Hemodialysis Access - ITurnbull

Hemodialysis Access - ITurnbull - Hemodialysis access...

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Unformatted text preview: Hemodialysis access Hemodialysis Irene Turnbull 1/31/2007 Hemodialysis access Hemodialysis The number of patients with end-stage renal The disease (ESRD) in the United States has increased steadily. increased 2030: 2.24 million patients with ESRD. The creation and maintenance of functioning The vascular access, along with the associated complications, constitute the most common cause of morbidity, hospitalization, and cost in patients with end-stage renal disease. Vascular Access via Percutaneous Catheters useful method of gaining immediate access to the circulation. circulation. associated with associated higher risks. the use-life of this type of access is shorter than that of AVFs. Noncuffed catheters Noncuffed Short term: <3 weeks Vascular Access via Percutaneous Catheters: cuffed catheters Cuffed catheters Cuffed Patients who will require long-term access should have a tunneled catheter placed. allow so-called no-needle dialysis with high flow rates rates eliminate the problem of eliminate vascular steal placed in a subcutaneous tunnel under fluoroscopic guidance guidance Vascular Access via Percutaneous Catheters: cuffed catheters Catheters: The Dacron cuff allows tissue The ingrowth that helps reduce the risk of infection when compared with noncuffed catheters. Hemodialysis access: complications Hemodialysis Complications can be divided into those Complications that occur secondary to catheter placement and those that occur later. The early complications of subclavian or internal jugular placement include pneumothorax, arterial injury, thoracic duct injury, air embolus, inability to pass the catheter, bleeding, nerve injury, and great vessel injury. Hemodialysis access: complications Hemodialysis A chest radiograph must be taken after catheter chest placement to rule out pneumothorax and injury to the great vessels and to check for position of the catheter. The incidence of pneumothorax is 1% to 4%,the incidence of injury to the great vessels is less than 1%. incidence Thrombotic complications occur in 4% to 10% of patients Thrombotic Infection may occur soon after placement (3 to 5 days) or late in the life of the catheter and may be at the exit site or the cause of catheter-related sepsis. Rate of infection between 0.5 and 3.9 episodes per 1000 catheter-days. catheter-days. Catheter thrombosis increases the incidence of catheter Catheter sepsis. sepsis. Vascular Access via Arteriovenous Fistulas Vascular The ideal vascular access The – permits a flow rate that is adequate for the permits dialysis prescription (³ 300 ml/min), – can be used for extended periods, can – and has a low complication rate. and The native AVF remains the gold standard Arteriovenous fistulas Arteriovenous The standard by which all other fistulas are measured, is The the Brescia-Cimino fistula. (2 year patency: 55% to 89%) the •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 (anatomic snuff-box) radiocephalic fistula (Brescia-Cimino) Vascular access via AVFs: Vascular brachiocephalic fistula brachiobasilic fistula brachiobasilic Arteriovenous fistulas: Complications Arteriovenous Failure to mature Failure Stenosis at the proximal venous limb (48%). Thrombosis (9%) Aneurysms (7%) Aneurysms Heart failure Heart The arterial steal syndrome and its ensuing ischemia occur in about 1.6%: pain, weakness, paresthesia, muscle atrophy, and, if left untreated, gangrene Venous hypertension distal to the fistula : distal tissue swelling, hyperpigmentation, skin induration, and eventual skin ulceration. eventual Prosthetic Grafts for vascular access Prosthetic 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. higher Options for treating steal DRIL procedure DRIL distal revascularizationiinterval ligation nterval excision of a portion of the vein excision plication w/ mattress or plication continuous sutures crossed PTFE band interposition of a 4 mm PTFE interposition Treatment of venous access complications. Treatment Venous angioplasty Graft thrombolysis Contraindications to Thrombolytic Therapy Contraindications Absolute Absolute Recent major bleeding Recent Recent stroke Recent major surgery or trauma Irreversible ischemia of end organ Intracranial pathology Recent ophthalmologic procedure Relative History of gastrointestinal bleeding or active peptic ulcer disease active Underlying coagulation abnormalities Uncontrolled hypertension Pregnancy Hemorrhagic retinopathy Hemodialysis access access Quality of life and overall outcome could be Quality improved significantly for hemodialysis patients if two primary goals were achieved: – Increased placement of native AVFs: a minimum Increased of 50% of new dialysis patients should have primary AVFs. primary – Detection of dysfunctional access before Detection thrombosis of the access route occurs. thrombosis National Kidney Foundation Dialysis Outcome and Quality Initiative (NKF-DOQI) ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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