Hemodialysis access - PowerPoint Presentation

Slide1

Hemodialysis access

Sharifi

95Slide2

Hemodialysis access

Irene Turnbull

1/31/2007Slide3

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. Slide4

Vascular Access via Percutaneous Catheters

useful method of gaining immediate access to the circulation.

associated with higher risks.

the use-life of this type of access is shorter than that of AVFs.

Noncuffed catheters

Short term: <3 weeksSlide5

Vascular Access via Percutaneous Catheters: cuffed catheters

Cuffed catheters

Patients who will require long-term access should have a tunneled catheter placed.

allow so-called no-needle dialysis with high flow rates

eliminate the problem of vascular steal

placed in a subcutaneous tunnel under fluoroscopic guidanceSlide6

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. Slide7

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. Slide8

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-days.

Catheter thrombosis increases the incidence of catheter sepsis.Slide9

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.

The native AVF remains the gold standard Slide10

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 (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. Slide11

Noninvasive Criteria for Selection of Upper-Extremity Arteries and Veins for Dialysis Access Procedures

Venous examination

   Venous luminal diameter

³

2.5 mm for autogenous AVFs,

³

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

³

2.0 mm

   Absence of pressure differential

³

20 mm Hg between arms

   Patent palmar arch

Slide12

radiocephalic fistula (anatomic snuff-box)

radiocephalic fistula (Brescia-Cimino) Slide13

Vascular access via AVFs:

brachiocephalic fistula

brachiobasilic fistula Slide14

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 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.Slide15

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.Slide16

Options for treating steal

DRIL procedure

distal revascularization-interval ligation

excision of a portion of the vein

plication w/ mattress or continuous sutures

crossed PTFE band

interposition of a 4 mm PTFESlide17

Treatment of venous access complications.

Venous angioplasty

Graft thrombolysisSlide18

Contraindications to Thrombolytic Therapy

Absolute

  Recent major bleeding

  Recent stroke

  Recent major surgery or trauma

  Irreversible ischemia of end organ

  Intracranial pathology  Recent ophthalmologic procedureRelative

History of gastrointestinal bleeding or active peptic ulcer disease

  Underlying coagulation abnormalities

  Uncontrolled hypertension

  Pregnancy

  Hemorrhagic retinopathySlide19

Hemodialysis access

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 primary AVFs.

Detection of dysfunctional access before thrombosis of the access route occurs.

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