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Unformatted text preview: Hemodialysis access
1/31/2007 Hemodialysis access
The number of patients with end-stage renal
disease (ESRD) in the United States has
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. Vascular Access via Percutaneous
useful method of
access to the
the use-life of this
type of access is
shorter than that of
AVFs. Noncuffed catheters
Short term: <3 weeks Vascular Access via Percutaneous
Catheters: cuffed catheters
Patients who will require
long-term access should
have a tunneled catheter
allow so-called no-needle
dialysis with high flow
eliminate the problem of
vascular steal placed in a subcutaneous
tunnel under fluoroscopic
guidance Vascular Access via Percutaneous
Catheters: cuffed catheters
The Dacron cuff allows tissue
ingrowth that helps reduce the risk
of infection when compared with
noncuffed catheters. Hemodialysis access: complications
Complications can be divided into those
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
A chest radiograph must be taken after catheter
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%.
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 exit
site or the cause of catheter-related sepsis.
Rate of infection between 0.5 and 3.9 episodes per 1000
Catheter thrombosis increases the incidence of catheter
sepsis. Vascular Access via Arteriovenous Fistulas
The ideal vascular access
– permits a flow rate that is adequate for the
dialysis prescription (³ 300 ml/min),
– can be used for extended periods,
– and has a low complication rate.
and The native AVF remains the gold standard Arteriovenous fistulas
The standard by which all other fistulas are measured, is
the Brescia-Cimino fistula. (2 year patency: 55% to 89%)
•radial branch-cephalic direct access
•autogenous ulnar-cephalic forearm
•autogenous brachial-cephalic upper
•access (antecubital vein to the
•autogenous brachial-basilic upper
arm transposition (basilic vein
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 luminal diameter ≥ 2.5 mm for autogenous AVFs, ≥ 4.0 mm
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 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:
brachiocephalic fistula brachiobasilic fistula
brachiobasilic Arteriovenous fistulas: Complications
Failure to mature
Stenosis at the proximal venous limb (48%).
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
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
distal revascularizationiinterval ligation
nterval excision of a portion of the vein
plication w/ mattress or
crossed PTFE band
interposition of a 4 mm PTFE
interposition Treatment of venous access complications.
Venous angioplasty Graft thrombolysis Contraindications to Thrombolytic Therapy
Recent major bleeding
Recent major surgery or trauma
Irreversible ischemia of end organ
Recent ophthalmologic procedure
History of gastrointestinal bleeding or
active peptic ulcer disease
Underlying coagulation abnormalities
Hemorrhagic retinopathy Hemodialysis
Quality of life and overall outcome could be
improved significantly for hemodialysis
patients if two primary goals were achieved:
– Increased placement of native AVFs: a minimum
of 50% of new dialysis patients should have
– 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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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.
- Fall '11