95 Hemodialysis access Irene Turnbull 1312007 Hemodialysis access The number of patients with endstage renal disease ESRD in the United States has increased steadily 2030 224 million patients with ESRD ID: 774590
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Hemodialysis access
Sharifi
95
Slide2Hemodialysis access
Irene Turnbull
1/31/2007
Slide3Hemodialysis 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.
Slide4Vascular 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 cathetersShort term: <3 weeks
Slide5Vascular 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 rateseliminate the problem of vascular steal
placed in a subcutaneous tunnel under fluoroscopic guidance
Slide6Vascular Access via Percutaneous Catheters: cuffed catheters
The Dacron cuff allows tissue ingrowth that helps reduce the risk of infection when compared with noncuffed catheters.
Slide7Hemodialysis 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.
Slide8Hemodialysis 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.
Slide9Vascular 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
Slide10Arteriovenous 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.
Slide11Noninvasive 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 occlusionArterial examination Arterial luminal diameter ³ 2.0 mm Absence of pressure differential ³ 20 mm Hg between arms Patent palmar arch
Slide12radiocephalic fistula (anatomic snuff-box)
radiocephalic fistula (Brescia-Cimino)
Slide13Vascular access via AVFs:
brachiocephalic fistula
brachiobasilic fistula
Slide14Arteriovenous 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.
Slide15Prosthetic 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.
Slide16Options for treating steal
DRIL procedure
distal revascularization-interval ligation
excision of a portion of the veinplication w/ mattress or continuous sutures crossed PTFE band interposition of a 4 mm PTFE
Slide17Treatment of venous access complications.
Venous angioplasty
Graft thrombolysis
Slide18Contraindications 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 retinopathy
Slide19Hemodialysis 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)