Vascular Access For Hemodialysis

Paul Tahalele, MD, Ph.D, FInaCS, FCTS Professor of Surgery Chief of Surgical Department. Medical School Airlangga University Surabaya, Indonesia

Definition

Vascular access is the circulatory site that allows the connection between the patients circulation and the dialyzer
The two most common types of chronic access used for hemodialysis are :

Arterio-venous (AV) fistula Arterio-venous (AV) graft

http://classes.kumc.edu/cahe/respcared/cybercas/dialysis/franvasc.html,

Last accessed : 2004

Multidisciplinary Hemodialysis Vascular Access Team

Began informally in the early 1990s Arteriovenous fistula

1960

(Surendra shenoy et al, 2002. In: Dialysis Access, ed. RJ Gray p.10)

Scribner, Dillard, and Quinton (an internist, a surgeon,

and an engineer), introcuded first long-term cannulation for artery and vein using Silastic shunt

1966

Brescia, Cimino and coworkers reported the autologous

subcutaneous arteriovenous fistula
(Brescia MJ, Cimino JE, Appel K, et al. N Eng J Med 275:1089,1966.)

Types of Vascular Access for Hemodialysis

a)

Central Venous Access

Double lumen catheter (Hickmann cath., Groshong cath., etc) Port A-Cath

b)
c)

External shunt : Scribner shunt Internal shunt :

AV fistula AV graft

Double Lumen Catheter

Groshong catheter

5 Hospitals in Surabaya 120-140 HD pts per year.

Hemodialysis

HEMODIALYSIS PORT

AV Shunt (Brescia-Cimino shunt)

Implementation of the Dialysis outcomes Quality Initiative (DOQI) guidelines for vascular access management (1997)
Multidisciplinary

approach :

Nephrologist Surgeon Interventional radiologist

DOQI guideline
a) Diagnostic Evalution Prior to Permanent Access Selection
Preoperative Venography Other imaging studies : USG doppler

Flow Vein Mapping Mapping upper arm cephalic vein Forearm veins in obese patients

Anatomy

DOQI guideline
b) Selection of permanent vascular access :
AV Fistula (15%) AV graft (85%) : 1980 - 1990

1996 2000 : Fistula 30 60%

RJ Gray. Washington Hospital Center, 2002

Tabel 1. Incidence of Hemodialysis Vascular Access Placed For the years 1996 - 2000
Year Fistulae Grafts Total New Access Fistula %

1996 1997

21 41

50 53

71 94

30 44

1998
1999 2000

76
77 75

82
77 50

158
154 125

48
50 60

RJ Gray. Washington Hospital Center, 2002

DOQI guideline
c) Type and location of dialysis AV grafts placement
Saphenous vein Graft (SVG) Prosthesis Dacron graft

Preoperative preparation

Patient :

Informed consent Nondominant arm Pressure differential < 20 mmHg between arms Patient palmar arch has to be good

Arterial requirements

Allen test

Arterial lumen diameter 2.0 mm at point of anastomosis

Venous requirements

Luminal diameter 2 mm at anastomosis

point Absence of obstruction Straight segment for cannulation Within 1 cm of surface Continuity with central veins

USG Doppler

Allen Test
1.

2. 3.

4.

Position the patient so that he or she is facing you with their arm extended with the palm turned upward Compress both the radial and ulnar arteries at the wrist With the arteries compressed firmly, instruct the patient to create a fist repetitively to cause the palm to blanch When the patients hand is blanched, release your compression of the ulnar artery and watch the palm to determine if it becomes pink. Then release all compression :
Pale Pink Allen test positive Allen test negative Abnormal flow Normal flow

5.

Repeat steps 2-4 for the radial artery

Allen Test

Operation Technique

Prepare the forearm

Wash the upper and forearm with savlon And desinfects with povidone iodine 10%

Put the sterile drapping until the 1/3 distal upper arm

Standard equipment for AV shunt surgery

Skin Identification of radial artery and cephalic vein pathway

Skin Identification of brachial artery and cubiti vein pathway

Local Anesthesia :
Xylocain or Lidocain 1-2% 10 cc

Hockey Stick Incision the skin

Identification of cephalic vein, radial artery & separates it from surrounding tissue

Oblique Cut the vein after ligation the distal part and lumen dilatation

Oblique cut the artery after ligation the distal part and lumen dilatation

End to End Anastomosis

After anastomosis, release the bulldog clamp

Thrill Palpation on the vein line

Suture only the skin

Bandage the arm

Complications of AV fistulas for hemodialysis

Primary thrombosis fistula Secondary thrombosis fistula Proximal venous stenosis-hand hyperaemia Puncture site infection Aneurysm formation Cavernous transformation Left ventricular failure (very rare)

Complications of subclavian vein catheterization for hemodialysis

During insertion

During or between dialysis

Pneumothoraks Hematothoraks Subclavian artery injury Brachial plexus injury Caval perforation Guide-wire fracture

Thrombus formation Pulmonary embolus Sepsis

Exit site Bloodstream Air embolus Haemorrhage Haemopericardium Intrapulmonary haemorrhage

Disconnection

Migration

CLINICAL SIGNIFICANCE

Severe upper-extremity edema; high-pressure, dilated upperarm veins

Severe upper-extremity edema; secondary to subclavian lesions in two patients with ipsi-lateral functional arteriovenous dialysis accesses

Dr.Soetomo Hospital Experience of AV Shunt Surgery

N : 687 pts.
Male (474 pts., 69%) ; Female (213 pts., 31%); Age : 19 87 year (51 32)

Etiology :
Primary CRF :622 (90,6%) Secondary CRF : 65 (9,4%)

1998 2003 (6 years)

Tabel 2. CRF patient with AV shunt surgery at RSU Dr. Soetomo during 6 years (1998s/d2003)
Year 1998 1999 2000 2001 2002 2003 Total % Male 67 110 67 86 61 63 474 69,0% Female 38 41 24 34 41 35 213 31,0% Total 105 171 91 120 102 78 687 100%

Tabel 3. Percentage of the AV Shunt Surgery Failure at Dr. Soetomo Hospital during 6 years (1998s/d 2003)

Year 1998 1999 2000 2001 2002 2003 Total

1st Operation

2nd Operation

105 171 91 120 102 78 687

6 12 8 12 6 9 56

% 5,71 7,02 8,79 10,0 5,88 11,54 8,15

Tabel 4. Correlation between surgeon and failure of the first AV shunt surgery
Surgeon
Vascular surgeon Resident

1st Operation
331 (48,18%) 356 (51,82%)

Revition
18/331 (2,42%) 48/356 (13,48%)

Total

687 (100%)

56/687 (8,15%)

Strategies & tips for AV shunt surgery

Check the general condition

Consciousness ? Restless ? Dyspneu ? Blood Pressure ? Tx : Sedative drugs

Minimum 140/90

Check the local condition

Oedema ? Sign of puncture site residue ? Scleroting or thromboplebitis of the vein ?

Technique
Distally as possible (1/3 distal forearm) on nondominant arm
Dont pass the styloid processus of radius

If not possible, find the contralateral one

If there is edema on both side, put the double lumen catheter

If its still not possible, try the cubiti region. Next if not possible, try the graft surgery (autologus or prosthesis) Still fail, do the shunt on femoral region between great saphenous vein and femoral artery The last is Port A-Cath