Susanna Shin, MD, FACS, RPVI Assistant Professor of Surgery Division of Vascular Surgery, University of Washington University of Washington Medical Center Hemodialysis Access
Susanna Shin, MD, FACS, RPVI
Assistant Professor of Surgery
Division of Vascular Surgery, University of Washington
University of Washington Medical Center
Hemodialysis Access
DISCLOSURESusanna Shin, MD
• No relevant financial relationship reported
End Stage Renal Disease
• Chronic Kidney Disease– Stages 1-5
• Renal Replacement Therapy– Hemodialysis
– Peritoneal Dialysis
– Kidney Transplant
• Not just numbers– GFR < 15cc/min
• eGFR: calculated from creatinine age, body size and gender
– Weight loss, N/V, itching, fatigue/malaise, H/A, Confusion/LOC, SOB
Hemodialysis
• Renal Replacement Therapy
– Hemodialysis
– Peritoneal Dialysis
– Kidney Transplant
Hemodialysis
• Hemodialysis
– Center (vs Home)
– 3-5hours, 3days/week
– Fluid Removal (decreased BP common)
– Filtration of blood
Hemodialysis Access
• Arteriovenous Fistula (AVF)
– Direct connection between artery and superficial vein
– Superficial vein (cephalic or basilic) accessed with HD needles
• Arteriovenous Graft (AVG)
– Prosthetic material (ePTFE) between artery and vein
– Graft accessed with HD needles
• Tunneled Dialysis Catheter (TDC)
– Usually in Internal Jugular Vein or Common Femoral Vein
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk: AVF < AVG << TDC
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk
– Better long-term patency
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk
– Better long-term patency
– Relies on native veins
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk
– Better long-term patency
– Relies on native veins • Basilic and Cephalic Veins - often scarred
• No PIVs and Blood Draws
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk
– Better long-term patency
– Relies on native veins
– 8-12 weeks minimum usually for maturation
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk
– Better long-term patency
– Relies on native veins
– 8-12 weeks minimum usually for maturation • CKD 4 ESRD?
Hemodialysis Access
• Arteriovenous Fistula
– Less infection risk
– Better long-term patency
– Relies on native veins
– 8-12 weeks minimum usually for maturation
– Mature AVF: • ~6mm diameter
• <6mm from skin surface
• >600cc/min flow
• >6-10cm accessible
Hemodialysis Access
• Normal Anatomy
– Arteries
• Brachial
• Radial
– Superficial Veins
• Cephalic
• Basilic
Hu et al, 2016
Radial
Artery
Brachial
Artery
Basilic
Vein
Cephalic
Vein
Hemodialysis Access
Radiocephalic
AV Fistula
• Arteriovenous Fistula Types
– Radiocephalic
– Brachiocephalic
– Brachiobasilic with Basilic Vein Transposition
Hemodialysis Access
• Arteriovenous Fistula Types
– Radiocephalic
– Brachiocephalic
– Brachiobasilic with Basilic Vein Transposition
Hu et al, 2016
Brachiocephalic
AV Fistula
Hemodialysis Access
• Arteriovenous Fistula Types
– Radiocephalic
– Brachiocephalic
– Brachiobasilic with Basilic Vein Transposition
Hu et al, 2016
Brachiobasilic
AV Fistula,
transposed
Basilic Vein
Hemodialysis Access
• Arteriovenous Graft
– Firmer
– Radial, Brachial, Axillary arteries
– Straight vs Looped
Hemodialysis Access
• Arteriovenous Fistula/Graft Creation Considerations
– Non-dominant vs Dominant Upper Extremity
– Distal vs Proximal
– Cephalic vs Basilic
– >3mm vs <2.5mm
– Arm swelling
– Central vein stenosis
– Pacemaker/Port
– Blood pressure asymmetry/differential
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal • AVF/AVG “steal” blood from hand
• Higher Immediate Risk– Small stature
– Large vein
– AVG
• Symptoms– HAND/FINGER numbness, tingling, pain, cramping, weakness, wounds
• Treatment– Non-operative
– Ligation
– Surgical Revision (DRIL, PAI, RUDI)
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis• Inadequate dialysis
• Decreased Thrill
• Alarms– Low Flow
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis
– Recirculation• Arterial or Venous Stenosis
Hemodialysis
Machine
Arterial
cannula Venous
cannula
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis
– Recirculation
– Venous Stenosis• Pulsatile
• Prolonged bleeding
• High Pressure Alarm
• Aneurysmal AVF
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis
– Recirculation
– Venous Stenosis
– Aneurysm vs Pseudoaneurysm
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis
– Recirculation
– Venous Stenosis
– Aneurysm vs Pseudoaneurysm
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis
– Recirculation
– Venous Stenosis
– Aneurysm vs Pseudoaneurysm
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis
– Recirculation
– Venous Stenosis
– Aneurysm vs Pseudoaneurysm• ? Venous Outflow Stenosis
• ? Transplant
• ? High Flow
• ? Poor access technique
Hemodialysis Access
• Post-op/Surveillance Considerations
– Steal
– Arterial Stenosis
– Recirculation
– Venous Stenosis
– Aneurysm vs Pseudoaneurysm
– Ulceration• Rupture
• Infection
Hemodialysis Access
• Take Home Points
– Minimize time with TDC
– Protect native veins
– Alert Vascular Surgeon• Pulsatile AVF
• Weak thrill AVF
• Ulcerated skin
• Aneurysmal AVF
• Hand weakness, pain, cramping, new wounds
• Pressure alarms
• Prolonged bleeding after dialysis