Hemodialysis Access - ITurnbull

7/27/2019 Hemodialysis Access - ITurnbull

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Hemodialysis access

Irene Turnbull

1/31/2007


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Hemodialysis access

The number of patients with end-stage renal

disease (ESRD) in the United States has

increased steadily.

2030: 2.24 million patients with ESRD.The creation and maintenance of functioning

vascular access, along with the associated

complications, constitute the most common

cause of morbidity, hospitalization, and cost in

patients with end-stage renal disease.


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Vascular Access via Percutaneous

Catheters

useful method ofgaining immediateaccess to thecirculation.

associated withhigher risks.

the use-life of this

type of access isshorter than that ofAVFs.

Noncuffed catheters

Short term:


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Catheters: cuffed catheters

Cuffed catheters

Patients who will require

long-term access should

have a tunneled catheterplaced.

allow so-called no-needle

dialysis with high flow

rates

eliminate the problem of

vascular steal

placed in a subcutaneous

tunnel under fluoroscopic

guidance


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Catheters: cuffed cathetersThe Dacron cuff allows tissueingrowth that helps reduce the riskof infection when compared withnoncuffed catheters.


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Hemodialysis access: complications

Complications can be divided into thosethat occur secondary to catheterplacement and those that occur later.

The early complications of subclavian orinternal jugular placement includepneumothorax, arterial injury, thoracic ductinjury, air embolus, inability to pass thecatheter, bleeding, nerve injury, and greatvessel injury.


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Hemodialysis access: complications

A chest radiograph must be taken after catheterplacement to rule out pneumothorax and injury to thegreat vessels and to check for position of the catheter.

The incidence of pneumothorax is 1% to 4%,theincidence of injury to the great vessels is less than 1%.

Thrombotic complications occur in 4% to 10% of patients

Infection may occur soon after placement (3 to 5 days)or late in the life of the catheter and may be at the exitsite or the cause of catheter-related sepsis.

Rate of infection between 0.5 and 3.9 episodes per 1000catheter-days.

Catheter thrombosis increases the incidence of cathetersepsis.


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Vascular Access via Arteriovenous Fistulas

The ideal vascular access

permits a flow rate that is adequate for the

dialysis prescription ( 300 ml/min),

can be used for extended periods,

and has a low complication rate.

The native AVF remains the gold standard


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Arteriovenous fistulas

The standard by which all other fistulas are measured, isthe 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.


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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 armAbsence 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


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radiocephalic fistula

(anatomic snuff-box)

radiocephalic fistula

(Brescia-Cimino)


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Vascular access via AVFs:

brachiocephalic fistula brachiobasilic fistula


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Arteriovenous fistulas: Complications

Failure to mature

Stenosis at the proximal venous limb (48%).

Thrombosis (9%)

Aneurysms (7%)

Heart failure

The arterial steal syndrome and its ensuing ischemiaoccur in about 1.6%: pain, weakness, paresthesia,muscle atrophy, and, if left untreated, gangrene

Venous hypertension distal to the fistula : distal tissueswelling, hyperpigmentation, skin induration, andeventual skin ulceration.


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Prosthetic Grafts for vascular access

Upper arm grafts have a high flow rate and a low

incidence of thrombosis.

higher incidence of ischemia in the hand

higher rate of stenosis, sec to endothelial hyperplasia.


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Options for treating stealDRIL procedure

distal revascularization-

interval ligation

excision of a portion of the veinplication w/ mattress or

continuous sutures

crossed PTFE band

interposition of a 4 mm PTFE


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Treatment of venous access complications.

Venous angioplasty Graft thrombolysis


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Contraindications to Thrombolytic Therapy

Absolute

Recent major bleedingRecent strokeRecent major surgery or traumaIrreversible ischemia of end organ

Intracranial pathologyRecent ophthalmologic procedure

Relative

History of gastrointestinal bleeding oractive peptic ulcer disease

Underlying coagulation abnormalitiesUncontrolled hypertensionPregnancyHemorrhagic retinopathy


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Hemodialysis

access

Quality of life and overall outcome could be

improved significantly for hemodialysispatients if two primary goals were achieved:

Increased placement of native AVFs: a minimum

of 50% of new dialysis patients should have

primary AVFs. Detection of dysfunctional access before

thrombosis of the access route occurs.

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

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Hemodialysis Access - ITurnbull