Vascular access for haemodialysis prof. ahmed halawa

1. Vascular Access for
Haemodialysis
Ahmed Halawa
Sheffield Kidney Institute

2. In Egypt
• Poorly planned
• Done by a junior surgeon, not usually
specialized
• At the end of the list

3. Renal replacement therapy
– Haemodialysis
– Peritoneal dialysis
– Transplantation

4. Haemodialysis
• Need a conduit that can be needled/used
frequently
– Autogenous arteriovenous fistula
– PTFE graft
– Tunnelled line

5. Formation of Fistula
• Multiple options
– Radial artery to
cephalic vein
– Brachial artery to
cephalic vein
– Basilic vein to brachial
artery (transposition)
– Long Saphenous vein
to superficial femoral
artery (transposition)

6. Formation of Fistula

7. What makes a good fistula?
A good fistula has:-
• Good long term patency
• Size >5mm
• Adequate blood flow >350ml/min
• Low revision/intervention rate
• Low infection rate
• Low thrombosis rate

8. Fistula Maturation
• An AVF forms a low resistance pathway
• Volume flow through fistula increases due
to low resistance
• Distal extremity perfusion is maintained by
increase in cardiac output
• Flow in proximal artery needs to increase
to meet demands of the AVF
• Normal brachial artery flow 50ml/min

9. Factors that lead to good fistula
• Arterial
• Size >1.6 mm
• Lack of calcification
• Flow pattern

10. Factors that lead to good fistula
• Venous
• >2.2 mm without
tourniquet
• No evidence of
stenosis/thrombosis
• Depth
• Central venous patency

11. PTFE Graft

12. PTFE Graft

13. Brachiobasilic Vein Transposition

14. Brachiobasilic Vein Transposition

15. Complications

16. Steal Syndrome
• Severe ischaemia 1-8% of access
procedures
• Chronic pain
• Tissue loss
• Non functioning extremity
• Graded 0 (no steal) to 3 (severe)
• Secondary to
• High fistula flow
• Poor collateral perfusion (particularly diabetics)
• Rarely inflow stenosis

17. Steal Syndrome

18. Steal Syndrome
Duplex Doppler ultrasound of the left antecubital fossa demonstrating
a significant steal syndrome. Blood enters the proximal brachial artery
(1) and >70% is shunted through the PTFE graft (3) with <30% flow
through the native distal artery (2).

19. Steal Syndrome

20. Management of Steal Syndrome

21. Management of Steal Syndrome

22. Management of Steal Syndrome
• Distal reconstruction
and interval ligation
(DRIL)
• Preferable to use vein
• Increased risk
thrombosis PTFE
• 9 case series
• Symptoms resolved 33
to 100%
• Improved 17 to 66%
• No change 1 series 11%
• DRIL patency 86 to
100%

23. Aneurysm

24. Pseudoaneurysm

25. Aneurysm and Pseudoaneurysm
Indications for revision/repair of AV fistula aneurysm:
• The skin overlying the fistula is (ischemic) compromised
• There is a risk of fistula rupture
• Available puncture sites are limited
indications for revision/repair of pseudoaneurysm formation :
• Symptomatic or threatens the viability of the overlying skin
• Evidence of infection
• Pseudoaneurysm that is enlarging in size or that exceeds twice the
diameter of the graft
• Limited number of cannulation sites
Cannulation through a pseudoaneurysm must be avoided

26. Venous Hypertension
Sign and symptoms:
severe upper limb edema
skin discoloration
access dysfunction
peripheral ischaemia with resultant fingertip ulceration.
In most cases, the underlying venous pathology follows
ipsilateral central venous catheter placement with
consequent venous stenosis.

27. Venous Hypertension

28. Venous Hypertension
Treatment
•Angioplasty of the stenosis
•Bypass
•Disconnection of the fistula

29. Infection
The second most common cause of AV access
failure (0-3% in AVF and 6%-25%in AV grafts)
Treatment:
AVFs: Local drainage and antibiotic therapy for
6 weeks
AV grafts: Antibiotic therapy and surgical
treatment (in most cases complete excision of
prosthetic graft)

30. Haematoma

31. Haematoma
• Small and not expanding Conserve
• Large or expanding Drainage

32. Buttonhole Technique
for
Cannulation of AV Fistulae

33. Buttonhole Structure

34. Needles – sharp and blunt

35. Buttonhole Technique
• Reuse same sites
each treatment with
blunt needles
• Must follow the
track/tunnel of the
original cannulation

36. Doppler Ultrasound Of The
Tunnel

37. Benefits for the patient
• Less painful – elimination of anesthetic
• Fewer infections
• Fewer missed needle sticks
• Fewer haematomas
• Cannulation of access takes less time

38. Why to offer the Buttonhole Technique?
• Prolong AV fistula life
• Decrease hospitalizations related to access
infections and complications
• Promote patient self-cannulation
• Decrease pain associated with needle
cannulation

39. Rope-Ladder Technique
for
Cannulation of AV Fistulae

40. Rope Ladder

41. Buttonhole vs Rope-Ladder
Am J Kidney Dis.
2014;64(6):918-936

42. References
• Atlas of Dialysis Vascular Access
http://c.ymcdn.com/sites/www.asdin.org/resource/resmgr/imported/atlas%20of%20dialysis
%20access.pdf
• Field A,Backwell J,Jaipersad A; et al,. Distal Revascularisation with Interval Ligation (DRIL): An
Experience. Ann R Coll Surg Engl. 2009 Jul; 91(5): 394–398
• Treatment of vascular steal syndrome Date written: August 2011: Christine Russel. Available
from: http://www.cari.org.au/Dialysis/dialysis%20vascular
%20access/Treatment_of_steal_syndrome.pdf
• van Hoek F, Scheltinga MR, Kouwenberg I et al. Steal in hemodialysis patients depends on type
of vascular access. European Journal of Vascular & Endovascular Surgery. 2006; 32: 710-7.
• Clinical Practice Recommendations for Use of Buttonhole Technique for Cannulation of
Arteriovenous Fistulae. Available from;
http://www.britishrenal.org/BritishRenalSociety/files/64/64c14da8-6738-4828-a326-
526c731ff565.pdf
• Ben Wong et al,. Buttonhole Versus Rope-Ladder Cannulation of Arteriovenous
Fistulas for Hemodialysis: A Systematic Review. Am J Kidney Dis. 2014;64(6):918-936
http://www.wanfang.gov.tw/Upload/WebDownLoadFile1201505141512177.pdf

43. Thank You