Dialysis Access "Catheters, Grafts, Fistulas...Oh My"
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Dialysis Access "Catheters, Grafts, Fistulas...Oh My"

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Dialysis Access "Catheters, Grafts, Fistulas...Oh My" Dialysis Access "Catheters, Grafts, Fistulas...Oh My" Presentation Transcript

  • Dialysis Access “Catheters, Grafts and Fistulas … Oh My!” John O. Colonna, II, MD, FACS Surgical Director Kidney Transplant Program Sentara Norfolk General
  • Objectives
    • Dialysis – scope of the problem
    • Catheters
    • AV grafts
    • AV fistulas
    • Present DOQI guidelines
    • Algorithm for chronic access
    • Algorithm for monitoring / salvage
  • Magnitude of Renal Failure
    • 300,000 dialysis patients
    • Dialysis population – inc 10%/yr
    • Dialysis access is most common vascular surgery procedure
    • Problems with dialysis access are a major reason for hospitalization in renal failure patients
  • Evaluation of Patients for Dialysis Access
    • Urgency of dialysis?
    • Prior access procedures
    • Inspection of superficial arm veins with tourniquet
    • Venous collateralization?
    • Pulse assessment (Allen’s test)
  • Acute Dialysis Options
    • Percutaneous catheter
      • Firmer – plastic
      • Bedside insertion
      • In-hospital use
    • Tunneled catheter
      • Softer – silicone
      • Operative insertion
      • Potential for long-term use
  • Advantages
    • Universally applicable
    • Multiple access sites
    • No maturation time – can be used immediately
  • Advantages
      • No direct hemodynamic effects on the circulation
      • Allows time for maturation of native AVF
      • Thrombotic complications simple to correct
  • Insertion of Catheters Site Selection
    • Right internal jugular preferred
    • Avoid subclavian veins
    • Previous catheter locations ?
    • Known stenoses / occlusions ?
    • Site-Rite examination
  • Insertion of Catheters Types of Catheters
    • Curved vs. Straight Catheters
    • Length of catheter determined by site of access
      • Right IJ – 19 cm
      • Left IJ – 23 cm
      • Femoral – 27 cm
      • Extra long catheters available
      • Adjust for small / pediatric patients
  • Insertion of Catheters Technical Considerations
    • Positioning
    • Fluoroscopic guidance
    • Seldinger technique
    • Avoid kinking of catheter
    • Both lumens should irrigate and aspirate freely
    • Venography helpful in difficult cases
  • Disadvantages
    • Typically have the shortest long term patency rates of all permanent access procedures
    • Lower blood flow rates obligating longer dialysis times
    • External device
  • Disadvantages
    • Morbidity
      • Insertion complications
      • Thrombosis
      • Infection
      • > 3 months - morbidity excessive
    • Risk of central vein stenosis or occlusion
      • Limits chronic access options
  • Chronic Dialysis Options
    • Tunneled dialysis catheter
    • Arterio – venous graft
    • Arterio – venous fistula
    • Peritoneal dialysis
    • Renal Transplant
  • Chronic AV Access Principles
    • Start distal
    • Nondominant extremity if veins are equivalent
    • Lower extremity less preferable
    • Catheters are always last resort
      • AVF / AVG / PD / Tx options exhausted
      • Hypercoagulable
  • Preop Planning
    • Duplex US Vein Mapping
      • Non-invasive, no IV contrast
      • Reliable vein diameters
      • Assess for central vein stenosis
    • Venogram
      • Locate vein branching
      • Identify / treat stenoses
    • Noninvasive arterial testing
  • Chronic Dialysis Options
    • AV Graft
      • Subcutaneously placed conduit between an artery and vein
      • Usually PTFE
      • 10 – 14 day delay before use
      • “ Early stick” grafts available
  • AV Graft Complications
    • Graft dysfunction
    • Graft thrombosis
    • Graft infection
    • Steal syndrome
    • Graft deterioration - pseudoaneurysms
  • Chronic Dialysis Options AV fistula
    • Direct anastomosis between an artery and vein
    • Radio-cephalic (Brescia – Cimino)
    • Brachio-cephalic (Kaufman)
    • Brachio-basilic (transposition)
    • 8-12 week maturation time
  • AV Fistula Complications
    • Failure to mature
    • Difficulty accessing fistula
    • Steal syndrome
    • Aneurysmal degeneration
    • Excessive flow
  • AVF Nonmaturation
    • Inability to cannulate AVF 3-4mo after creation
    • Higher incidence in women & diabetics
    • Fistulogram
      • Anastomotic stenosis
      • Inadequate vein
      • Multiple branching / stealing veins
  • AVF vs. AVG
    • AV Graft
      • High short-term patency
      • Ease of cannulation
    • AV Fistula
      • Better long-term patency
      • Often a “One and Done” operation
      • Fewer revisions required
      • Minimal risk of infection with AVF
  • Monitoring AV Access Function Identifying the Failing Access
    • Physical Exam
      • Pulsatile fistula vs. continuous thrill
      • Arm swelling – venous hypertension
    • Dialysis Data
      • Elevated Venous pressure
      • Falling K T / V
      • Decreased Urea Reduction Rate
      • Increased Urea Recirculation
  • Evaluating the Failing Access
    • Duplex ultrasound
    • Fistulogram
      • Identifies anatomic abnormalities
      • Allows for pre-emptive percutaneous intervention
      • Guides surgical intervention
  • AVF Salvage
    • Balloon vs patch angioplasty for short segment vein stenosis
    • Graft interposition for long segment vein stenosis
    • Revise vs balloon AVF anastomotic stenosis
    • Ligation of stealing vein branches
    • Balloon angioplasty/stenting for central venous stenosis
  • DOQI Guidelines
    • D ialysis O utcomes Q uality I nitiative
    • NKF sponsored
    • Current goals:
      • <10% long-term (>90day) catheter usage
      • >40% functioning AVF/dialysis unit
      • >50% AVF of new access procedures
  • Chronic AV Access Algorithm
    • Radio-cephalic AVF
    • Brachio-cephalic AVF
    • Basilic vein transposition
    • Forearm loop graft
    • Brachio-axillary AVG
    • Femoral loop AVG
  • Conclusions
    • Catheters for acute dialysis
      • Complications limit long term usefulness
    • AVF or AVG for chronic dialysis
      • AVF superior to AVG
    • Identification of the failing access permits pre-emptive intervention
    • DOQI guidelines
      • <10% long-term catheter usage
      • >40% functioning AVF/dialysis unit
      • >50% AVF of new access procedures