Hemodialysis accessHemodialysis access

Hemodialysis accessHemodialysis access

The number of patients with end-stage renal The number of patients with end-stage renal disease (ESRD) in the United States has disease (ESRD) in the United States has increased steadily.increased steadily.

2030: 2.24 million patients with ESRD.2030: 2.24 million patients with ESRD.

The creation and maintenance of functioning The creation and maintenance of functioning vascular access, along with the associated vascular access, along with the associated complications, constitute the most common complications, constitute the most common cause of morbidity, hospitalization, and cost in cause of morbidity, hospitalization, and cost in patients with end-stage renal disease. patients with end-stage renal disease.

Vascular Access via Percutaneous Vascular Access via Percutaneous Catheters Catheters

useful method of useful method of gaining immediate gaining immediate access to the access to the circulation.circulation.associated with associated with higher risks. higher risks. the use-life of this the use-life of this type of access is type of access is shorter than that of shorter than that of AVFs. AVFs.

Noncuffed cathetersNoncuffed cathetersShort term: <3 weeksShort term: <3 weeks

Vascular Access via Percutaneous Vascular Access via Percutaneous Catheters: cuffed catheters Catheters: cuffed catheters

Cuffed cathetersCuffed catheters

Patients who will require Patients who will require long-term access should long-term access should have a tunneled catheter have a tunneled catheter placed. placed.

allow so-called no-needle allow so-called no-needle dialysis with high flow dialysis with high flow ratesrates

eliminate the problem of eliminate the problem of vascular steal vascular steal

placed in a subcutaneous placed in a subcutaneous tunnel under fluoroscopic tunnel under fluoroscopic guidanceguidance

Vascular Access via Percutaneous Vascular Access via Percutaneous Catheters: cuffed cathetersCatheters: cuffed catheters

The Dacron cuff allows tissue The Dacron cuff allows tissue ingrowth that helps reduce the risk ingrowth that helps reduce the risk of infection when compared with of infection when compared with noncuffed catheters. noncuffed catheters.

Hemodialysis access: complicationsHemodialysis access: complications

Complications can be divided into those Complications can be divided into those that occur secondary to catheter that occur secondary to catheter placement and those that occur later. placement and those that occur later. The early complications of subclavian or The early complications of subclavian or internal jugular placement include internal jugular placement include pneumothorax, arterial injury, thoracic duct pneumothorax, arterial injury, thoracic duct injury, air embolus, inability to pass the injury, air embolus, inability to pass the catheter, bleeding, nerve injury, and great catheter, bleeding, nerve injury, and great vessel injury. vessel injury.

Hemodialysis access: complicationsHemodialysis access: complications

A chest radiograph must be taken after catheter A chest radiograph must be taken after catheter placement to rule out pneumothorax and injury to the placement to rule out pneumothorax and injury to the great vessels and to check for position of the catheter. great vessels and to check for position of the catheter. The incidence of pneumothorax is 1% to 4%,the The incidence of pneumothorax is 1% to 4%,the incidence of injury to the great vessels is less than 1%.incidence of injury to the great vessels is less than 1%.Thrombotic complications occur in 4% to 10% of patients Thrombotic complications occur in 4% to 10% of patients Infection may occur soon after placement (3 to 5 days) Infection may occur soon after placement (3 to 5 days) or late in the life of the catheter and may be at the exit or late in the life of the catheter and may be at the exit site or the cause of catheter-related sepsis. site or the cause of catheter-related sepsis. Rate of infection between 0.5 and 3.9 episodes per 1000 Rate of infection between 0.5 and 3.9 episodes per 1000 catheter-days.catheter-days.Catheter thrombosis increases the incidence of catheter Catheter thrombosis increases the incidence of catheter sepsis.sepsis.

Vascular Access via Arteriovenous FistulasVascular Access via Arteriovenous Fistulas

The ideal vascular access The ideal vascular access – permits a flow rate that is adequate for the permits a flow rate that is adequate for the

dialysis prescription (³ 300 ml/min), dialysis prescription (³ 300 ml/min), – can be used for extended periods, can be used for extended periods, – and has a low complication rate. and has a low complication rate.

The native AVF remains the gold standard The native AVF remains the gold standard

Arteriovenous fistulasArteriovenous fistulasThe standard by which all other fistulas are measured, is The standard by which all other fistulas are measured, is

the Brescia-Cimino fistula. (2 year patency: 55% to 89%)the Brescia-Cimino fistula. (2 year patency: 55% to 89%)

•radial branch-cephalic direct access (snuffbox fistula), •autogenous ulnar-cephalic forearm transposition, •autogenous brachial-cephalic upper arm direct •access (antecubital vein to the brachial artery),•autogenous brachial-basilic upper arm transposition (basilic vein transposition).

These options should be exhausted before nonautogenous material is used for dialysis access.

Noninvasive Criteria for Selection of Upper-Extremity Arteries and Veins for Dialysis Access Procedures

Venous examination   Venous luminal diameter 2.5 mm for autogenous AVFs, 4.0 mm for      bridge AV grafts   Absence of segmental stenoses or occluded segments   Continuity with the deep venous system in the upper arm   Absence of ipsilateral central vein stenosis or occlusion

Arterial examination   Arterial luminal diameter 2.0 mm   Absence of pressure differential 20 mm Hg between arms   Patent palmar arch

radiocephalic fistula radiocephalic fistula (anatomic snuff-box) (anatomic snuff-box)

radiocephalic fistula radiocephalic fistula (Brescia-Cimino) (Brescia-Cimino)

Vascular access via AVFs:Vascular access via AVFs:

brachiocephalic fistulabrachiocephalic fistula brachiobasilic fistula brachiobasilic fistula

Arteriovenous fistulas: ComplicationsArteriovenous fistulas: Complications

Failure to mature Failure to mature Stenosis at the proximal venous limb (48%). Stenosis at the proximal venous limb (48%). Thrombosis (9%) Thrombosis (9%) Aneurysms (7%)Aneurysms (7%)Heart failure Heart failure The arterial steal syndrome and its ensuing ischemia The arterial steal syndrome and its ensuing ischemia occur in about 1.6%: pain, weakness, paresthesia, occur in about 1.6%: pain, weakness, paresthesia, muscle atrophy, and, if left untreated, gangrene muscle atrophy, and, if left untreated, gangrene Venous hypertension distal to the fistula : distal tissue Venous hypertension distal to the fistula : distal tissue swelling, hyperpigmentation, skin induration, and swelling, hyperpigmentation, skin induration, and eventual skin ulceration.eventual skin ulceration.

Prosthetic Grafts for vascular accessProsthetic Grafts for vascular access

Upper arm grafts have a high flow rate and a low Upper arm grafts have a high flow rate and a low incidence of thrombosis. incidence of thrombosis.

higher incidence of ischemia in the hand higher incidence of ischemia in the hand

higher rate of stenosis, sec to endothelial hyperplasia.higher rate of stenosis, sec to endothelial hyperplasia.

Options for treating steal Options for treating steal DRIL procedureDRIL procedure

distal revascularization-distal revascularization-interval ligation interval ligation

excision of a portion of the veinexcision of a portion of the vein

plication w/ mattress or plication w/ mattress or continuous sutures continuous sutures

crossed PTFE band crossed PTFE band

interposition of a 4 mm PTFEinterposition of a 4 mm PTFE

Treatment of venous access complications.Treatment of venous access complications.

Venous angioplastyVenous angioplasty Graft thrombolysisGraft thrombolysis

Contraindications to Thrombolytic TherapyContraindications to Thrombolytic Therapy

AbsoluteAbsolute    

   Recent major bleedingRecent major bleeding  Recent stroke  Recent stroke  Recent major surgery or trauma  Recent major surgery or trauma  Irreversible ischemia of end organ  Irreversible ischemia of end organ  Intracranial pathology  Intracranial pathology  Recent ophthalmologic procedure  Recent ophthalmologic procedure

RelativeRelative      

History of gastrointestinal bleeding or History of gastrointestinal bleeding or active peptic ulcer diseaseactive peptic ulcer disease  Underlying coagulation abnormalities  Underlying coagulation abnormalities  Uncontrolled hypertension  Uncontrolled hypertension  Pregnancy  Pregnancy  Hemorrhagic retinopathy  Hemorrhagic retinopathy

Hemodialysis Hemodialysis accessaccess

Quality of life and overall outcome could be Quality of life and overall outcome could be improved significantly for hemodialysis improved significantly for hemodialysis patients if two primary goals were achieved: patients if two primary goals were achieved: – Increased placement of native AVFs: a minimum Increased placement of native AVFs: a minimum

of 50% of new dialysis patients should have of 50% of new dialysis patients should have primary AVFs.primary AVFs.

– Detection of dysfunctional access before Detection of dysfunctional access before thrombosis of the access route occurs.thrombosis of the access route occurs.

National Kidney Foundation Dialysis Outcome and Quality Initiative (NKF-DOQI)