Does cannulation technique impact arteriovenous fistula

and graft survival?

Maria Teresa Parisotto| CANNT 2017 | Halifax| October 20th, 2017

Preserving the AVF as the patient lifeline: reduced mortality with the AVF compare to Catheter

Polkinghorne et al. J Am Soc Nephrol 15: 477-486, 2004

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0

0.2

0.4

0.6

0.8

1

0 12 24 36

AVF

Catheter

Su

rviv

al

Months

p<0.001

ANZDATA Register

Vascular Access Major Cause of Hospitalisation

Rayner et al. Nephrol Dial Transplant 19: 108-120, 2004

0%

20%

40%

60%

80%

100%

France Germany Italy Spain UK

CV related VA related Infection related Gastrointestinal

DOPPS

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% of VA cannulations

Thrombosis 16,5%

Hemorrage 7,5%

Infection 5,5%

Aneurysm 4,1%

Complications Associated to VA Cannulation

Yürügen and Erdogan, J Vasc Access 2001; 2: 119-124 (Data from Master Thesis at Istanbul University)

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Preserving the Vascular Access is our responsibility

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Phases of Vascular Access Management

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Assessment and

preparation

Cannulation

Monitoring

during treatment

Disconnection

VA creation

Haemostasis

VA surveillance

Phases of Vascular Access Management

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Assessment and

preparation

Cannulation

Monitoring

during treatment

Disconnection

VA creation

Haemostasis

VA surveillance

Fresenius Medical Care

Survey

Vascular Access Cannulation: Study Design

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1. Objective:

Snapshot on the current practice of vascular access cannulation

2. Design:

International, multi-centre, observational, cross-sectional survey

3. Centres:

Dialysis centres of the Fresenius Medical Care network in Europe, Middle East, Africa, participation on voluntary basis

4. Procedures:

Anonymous documentation of vascular access and its cannulation once per patient (Patient Questionnaire) at appointed date (April ‘09)

Vascular Access Cannulation: Inclusion criteria

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Vascular Access Cannulation: Participating Countries and Centres

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33/1,729

5/496 31/1,048

34/

3,394

(Numbers: Centres/Patients by country)

+ South Africa

2/41 44/2,097

4/256

4/766

10/870

4/110

10 countries / 171 centres / 10,807 patients

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Descriptive Statistics

Type of Vascular Access:

AVF: 90.9%

AVG : 9.1%

Location of the VA:

Arm: 98.7%

Leg: 1.3%

Left arm: 72.2%

Right arm: 21.8%

Lower arm 49.6%

Upper arm: 50.4%

Descriptive Statistics

Cannulation technique:

Area: 61.0%

Rope Ladder: 31.0%

Buttonhole: 6.1%

Missing data 1.8%

Survey results (1/2)

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Descriptive Statistics

Needle sizes:

15G: 61.3%

16G : 33.2%

14G: 3.0%

17G: 2.5%

Direction of arterial needle puncture:

Antegrade: 63.0% Retrograde: 37.0%

Direction of bevel:

Upward: 72.3% Downward: 27.7%

Descriptive Statistics

Rotation of needle after cannulation:

Yes: 43.2% No: 54.5%

Nurses 'experience in dialysis

> 5 years: 66.0%

2 – 5 years: 19.0%

1 – 2 years 7.0%

< 1 year 8.0%

Survey results (2/2)

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With the data collected we did three types of evaluations:

1. The variables possibly influencing the probability of reaching an adequate dialysis dose (Kt/V ≥ 1.2)

2. The nursing practices possibly influencing the development of “acute cannulation complications” (multiple-cannulation, infiltration, haematoma, haemorrhage, unknown)

3. The cannulation technique vs vascular access survival (7.058 patients observed for 3 years)

Analysis of the data

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1. Analysis of variables related to the probability of reaching an adequate dialysis dose

Logistic regression on the odds ratio to reach Kt/V > 1.2

Odds ratio 95% confidence interval P-value

Gender (male vs. female) 0.293 0.243 - 0.354 <0.001 Post-dialytic body weight (per kg) 0.938 0.933 - 0.944 <0.001 Treatment time (per min) 1.036 1.032 - 1.041 <0.001 Treatment modality (on-line HDF vs. HD) 1.886 1.603 - 2.219 <0.001 Direction of arterial needle (retrograde vs. antegrade) 1.275 1.088 - 1.494 0.003 Needle size (vs. 17 G) 16 G 2.962 1.786 – 4.913 <0.001 15 G 6.626 3.963 – 11.079 <0.001 14 G 12.145 6.016 – 24.520 <0.001 Fistula type (graft vs. native arterio-venous fistula) 1.930 1.446 – 2.576 <0.001 Blood flow (vs. < 300 ml/min) 300 – 350 2.172 1.755 – 2.687 <0.001 350 – 400 2.651 2.103 – 3.343 <0.001 >400 3.156 2.274 – 4.380 <0.001 Dialyser surface (vs. 1.30 – 1.50 m2) 1.51 – 1.80 1.582 1.279 – 1.957 <0.001 >1.80 1.578 1.222 – 2.037 <0.001

Gauly A, Parisotto MT, et al. “Vascular Access Cannulation in Hemodialysis Patients – A Survey of Current Practice and its Relation to Dialysis Dose”. JVasc Access 2011; 12 (4): 358-364

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1. Analysis of variables related to the probability of reaching an adequate dialysis dose

Logistic regression on the odds ratio to reach Kt/V > 1.2

Odds ratio 95% confidence interval P-value

Gender (male vs. female) 0.293 0.243 - 0.354 <0.001 Post-dialytic body weight (per kg) 0.938 0.933 - 0.944 <0.001 Treatment time (per min) 1.036 1.032 - 1.041 <0.001 Treatment modality (on-line HDF vs. HD) 1.886 1.603 - 2.219 <0.001 Direction of arterial needle (retrograde vs. antegrade) 1.275 1.088 - 1.494 0.003 Needle size (vs. 17 G) 16 G 2.962 1.786 – 4.913 <0.001 15 G 6.626 3.963 – 11.079 <0.001 14 G 12.145 6.016 – 24.520 <0.001 Fistula type (graft vs. native arterio-venous fistula) 1.930 1.446 – 2.576 <0.001 Blood flow (vs. < 300 ml/min) 300 – 350 2.172 1.755 – 2.687 <0.001 350 – 400 2.651 2.103 – 3.343 <0.001 >400 3.156 2.274 – 4.380 <0.001 Dialyser surface (vs. 1.30 – 1.50 m2) 1.51 – 1.80 1.582 1.279 – 1.957 <0.001 >1.80 1.578 1.222 – 2.037 <0.001

Gauly A, Parisotto MT, et al. “Vascular Access Cannulation in Hemodialysis Patients – A Survey of Current Practice and its Relation to Dialysis Dose”. JVasc Access 2011; 12 (4): 358-364

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1. Analysis of variables related to the probability of reaching an adequate dialysis dose

Logistic regression on the odds ratio to reach Kt/V > 1.2

Odds ratio 95% confidence interval P-value

Gender (male vs. female) 0.293 0.243 - 0.354 <0.001 Post-dialytic body weight (per kg) 0.938 0.933 - 0.944 <0.001 Treatment time (per min) 1.036 1.032 - 1.041 <0.001 Treatment modality (on-line HDF vs. HD) 1.886 1.603 - 2.219 <0.001 Direction of arterial needle (retrograde vs. antegrade) 1.275 1.088 - 1.494 0.003 Needle size (vs. 17 G) 16 G 2.962 1.786 – 4.913 <0.001 15 G 6.626 3.963 – 11.079 <0.001 14 G 12.145 6.016 – 24.520 <0.001 Fistula type (graft vs. native arterio-venous fistula) 1.930 1.446 – 2.576 <0.001 Blood flow (vs. < 300 ml/min) 300 – 350 2.172 1.755 – 2.687 <0.001 350 – 400 2.651 2.103 – 3.343 <0.001 >400 3.156 2.274 – 4.380 <0.001 Dialyser surface (vs. 1.30 – 1.50 m2) 1.51 – 1.80 1.582 1.279 – 1.957 <0.001 >1.80 1.578 1.222 – 2.037 <0.001

Gauly A, Parisotto MT, et al. “Vascular Access Cannulation in Hemodialysis Patients – A Survey of Current Practice and its Relation to Dialysis Dose”. JVasc Access 2011; 12 (4): 358-364

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2. Logistic regression model evaluating nursing practice in respect to the event “acute cannulation complication” (multiple-cannulation, infiltration, haematoma, haemorrhage, unknown)

Nursing practice aspect

OR

95% confidence Interval

p-value

Variable Reference Category Lower limit Higher limit

Needle gauge 15

14 0.545 0.199 1.491 NS

16 1.305 1.016 1.676 0.037

17 4.245 2.548 7.072 <0.001

Back-eye needle No Yes 1.879 1.409 2.508 <0.001

Cannulation technique Rope-Ladder Buttonhole 0.559 0.332 0.942 0.029

Area 0.613 0.482 0.780 <0.001

1st needle inserted Arterial Venous 1.677 1.306 2.155 <0.001

Needle axis rotation No Yes 1.522 1.206 1.921 <0.001

Needle fixation Butterfly

Chevron 0.836 0.474 1.475 NS

U-Shape 0.754 0.461 1.232 NS

Others 0.561 0.347 0.905 0.018

Parisotto MT et Al.“Elements of dialysis nursing practice associated with successful cannulation: result of an international survey” J Vasc Access 2017; 18(2): 114 – 119. Open Access DOI: 10.5301/jva.5000617

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Nursing practice aspect

OR

95% confidence Interval

p-value

Variable Reference Category Lower limit Higher limit

Needle gauge 15

14 0.545 0.199 1.491 NS

16 1.305 1.016 1.676 0.037

17 4.245 2.548 7.072 <0.001

Back-eye needle No Yes 1.879 1.409 2.508 <0.001

Cannulation technique Rope-Ladder Buttonhole 0.559 0.332 0.942 0.029

Area 0.613 0.482 0.780 <0.001

1st needle inserted Arterial Venous 1.677 1.306 2.155 <0.001

Needle axis rotation No Yes 1.522 1.206 1.921 <0.001

Needle fixation Butterfly

Chevron 0.836 0.474 1.475 NS

U-Shape 0.754 0.461 1.232 NS

Others 0.561 0.347 0.905 0.018

Parisotto MT et Al.“Elements of dialysis nursing practice associated with successful cannulation: result of an international survey” J Vasc Access 2017; 18(2): 114 – 119. Open Access DOI: 10.5301/jva.5000617

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2. Logistic regression model evaluating nursing practice in respect to the event “acute cannulation complication” (multiple-cannulation, infiltration, haematoma, haemorrhage, unknown)

● Out of the 10,807 patients enrolled for the original survey, access survival data was available for 7,058 (65%)

● Primary outcome was the time of the first surgical access intervention, where survey date serves as baseline.

● The observation period was 3 years (from April 2009 till March 2012).

● To adjust for individual patient differences, the following information was extracted from the clinical

database:

• Patient age and gender, BMI, prevalence of diabetes, use of ACE inhibitors, platelet anti-aggregants, salicylic acid and anticoagulants.

3. Cannulation techniques vs vascular access survival (1/3)

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Mean age was 63.5+15.0 years;

38.5% were female;

27.1% were diabetics;

90.6% had a native fistula;

9.4% had a graft;

51.2% of patients, had a distal access location;

51.1% were treated with anti-aggregants;

2.8% anti-coagulant.

Descriptive Statistics

● Out of the 10,807 patients enrolled for the original survey, access survival data was available for 7,058 (65%)

● Primary outcome was the time of the first surgical access intervention, where survey date serves as baseline.

● The observation period was 3 years (from April 2009 till March 2012).

● To adjust for individual patient differences, the following information was extracted from the clinical

database:

• Patient age and gender, BMI, prevalence of diabetes, use of ACE inhibitors, platelet anti-aggregants, salicylic acid and anticoagulants.

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3. Cannulation techniques vs vascular access survival (1/3)

Needle sizes:

15G: 63.7%

16G : 32.2%

14G: 2,7%

17G: 1.4%

Cannulation technique:

Area: 65.8%

Rope Ladder: 28.2%

Buttonhole: 6%

Descriptive Statistics

● Out of the 10,807 patients enrolled for the original survey, access survival data was available for 7,058 (65%)

● Primary outcome was the time of the first surgical access intervention, where survey date serves as baseline.

● The observation period was 3 years (from April 2009 till March 2012).

● To adjust for individual patient differences, the following information was extracted from the clinical

database:

• Patient age and gender, BMI, prevalence of diabetes, use of ACE inhibitors, platelet anti-aggregants, salicylic acid and anticoagulants.

Direction of arterial puncture:

Antegrade: 57.3% Retrograde: 42.7%

The prevalent combination between arterial needle puncturing and bevel direction:

Antegrade with bevel upward: 43.1% Retrograde with bevel down: 27.1%

Median blood flow:

350 -400 mL / min

Descriptive Statistics

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3. Cannulation techniques vs vascular access survival (1/3)

Parameter Category Reference HR 95% CI p value Marginal

p value

Age 18-50 years 65-76 years >75 years

50-65 years 1.01 1.03 1.45

0.86 0.89 1.26

1.19 1.18 1.67

0.91 0.72 <0.0001

<0.0001

Gender Male Female 0.93 0.84 1.04 0.21

Diabetes Yes No 1.12 1.00 1.26 0.06

Heart failure Yes No 1.39 1.12 1.72 0.003

Vintage 6-24 months ≥24 months Unknown

0-6 months 1.04 0.98 0.55

0.81 0.77 0.26

1.33 1.24 1.18

0.79 0.84 0.13

0.34

Platelet Antiaggregants

Yes No 1.11 1.00 1.24 0.05

Fistula type Graft Fistula 1.74 1.48 2.06 <0.0001

AV-fistula location Right Left 1.13 1.01 1.27 0.03

AV-fistula location Proximal Distal 1.49 1.33 1.67 <0.0001

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Cox model with primary outcome vascular survival

Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: 10.1038/ki.2014.96

Parameter Category Reference HR 95% CI p value Marginal p

value

Needle size 14 G 16 G 17 G

15 G 1.25 1.21 1.42

0.85 1.07 0.93

1.83 1.38 2.17

0.26 0.003 0.11

0.01

Cannulation technique Buttonhole Rope-Ladder

Area 0.78 0.89

0.61 0.79

1.00 1.00

0.05 0.06

0.04

Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down

Antegrade + Bevel Up 0.97 0.93 1.18

0.82 0.81 1.01

1.14 1.07 1.37

0.71 0.32 0.04

0.03

Blood flow <300 mL/min 350-400 mL/min >400 mL/min

300-350 mL/min 1.18 0.91 0.93

1.01 0.80 0.75

1.36 1.04 1.15

0.03 0.16 0.49

0.03

Venous pressure

<100 mmHg 150-200 mmHg 200-300 mmHg >300 mmHg

100-150 mmHg

1.51 1.40 1.87 2.09

1.11 1.20 1.54 1.21

2.07 1.64 2.26 3.59

0.009 <0.0001 <0.0001 0.008

<0.0001

Arm compression at time of cannulation

None Tourniquet

Patient assistance 1.25 1.30

1.04 1.07

1.49 1.58

0.02 0.008

0.02

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Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: 10.1038/ki.2014.96

Cox model with primary outcome vascular survival

Parameter Category Reference HR 95% CI p value Marginal p

value

Needle size 14 G 16 G 17 G

15 G 1.25 1.21 1.42

0.85 1.07 0.93

1.83 1.38 2.17

0.26 0.003 0.11

0.01

Cannulation technique Buttonhole Rope-Ladder

Area 0.78 0.89

0.61 0.79

1.00 1.00

0.05 0.06

0.04

Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down

Antegrade + Bevel Up 0.97 0.93 1.18

0.82 0.81 1.01

1.14 1.07 1.37

0.71 0.32 0.04

0.03

Blood flow <300 mL/min 350-400 mL/min >400 mL/min

300-350 mL/min 1.18 0.91 0.93

1.01 0.80 0.75

1.36 1.04 1.15

0.03 0.16 0.49

0.03

Venous pressure

<100 mmHg 150-200 mmHg 200-300 mmHg >300 mmHg

100-150 mmHg

1.51 1.40 1.87 2.09

1.11 1.20 1.54 1.21

2.07 1.64 2.26 3.59

0.009 <0.0001 <0.0001 0.008

<0.0001

Arm compression at time of cannulation

None Tourniquet

Patient assistance 1.25 1.30

1.04 1.07

1.49 1.58

0.02 0.008

0.02

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Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: 10.1038/ki.2014.96

Cox model with primary outcome vascular survival

Parameter Category Reference HR 95% CI p value Marginal p

value

Needle size 14 G 16 G 17 G

15 G 1.25 1.21 1.42

0.85 1.07 0.93

1.83 1.38 2.17

0.26 0.003 0.11

0.01

Cannulation technique Buttonhole Rope-Ladder

Area 0.78 0.89

0.61 0.79

1.00 1.00

0.05 0.06

0.04

Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down

Antegrade + Bevel Up 0.97 0.93 1.18

0.82 0.81 1.01

1.14 1.07 1.37

0.71 0.32 0.04

0.03

Blood flow <300 mL/min 350-400 mL/min >400 mL/min

300-350 mL/min 1.18 0.91 0.93

1.01 0.80 0.75

1.36 1.04 1.15

0.03 0.16 0.49

0.03

Venous pressure

<100 mmHg 150-200 mmHg 200-300 mmHg >300 mmHg

100-150 mmHg

1.51 1.40 1.87 2.09

1.11 1.20 1.54 1.21

2.07 1.64 2.26 3.59

0.009 <0.0001 <0.0001 0.008

<0.0001

Arm compression at time of cannulation

None Tourniquet

Patient assistance 1.25 1.30

1.04 1.07

1.49 1.58

0.02 0.008

0.02

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Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: 10.1038/ki.2014.96

Cox model with primary outcome vascular survival

Parameter Category Reference HR 95% CI p value Marginal p

value

Needle size 14 G 16 G 17 G

15 G 1.25 1.21 1.42

0.85 1.07 0.93

1.83 1.38 2.17

0.26 0.003 0.11

0.01

Cannulation technique Buttonhole Rope-Ladder

Area 0.78 0.89

0.61 0.79

1.00 1.00

0.05 0.06

0.04

Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down

Antegrade + Bevel Up 0.97 0.93 1.18

0.82 0.81 1.01

1.14 1.07 1.37

0.71 0.32 0.04

0.03

Blood flow <300 mL/min 350-400 mL/min >400 mL/min

300-350 mL/min 1.18 0.91 0.93

1.01 0.80 0.75

1.36 1.04 1.15

0.03 0.16 0.49

0.03

Venous pressure

<100 mmHg 150-200 mmHg 200-300 mmHg >300 mmHg

100-150 mmHg

1.51 1.40 1.87 2.09

1.11 1.20 1.54 1.21

2.07 1.64 2.26 3.59

0.009 <0.0001 <0.0001 0.008

<0.0001

Arm compression at time of cannulation

None Tourniquet

Patient assistance 1.25 1.30

1.04 1.07

1.49 1.58

0.02 0.008

0.02

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Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: 10.1038/ki.2014.96

Cox model with primary outcome vascular survival

Parameter Category Reference HR 95% CI p value Marginal p

value

Needle size 14 G 16 G 17 G

15 G 1.25 1.21 1.42

0.85 1.07 0.93

1.83 1.38 2.17

0.26 0.003 0.11

0.01

Cannulation technique Buttonhole Rope-Ladder

Area 0.78 0.89

0.61 0.79

1.00 1.00

0.05 0.06

0.04

Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down

Antegrade + Bevel Up 0.97 0.93 1.18

0.82 0.81 1.01

1.14 1.07 1.37

0.71 0.32 0.04

0.03

Blood flow <300 mL/min 350-400 mL/min >400 mL/min

300-350 mL/min 1.18 0.91 0.93

1.01 0.80 0.75

1.36 1.04 1.15

0.03 0.16 0.49

0.03

Venous pressure

<100 mmHg 150-200 mmHg 200-300 mmHg >300 mmHg

100-150 mmHg

1.51 1.40 1.87 2.09

1.11 1.20 1.54 1.21

2.07 1.64 2.26 3.59

0.009 <0.0001 <0.0001 0.008

<0.0001

Arm compression at time of cannulation

None Tourniquet

Patient assistance 1.25 1.30

1.04 1.07

1.49 1.58

0.02 0.008

0.02

FME © Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 28 CANNT 20.10.2017

Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: 10.1038/ki.2014.96

Cox model with primary outcome vascular survival

Parameter Category Reference HR 95% CI p value Marginal p

value

Needle size 14 G 16 G 17 G

15 G 1.25 1.21 1.42

0.85 1.07 0.93

1.83 1.38 2.17

0.26 0.003 0.11

0.01

Cannulation technique Buttonhole Rope-Ladder

Area 0.78 0.89

0.61 0.79

1.00 1.00

0.05 0.06

0.04

Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down

Antegrade + Bevel Up 0.97 0.93 1.18

0.82 0.81 1.01

1.14 1.07 1.37

0.71 0.32 0.04

0.03

Blood flow <300 mL/min 350-400 mL/min >400 mL/min

300-350 mL/min 1.18 0.91 0.93

1.01 0.80 0.75

1.36 1.04 1.15

0.03 0.16 0.49

0.03

Venous pressure

<100 mmHg 150-200 mmHg 200-300 mmHg >300 mmHg

100-150 mmHg

1.51 1.40 1.87 2.09

1.11 1.20 1.54 1.21

2.07 1.64 2.26 3.59

0.009 <0.0001 <0.0001 0.008

<0.0001

Arm compression at time of cannulation

None Tourniquet

Patient assistance 1.25 1.30

1.04 1.07

1.49 1.58

0.02 0.008

0.02

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Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: 10.1038/ki.2014.96

Cox model with primary outcome vascular survival

• In summary, the study revealed that area cannulation technique, despite being the most commonly used, was inferior to both rope-ladder and buttonhole for the maintenance of Vascular Access functionality.

• With regard to the effect of needle and bevel direction, the combination of antegrade position of arterial needle with bevel up or down was significantly associated with better access survival than retrograde positioning with bevel down.

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Cannulation technique vs VA survival: Summary (1/2)

• Results referring to the type and location of access and the technical parameters (i.e. venous pressure) were as follows:

• There was an increased risk of access failure for graft versus fistula, proximal vs distal location, right arm vs left arm, and the presence of a venous pressure greater than 150 mmHg.

• The results on venous pressure are worth considering. A venous pressure of 200-250 mmHg is considered acceptable by the scientific community; the results of this study put these values under discussion. However, further investigations are required to clarify the topic fully.

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Cannulation technique vs VA survival: Summary (2/2)

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• Needle 17G – Ø 1.5 mm • Needle 15G – Ø 1.8 mm

Needle diameter vs blood flow and flow pattern vector

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Effect of needle angle during the treatment Fulker D. et al. The flow field near a venous needle in hemodialysis: a computational study.

Hemodial Int. 2013 Oct;17(4):602-11. doi: 10.1111/hdi.12029. Epub 2013 Mar 1.

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FME © Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 35 CANNT 20.10.2017

Effect of needle depth during the treatment Fulker D. et al. The flow field near a venous needle in hemodialysis: a computational study.

Hemodial Int. 2013 Oct;17(4):602-11. doi: 10.1111/hdi.12029. Epub 2013 Mar 1.

Antegrade puncturing may be fistula protective

• Increased risk of haematoma formation from retrograde filling

• Tract closure through flow force by antegrade puncture

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Effect of bevel direction in the arterial needle position (antegrade/retrograde)

Bevel Up

Bionic Medizintechnick GmbH

Bevel Down

Antegrade Retrograde

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Effect of bevel direction in the arterial needle position (antegrade/retrograde)

Bevel Up

Bionic Medizintechnick GmbH

Bevel Down

Antegrade Retrograde

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Effect of bevel direction in the arterial needle position (antegrade/retrograde)

Bevel Up

Bionic Medizintechnick GmbH

Bevel Down

Antegrade Retrograde

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Arterial needle antegrade: Effect of bevel up direction

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Arterial needle antegrade: Effect of bevel up direction

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Arterial needle antegrade: Effect of bevel up direction

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Arterial needle antegrade: Effect of bevel up direction

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Arterial needle antegrade: Effect of bevel up direction

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Arterial needle antegrade: Effect of bevel up direction

Arterial needle antegrade: Effect of bevel down direction

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Arterial needle antegrade: Effect of bevel down direction

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Arterial needle antegrade: Effect of bevel down direction

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Arterial needle antegrade: Effect of bevel down direction

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Arterial needle antegrade: Effect of bevel down direction

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• “… , taking access blood flow into consideration, no association was found between VA failure and extracorporeal blood flow for the range of extracorporeal blood flows commonly used in routine dialysis practice.

• Low extracorporeal blood flow (<310 mL/min) seems to be a surrogate for poor access blood flow.

• Some caution appears indicated when applying particularly high extracorporeal blood flow (>390 mL/min).”

Ponce P. et al. Hemodialysis International 2014 - Does the extracorporeal blood flow affect survival of the arteriovenous vascular access?

Blood flow and vascular access survival

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• “… , taking access blood flow into consideration, no association was found between VA failure and extracorporeal blood flow for the range of extracorporeal blood flows commonly used in routine dialysis practice.

• Low extracorporeal blood flow (<310 mL/min) seems to be a surrogate for poor access blood flow.

• Some caution appears indicated when applying particularly high extracorporeal blood flow (>390 mL/min).”

Blood flow and vascular access survival

Ponce P. et al. Hemodialysis International 2014 - Does the extracorporeal blood flow affect survival of the arteriovenous vascular access?

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Recommandations for an effective Vascular Access Management

VA Survival

Rope-ladder cannulation technique as preferred option and only when there is a limited area for cannulation sites, or for the potential self-care dialysis patients choose buttonhole

Arterial needle insertion in the antegrade direction (blood flow direction) and with bevel downward;

In the case of arterial needle retrograde position, the direction of the bevel should be upward

Avoid needle rotation!

15 G needles are recommended

Proper needle fixation

Blood flow 350 - 450 ml/min

Venous pressure around 150 mmHg

Correct haemostasis

Patients education to care for the Vascular Access

Clinical staff education on Vascular Access Management

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