Amir Hossein Miladipour MD

Nephrology ampTransplantation Section

Shohada Tajrish Hospital

Acute hemodialysis vascular access

Acute dialysis catheters

Cuffedtunneled dialysis catheters

Chronic hemodialysis vascular access

native arteriovenous (AV) fistulas

synthetic grafts

Acute Hemodialysis Catheters

Double-lumen non-cuffed non-tunneled hemodialysis catheters have become the preferred method for obtaining acute hemodialysis vascular access

An acute triple-lumen dialysis catheter has been developed The third lumen is available for blood drawing and the intravenous administration of drugs and fluid

The maximum blood flow is usually blood pump speeds of 300 mLmin with an actual blood flow of 250 mLmin or less

Acute Hemodialysis Catheters

Site of catheter Insertion can be inserted into the jugular subclavian

and femoral veinsRoutine use-life of catheters The limits on use-life are caused by infection

internal jugular catheters are suitable for 2 to 3 weeks of use

femoral catheters are usually used for a single treatment (ambulatory patients) or for 3 to 7 days in bed bound patients

Double lumen cuffed tunneled catheters Are principally constructed of silasticsilicone and other

soft flexible polymers which are less thrombogenic than polymers used in acute catheters

Require fluoroscopy for insertion due to their larger size and to the confirmation of tip location

Many allow right atrial tip location based on their soft polymer construction

Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters Usually blood pump speeds of 400 mLmin

Actual blood flow rates are almost always lower than those reported by the blood pump(20-30)

Compare to fistulas or arteriovenous grafts most patients require an increase in treatment time of approximately 20 percent to achieve equivalent urea removal

Cuffed tunneled catheter survival is highly variable 74 percent 1-year and a 43

percent 2-year catheter survival

Acute Double Lumen Catheter Complications

Complications associated with insertion Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires HemothoraxPneumothoraxCatheter-induced subclavian stenosis and subsequent

loss of the ipsilateral arm for future hemodialysis access

The location of the catheter in subclavian and internal jugular insertion should always be confirmed by x-ray prior to the initiation of hemodialysis or the administration of anticoagulants

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Acute hemodialysis vascular access

Acute dialysis catheters

Cuffedtunneled dialysis catheters

Chronic hemodialysis vascular access

native arteriovenous (AV) fistulas

synthetic grafts

Acute Hemodialysis Catheters

Double-lumen non-cuffed non-tunneled hemodialysis catheters have become the preferred method for obtaining acute hemodialysis vascular access

An acute triple-lumen dialysis catheter has been developed The third lumen is available for blood drawing and the intravenous administration of drugs and fluid

The maximum blood flow is usually blood pump speeds of 300 mLmin with an actual blood flow of 250 mLmin or less

Acute Hemodialysis Catheters

Site of catheter Insertion can be inserted into the jugular subclavian

and femoral veinsRoutine use-life of catheters The limits on use-life are caused by infection

internal jugular catheters are suitable for 2 to 3 weeks of use

femoral catheters are usually used for a single treatment (ambulatory patients) or for 3 to 7 days in bed bound patients

Double lumen cuffed tunneled catheters Are principally constructed of silasticsilicone and other

soft flexible polymers which are less thrombogenic than polymers used in acute catheters

Require fluoroscopy for insertion due to their larger size and to the confirmation of tip location

Many allow right atrial tip location based on their soft polymer construction

Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters Usually blood pump speeds of 400 mLmin

Actual blood flow rates are almost always lower than those reported by the blood pump(20-30)

Compare to fistulas or arteriovenous grafts most patients require an increase in treatment time of approximately 20 percent to achieve equivalent urea removal

Cuffed tunneled catheter survival is highly variable 74 percent 1-year and a 43

percent 2-year catheter survival

Acute Double Lumen Catheter Complications

Complications associated with insertion Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires HemothoraxPneumothoraxCatheter-induced subclavian stenosis and subsequent

loss of the ipsilateral arm for future hemodialysis access

The location of the catheter in subclavian and internal jugular insertion should always be confirmed by x-ray prior to the initiation of hemodialysis or the administration of anticoagulants

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Acute Hemodialysis Catheters

Double-lumen non-cuffed non-tunneled hemodialysis catheters have become the preferred method for obtaining acute hemodialysis vascular access

An acute triple-lumen dialysis catheter has been developed The third lumen is available for blood drawing and the intravenous administration of drugs and fluid

The maximum blood flow is usually blood pump speeds of 300 mLmin with an actual blood flow of 250 mLmin or less

Acute Hemodialysis Catheters

Site of catheter Insertion can be inserted into the jugular subclavian

and femoral veinsRoutine use-life of catheters The limits on use-life are caused by infection

internal jugular catheters are suitable for 2 to 3 weeks of use

femoral catheters are usually used for a single treatment (ambulatory patients) or for 3 to 7 days in bed bound patients

Double lumen cuffed tunneled catheters Are principally constructed of silasticsilicone and other

soft flexible polymers which are less thrombogenic than polymers used in acute catheters

Require fluoroscopy for insertion due to their larger size and to the confirmation of tip location

Many allow right atrial tip location based on their soft polymer construction

Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters Usually blood pump speeds of 400 mLmin

Actual blood flow rates are almost always lower than those reported by the blood pump(20-30)

Compare to fistulas or arteriovenous grafts most patients require an increase in treatment time of approximately 20 percent to achieve equivalent urea removal

Cuffed tunneled catheter survival is highly variable 74 percent 1-year and a 43

percent 2-year catheter survival

Acute Double Lumen Catheter Complications

Complications associated with insertion Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires HemothoraxPneumothoraxCatheter-induced subclavian stenosis and subsequent

loss of the ipsilateral arm for future hemodialysis access

The location of the catheter in subclavian and internal jugular insertion should always be confirmed by x-ray prior to the initiation of hemodialysis or the administration of anticoagulants

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Acute Hemodialysis Catheters

Site of catheter Insertion can be inserted into the jugular subclavian

and femoral veinsRoutine use-life of catheters The limits on use-life are caused by infection

internal jugular catheters are suitable for 2 to 3 weeks of use

femoral catheters are usually used for a single treatment (ambulatory patients) or for 3 to 7 days in bed bound patients

Double lumen cuffed tunneled catheters Are principally constructed of silasticsilicone and other

soft flexible polymers which are less thrombogenic than polymers used in acute catheters

Require fluoroscopy for insertion due to their larger size and to the confirmation of tip location

Many allow right atrial tip location based on their soft polymer construction

Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters Usually blood pump speeds of 400 mLmin

Actual blood flow rates are almost always lower than those reported by the blood pump(20-30)

Compare to fistulas or arteriovenous grafts most patients require an increase in treatment time of approximately 20 percent to achieve equivalent urea removal

Cuffed tunneled catheter survival is highly variable 74 percent 1-year and a 43

percent 2-year catheter survival

Acute Double Lumen Catheter Complications

Complications associated with insertion Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires HemothoraxPneumothoraxCatheter-induced subclavian stenosis and subsequent

loss of the ipsilateral arm for future hemodialysis access

The location of the catheter in subclavian and internal jugular insertion should always be confirmed by x-ray prior to the initiation of hemodialysis or the administration of anticoagulants

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double lumen cuffed tunneled catheters Are principally constructed of silasticsilicone and other

soft flexible polymers which are less thrombogenic than polymers used in acute catheters

Require fluoroscopy for insertion due to their larger size and to the confirmation of tip location

Many allow right atrial tip location based on their soft polymer construction

Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters Usually blood pump speeds of 400 mLmin

Actual blood flow rates are almost always lower than those reported by the blood pump(20-30)

Compare to fistulas or arteriovenous grafts most patients require an increase in treatment time of approximately 20 percent to achieve equivalent urea removal

Cuffed tunneled catheter survival is highly variable 74 percent 1-year and a 43

percent 2-year catheter survival

Acute Double Lumen Catheter Complications

Complications associated with insertion Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires HemothoraxPneumothoraxCatheter-induced subclavian stenosis and subsequent

loss of the ipsilateral arm for future hemodialysis access

The location of the catheter in subclavian and internal jugular insertion should always be confirmed by x-ray prior to the initiation of hemodialysis or the administration of anticoagulants

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters Usually blood pump speeds of 400 mLmin

Actual blood flow rates are almost always lower than those reported by the blood pump(20-30)

Compare to fistulas or arteriovenous grafts most patients require an increase in treatment time of approximately 20 percent to achieve equivalent urea removal

Cuffed tunneled catheter survival is highly variable 74 percent 1-year and a 43

percent 2-year catheter survival

Acute Double Lumen Catheter Complications

Complications associated with insertion Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires HemothoraxPneumothoraxCatheter-induced subclavian stenosis and subsequent

loss of the ipsilateral arm for future hemodialysis access

The location of the catheter in subclavian and internal jugular insertion should always be confirmed by x-ray prior to the initiation of hemodialysis or the administration of anticoagulants

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Acute Double Lumen Catheter Complications

Complications associated with insertion Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires HemothoraxPneumothoraxCatheter-induced subclavian stenosis and subsequent

loss of the ipsilateral arm for future hemodialysis access

The location of the catheter in subclavian and internal jugular insertion should always be confirmed by x-ray prior to the initiation of hemodialysis or the administration of anticoagulants

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Catheter Malfunction Definition

Failure to achieve blood flow rate at least 300mlmin on 2 consecutive occasions or less than 200mlmin on a single occasion

EarlyInproper positioning of catheter tip

subcutaneous kinking of catheterLate intraluminal thrombi and less commonly

extrluminal thrombi( fibrin tails)

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter Complications

Catheter thrombosis PreventionHeparin of either 1 mL = 1000 Units 1 mL= 5000 Units or 1

mL = 10000 Units can be usedalteplase (recombinant tissue-type plasminogen activator

rtPA)administration of alteplase (2 mg injected into each lumen)

was associated with significantly higher blood flow rates and better arterial and venous pressures compared with heparin

Treatment mdash Lytic agents such as urokinase and alteplase are effective

Non-cuffed catheters should be exchanged if flow is inadequate

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter ComplicationsCentral vein thrombosis and stenosis

occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent)

The KDOQI guidelines therefore recommend avoiding placement in the subclavian vein unless no other options are available

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter Complications

Infection

local exit site infection systemic bacteremia

Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site down the hemodialysis catheter into the blood stream

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter Complications

Prevention of infection

strict adherence to proper placement technique optimal exit site caremanagement of the catheter within the hemodialysis

facilityantiseptic or antibiotic-bonded hemodialysis

catheters minocycline-rifampin coated cathetercitrate4

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter Complications

MICROBIOLOGY Staphylococcal infection both coagulase-negative and S aureus

accounts for 40 to 81 percent of casesand enterococci and Gram negative rods

DIAGNOSIS Blood cultures colony count four-fold higher in blood drawn from the catheter

compared to the peripheral specimen had a sensitivity of 94 percent a specificity of 100 percent

A single bacterial count of gt100 cfumL from catheter cultures with an identical organism growing from the peripheral blood specimen

it is common to occur in the absence of evidence of an exit-site infection

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter Complications

Treatment of infection

initially treating with broad spectrum agents ( vancomycin and an aminoglycoside)

Obtaining of blood cultures two to four days after initiation of antibiotic therapy

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter Complications

Catheter removal All non-cuffed catheters should be removed in the presence of bacteremia if follow-up blood cultures remain positive for more than five days despite

appropriate antimicrobial therapy signs of accompanying exit-site or tunnel infection (erythema or pus at exit-

site) infection with Candida or an infected clot An infected clot should be suspected if infusing or drawing blood through the

line is difficult or associated with rigors the patient becomes hemodynamically unstable or if the fever persists or

cultures remain positive after two to four days Patients who remain febrile or have positive cultures after the catheter is

removed should undergo a thorough examination for metastatic complications (such as endocarditis and vertebral osteomyelitis)

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Double Lumen Catheter Complications

Recommendations All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene before and after patient contact

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and understand local trends in types of pathogens incidence and antimicrobial resistance

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Chronic hemodialysis vascular access

bull Native arteriovenous (AV) fistulasbull Synthetic grafts bull Double-lumen tunneled cuffed catheters

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Native arteriovenous (AV) fistulasconstructed with an end-to-side vein-to-artery

anastomosis between an artery and vein

Radial artery and cephalic vein (radiocephalic or wrist fistula)

Brachial artery and cephalic vein (brachiocephalic or upper arm fistula)

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Native arteriovenous (AV) fistulas

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Synthetic grafts

are constructed by anastomosing a synthetic conduit usually polytetrafluoroethylene (PTFE also known as Gortex) between an artery and vein

The 2006 KDOQI work group recommends a graft either of synthetic or biologic material

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Comparison of Fistulas and Grafts

Primary failure defined as an access that never provided reliable

hemodialysis In radiocephalic fistulas 24 to 35 percent

brachiocephalic fistula 9 to 12 and brachiobasilic fistulas 29 to 36 percent forearm grafts 0 to 13 percent upper arm grafts 0 to 3

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Comparison of Fistulas and Grafts

Time to use Grafts Grafts can be cannulated for hemodialysis earlier than fistulas Grafts can usually be cannulated within weeks Some times within days of surgeryFistulas Cannulation before two weeks of age should be avoided Cannulation between two to four weeks may be attempted but only if

the fistula is considered mature Cannulation after four weeks of maturation may be safe if the fistula

is mature Independent of the age of the fistula clinical examination prior to

cannulation is very important given that some fistulas require up to six months to mature

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Comparison of Fistulas and Grafts

Patencysecondary failure In native fistulas the risk of secondary failure is

low The 5-year and 10ndashyear cumulative patencies

for radiocephalic fistulas are reported to be 53 and 45 percent respectively

cumulative patency for PTFE grafts at one two and four years is approximately 67 50 and 43 percent respectively

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Comparison of Fistulas and Grafts

Complications grafts vs AVF Thrombosis 38 timesInfection 102Steal syndrome 5 in bothAneurysms 5 3venous hypertension 3 in bothseromasheart failure less than 1 in AVF local bleeding Thrombosis infection and seromas occur more frequently

with grafts than with fistulas

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Steal syndromeSymptoms and signsMild

Coldness numbness paresthesiaspain during dialysis with retained pulses

Severe(Indication for ischemia correction)

Constant pain severe numbnessa nonhealing ischemic fissuredigital cyanosis or gangrenefinger contracture

Mild symptoms and signs usually improve over a period of weeks with the development of collateral blood flow

Careful frequent observations and an alert nursing staff are required in this setting

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Aneurysm and PseudoaneurysmIndications for revisionrepair of AV fistula aneurysm The skin overlying the fistula is (ischemic)compromised There is a risk of fistula rupture Available puncture sites are limited

indications for revisionrepair of pseudoaneurysm formation symptomatic or threatens the viability of the overlying skin Evidence of infection Pseudoaneurysm that is enlarging in size or that exceeds twice the

diameter of the graft Limited number of cannulation sites

Cannulation through a pseudoaneurysm must be avoided

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Venous HypertensionSign and symptoms severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration

In most cases the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

InfectionThe second most commonn cause of AV access

failure(0-3 in AVF and 6-25in AV grafts)

TreatmentAVFsLocal drainage and antibiotic therapy for 6

weeks AV graftsantibiotic therapy and surgical

treatment( in most cases complete excision of prosthetic graft)

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Buttonhole Technique for

Cannulating AV Fistulae

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Buttonhole Structure

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Needles ndash sharp and blunt

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Buttonhole Technique

Reuse same siteseach treatment withblunt needles

Must follow thetracktunnel of theoriginal cannulator

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Doppler Ultrasound Tunnel

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Benefits for the patientLess painful ndash elimination of anestheticFewer infectionsFewer missed needle sticksFewer infiltrationshematomasCannulation of access takes less time

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation

Why offer the Buttonhole Technique

1048766 Prolong AV fistula life

1048766 Decrease hospitalizations related to

access infections and complications

1048766 Promote patient self-cannulation

1048766 Decrease pain associated with needle

Cannulation