Advanced Hemodialysis Access Procedures

1. VASCULAR ACCESS
PROCEDURES
Dr. Junish Bagga

2. WHAT IS VASCULAR ACCESS
• Rapid/direct – blood stream
• Central – tunneled/ non tunneled catheters
• Peripheral – AV fistula/graft
• SVS Guidelines
• Early referral
• Autogenous access
• Access surveillance

3. VASCULAR ACCESS AT INITIATION
OF HEMODIALYSIS
• 80% begin dialysis with CVC
• !6% AVF
• 3% grafts
Fistula first breakthrough initiative

4. PRIMARY GOALS
• Increase placement of native fistulas
• Detect access dysfunction before access thrombosis
• 65% of autogenous
• Catheter rate of less than 10 percent
• Patency rate of more than 3 years
• Thrombosis and infection rate of less than 0.25
episodes/patient-year and less than 1%over the
lifetime of access

5. TIMING OF ACCESS
• GFR of 30 ml/min should prompt referral and site protection
• Access should be created 6 months in advance
• Maturation of AV fistulas ideally requires 6-8 weeks

6. GENERAL PRINCIPLES/PATIENT
EVALUATION
• Obtain complete access history
• Delineate anatomy of inflow and outflow (radiology)
• Arm dominance
• Minimum diameter – artery 2mm, vein 2.5mm
• Exhaust upper extremity options
• Anticipate/ reduce complications
• Favor the use of autogenous conduits via transposition and translocation

7. PREFERRED ACCESS SITES
• Preferred
• Radiocephalic
• Brachiocephalic
• Basilic vein transposition
• Acceptable
• Forearm av loop graft
• Upper arm av graft

8. PRINCIPLES OF COMPLEX ACCESS
• Delineation of anatomy, cental vein?
• Find out the cause of previous failure, history, exam
• Involve nephrologist, previous surgeon, dialysis nurse
• Arterial/venous pathology
• Exhausted all other options

9. SAPHENOUS VEIN TO FOREARM
TRANSLOCATION
• Primary patency – more
than 75 percent

10. FEMORO-POPLITEAL VEIN TO ARM
TRANSLOCATION

11. BRACHIAL ACCESS WITH FEMORAL
VEIN
• Primary patency 79% 12 mo
• Secondary patency 100% 12
mo
• Steal 27%
• 23% vein harvest site
complications

12. AXILLARY- AXILLARY GRAFTS
• 24 month patency is 40-80 %
• Preserves contralateral access
• The venous limb should be
lateral
• Not associated with steal

14. CAVEAT FOR LEG ACCESS
• Exhaust all upper extremity options
• Objective documentation of arterial perfusion, PVRS wit toe pressures
• Preserve CFV, profunda femoris
• Mild chronic limb swelling is common
• Anti-coagulate 3-4 months

15. SAPHENOUS VEIN TRANSPOSITION
• 80 percent patency
• Wound complications

16. FEMORAL VEIN TRANSPOSITION
• 2 year primary patency of 75%
• 2 year secondary patency of 94%
• High risk of steal. Limit anastomosis
to 4-5mm
• Patients with PVD are not
candidates
• High flows (2000ml/min) may
exacerbate CHF

18. SFA-SFV GRAFTS
• Comparable patency.
• 21 %infection rate
• Avoids some of the the pannus and
lymphatics
• Preserves more proximal access
• Complications are easier to manage

19. FEMORO-FEMORAL GRAFTS
• 60% secondary patency at 2 years.
• 8-41% infection rate.
• Higher complications in obese patients

20. UNCONVENTIONAL PROCEDURES
• Axillary artery to
left renal vein
• External iliac
artery to left
renal vein

21. AXILLARY/BRACHIAL-JUGULAR
GRAFTS
• 60% secondary patency at 2 years
• No incidence of steal.
• 4-15% incidence of infection. Lower than
that of thigh access
• Difficult control in the setting of
complications

22. AXILLARY TO RIGHT ATRIUM

23. BRACHIAL ARTERY TO RIGHT
ATRIUM GRAFT

24. ARTERIAL INTERPOSITION GRAFTS
• 87% secondary patency at 3 years.
• 5% ischemia rate.
• Ischemia better tolerated in the
upper extrimity
• May have role in CHF
• Higher risk of bleeding

25. PTFE GRAFT
• Usually placed in
non dominant
forearm

26. LOOP CONFIGURATION PTFE GRAFT

27. STRAIGHT CONFIGURATION PTFE
GRAFT

29. ACCUSEAL, VECTRA…. GRAFT

32. HERO – HEMODIALYSIS RELIABLE
OUTFLOW
• 6mm PTFE graft with
titanium coupler at 1
end
• Venous outflow
component-19fr
silicone catheter
reinforced with a
nitinol braid to
prevent kinking

33. CATHETERS

34. SHORT TERM CATHETERS (NON-
TUNNELED CATHETERS

35. TUNNELED CATHETERS

36. UNCONVENTIONAL CATH
• Trans-thoracic superior vena
cava catheters
• Trans-lumbar vena-cava
catheters
• Trans-hepatic inferior vena
cava catheters

37. INTRALUMINAL THROMBUS

38. PROBLEM WITH CATHETERS
• Complications – pneumothorax, hemothorax
• Subcutaneous hematoma, wire emobolism, cardiac arrhythmia, cardiac perforation,
thoracic duct laceration, nerve injuries, catheter misplacement
• Air embolism, cath embolism, occlusion, thrombosis stenosis
• infection

39. PROBLEM WITH VASCULAR ACCESS
• Not all patients a re candidates for fistula
• It has been reported that 30% of AV fistulas never mature of are
able to be cannulated
• There are still a number of problems associated with grafts

40. THE PROBLEM WITH GRAFTS
• Traditional vascular grafts are often complicated by weeping during implantation
• Pseudoanneurysm formation after repeated needle sticks, and poor or incomplete
healing are common occurrences
• Risk of infection
• Bovine grafts - prone to aneurysms. When infected tend to fall apart

41. THE IDEAL VASCULAR ACCESS
GRAFT
• Never clots
• Never gets infected
• Easy to implant
• Easy to cannulate
• Does not bleed after cannulation
• Never forms pseudo-anneurysms

42. THANK YOU
• Know your patient
• Who can/cant accept failure
• Patient frustration/prior failed attempts in secondary procedures
• Explain that all access ultimately fails.!
• Take ownership of access