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Slide 1
2008/11/26 Arteriovenous Access for Hemodialysis R2
Slide 2
2008/11/26 AV fistula
Slide 3
2008/11/26 AV graft
Slide 4
2008/11/26 Why AV fistulas are better than grafts Less
hyperplesia of veinous intima less stenosis and eventual
obstruction higher long term patent rate Fewer inectious rate
Guidelines suggestion Early access evaluation and construction
Preoperative imaging
Slide 5
2008/11/26 Anticipating the need for AV access Progressive
renal failure GFR < 30 ml/min/1.73 m 2 Peritoneal dialysis :
back up AV fistula ? Kidney transplantation : < 6 months PICC :
risk of central vein steosis
Slide 6
2008/11/26 Preoperative evaluation Past history Physical
examination Image studies Doppler ultrasonography Venography
Arteriography Magnetic resonance Minimal vein and artery size Vein
dilation test Arterial dilation test Brachial artery flow
Mapping
Slide 7
2008/11/26 AV fistula Location wrist radiocephalic or
Brescia-Cimino fistula Construction side-of-artery-to-end-of-vein
anastomosis Perioperative care and maturation Blood flow should be
checked daily Never be used for venipuncture Hand exercises
requires at least 1 month blood flow
2008/11/26 Complication Pseudoaneurysm AV fistula observation,
avoiding puncture AV graft treated by resection and insertion of an
interposition graft if they are (a)rapidly expanding (b)>12 mm
in diameter (c)threatening viability of the overlying skin
Slide 18
2008/11/26 Complication Infection AV fistula - staphylococci -
6 weeks of antibiotics AV graft - occurs eventually in 5% ~ 20% -
Prophylactic antimicrobials - against G(-) and G(+) organisms as
well as against Enterococcus - Septicemia may occur without local
signs
Slide 19
2008/11/26 Complication Congestive heart failure Wrist and
forearm < Upper arm < Femoral Surgical narrowing or banding
vasodilators (minoxidil or hydralazine ) without concomitant
beta-blockade
Slide 20
2008/11/26 Clinical outcome goals and monitoring Establishment
of a vascular access team and continuous quality improvement (CQI)
Maximizing AV fistula placement at least 60% of all patients new to
H/D Goals for AV graft placement Failure rates, Cumulative patency
rates Rate of graft thrombosis Goals for limiting use of venous
catheters