and then the perf are coming down here and here you see kind of a remnant of where the radial veins would come in. But you can see it very robustly joining that lateral ulmer vein. Um And that's really the key. So most of our anastomosis, I would say would be approximately in this area. Um a single perforator common, we want it two millimeters or greater. Um But of course, that would be the absolute bottom, that would be the minimum. Um But of course, this one appears to be large. I'd say this is approximately 3, 3.5 millimeters. I mean, this is as big as the ulnar vein itself. So very nice size, perforated right there. Absolutely. And this lateral ulnar vein then becomes the lateral brachial vein. Um And then of course, there's these large bridging veins. Uh We see these classically between the ulnar system, not as robustly in the radio system, but definitely see this very nicely in the ulnar system. And then of course, this is talking about where the radial veins drain in um depending on the the body. Um Some people's vessels are larger than others. I'd say in general, the ulnar veins tend to be a lot larger. Um in that they are the confluence of the inner osseous veins. That's what IV stands for here in interosseous and then the proper ulnar veins to become the common ulnar vein. All right. So here's our first variation, Doctor Mala, this is multiple perforators can on this. Let's take a look here. So we've got a right arm here. So we can see on the bottom of the screen is the medial ulnar vein coursing along to the medial brachial vein. It's a large, that's a large medial brachial. It is, but it's a single vessel, right. And sometimes if you have a single brachial vein, but you know, it, it tends to be a little bit larger. So you can see the lateral ulnar vein coming off right there and kind of curving up. And so there's our lateral their vein right there. And from that, you can actually see three perforating veins moving up. So there's the lateral on their vein, perforator, one perforator, two perforator, number three, all going up to a superficial cephalic vein right there. And does it matter that there's multiple perforators here, would you say? No, it doesn't really, it's all there to carry the flow from the deep to the superficial. So if it's more than one, I think it makes it a great option in terms of outflow, you just have to decide where you want to do your anastomosis. And if you're going to choose it on the lateral side, I would probably say somewhere between perre or one perforator, two, put in an osteosis right there and all three will be utilized to carry that flow up. Yeah, definitely. I I'm for sure. And the way you could always confirm it would be to put a catheter here and inject. But I bet it comes down here and fills up that as Well, I think so. Um if you put it on the medial side, um you could also kind of join a similar spot where it would flow here and then up and out. I, I do like the multiple perforator. I think it actually, I think it's nice because you have more flow from the deep um to the superficial system. And of course, this one you see almost exclusively filling out the cephalic vein. And so, and again, it's all carrying flow into a cephalic. They're not carrying it to other vessels that you worry about competition. It's all feeding up into a cephalic. So you're fine. Absolutely. Well, here's another perforator variation. Can you orient us this one? All right. So here, what looks like a right arm also, let's look at the arteriogram. So we've got the ulnar artery labeled, right? And you've got your paired ulnar veins. And so take a look at the radial level now, so you've got your radial artery and radial vein. Now, remember I've, we've said over and over again, the perforating vein usually communicates superficial to radial level down to ulnar level. But what we see here is a variation where the perforator stops at the radial level and does not continue on to the ulnar level, right? So there's your, your perforating vein right there. So then the question is, is where's a viable anastomotic option for you? You could definitely go and look on the radial side, do a radial artery, radial vein and osteosis. But I think if we take a look here, we can see um what they did itself. So yeah, and you know, this one is one of those where I I think really oftentimes if there's any confusion about this, I think this is where a venogram is very helpful. Ultrasound is great for planning, great for showing you size of things, but also where you inject the contrast that tells you where everything is going to flow. And I think often times um that's very helpful. So you can see the kind of preferred a v fistula location near the perforator. Um And I, I think this is a, well, this is a well made point. You, you prefer to create endo a fistula um with the most direct communication, the perforator doesn't mean you have to. But I would say that would be the preferred way. But often times like I said, you know, we kind of give these artificial divisions um with the rapid filling of the, of the vessels, you can really tell sometimes if you don't put it exactly near that per it still makes it way there. And so you can see what they did here is they actually created an osteosis to the medial ulnar vein and you're getting ring flow over to the lateral, then down the radial vein into the perforating vein. So you still get good flow. And the first step would be getting your cy catheter down into that ulnar vein and doing your venogram from there. If you're getting perforating and cephalic flow from your venogram from the ulnar side, then I think it would be fine to make that anastomosis like they did here. Absolutely. Now, this is a interesting one here. You what your, you know, well, I like that. Doctor Mall. Exactly. What's not here. So, rather than seeing the perforator, which you could imagine should be right here, we've shown you a series of pictures where the perforator should be right here, but it's not filling. So it makes you wonder whether there's a valve preventing flow um or something along that line. So the perforator should be there. Um And so here opening up that perforator and then actually then seeing flow um down and up and out the perforator into the cephalic vein. So I think this is where it's really helpful to have done these and to know where the perforator should be because sometimes there could be a valve in that location or some reason why it's not filling, even though you do see it on ultrasound, that's why really, it's not just ultrasound and it's not just venography, they're really complementary to each other. They're very helpful in pairs, you know, using both so perforating variations. So the perforating veins are critical of the success of the endo A V fistula. So first of all, taking a look at them with the ultrasound, making sure the two millimeters are greater two millimeter being the very bare minimum. And also getting an idea of where they join, um tends to be the lateral radial vein and almost exclusively the lateral vein. I agree. And I'm less concerned about the tortuosity of the perforator. And I'm more following the flow of that perforator. And as long as there's communication from the deep vein where I'm anticipating my anastomosis through that perforator into a superficial vessel. Then I'm usually happy with it. Absolutely. Well, thank you for your attention. Thank you.
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