Dr osama el minshawy - vascular access complications

1. Vascular Access Complications
by
Osama El-Minshawy, MD
Professor of Medicine
Head of Nephrology Unit, Minia University,
Egypt

2. Agenda
 1-What is Vascular Access?
 2-Types of Vascular Access.
 3-Indications of different types of Vascular Access.
 4-Complications of vascular access
◦ Data from the US & different countries
◦ Data from El-Minia Governorate.

3. It is an access to the patient's blood stream, & is
essential to provide an appropriate dialysis dose in
patients with ESRD.
Also, vascular access is an important contribution to
long term survival of HD patients.

4.  1-What is Vascular Access?
 2-Types of Vascular Access.
 3-Indications of different types of Vascular Access.
 4-Complications of vascular access
◦ Data from the US & different countries
◦ Data from El-Minia Governorate.

5.  At present, three types of vascular access are
predominant:
1-AV (arteriovenous) fistula.
2-AV grafts.
3- venous catheters catheters.

8.  1-What is Vascular Access?
 2-Types of Vascular Access.
 3-Indications of different types of Vascular Access.
 4-Complications of vascular access
◦ Data from the US & different countries
◦ Data from El-Minia Governorate.

9.  AV fistula is indicated in:
◦ Chronic HD prescription
 Venous Catheters are indicated in:
◦ Acute Kidney Injury
◦ ESRD who need urgent HD but without available
mature access.
◦ ESRD on maintenance HD, who have lost their AV
fistula.
◦ PD patients whose abdomens are being rested prior
to new peritoneal catheter placement.
3-Indications of different types of
Vascular Access

11.  1-What is Vascular Access?
 2-Types of Vascular Access.
 3-Indications of different types of Vascular Access.
 4-Complications of vascular access
◦ Data from the US & different countries
◦ Data from El-Minia Governorate.

12. Data from the U.S. and different
Countries

13. Costs of vascular access procedures come to
$8,000-10,000 /patient / year in US hospitals.
This amount represents approximately 25% total ESRD
medical costs.
 HD vascular access dysfunction & complications are a
major cause of hospitalization among HD population,
they account for 16 - 25 % of hospital admission in HD
patients.
Vascular Access Cost in the US

15.  1-Non maturation of the access
 2-Stenosis & Thrombosis
 3-Infection
 4-Heart failure
 5-Ischemia and Nerve injury
 6-Aneurysms and pseudoaneurysms

16.  a-Narrow veins / Distorted veins
 b-Collateral veins
 c-Venous stenosis
 d-Arterial insufficiency

17.  1-Non maturation of the access
 2-Stenosis & Thrombosis
 3-Infection
 4-Heart failure
 5-Ischemia and Nerve injury
 6-Aneurysms and pseudoaneurysms

18. 2-Stenosis & thrombosis

19.  1-Non maturation of the access
 2-Stenosis & Thrombosis
 3-Infection
 4-Heart failure
 5-Ischemia and Nerve injury
 6-Aneurysms and pseudoaneurysms

20.  Responsible for loss of 20% of access
 Staph.
 fever/sepsis.

23.  1-Non maturation of the access
 2-Stenosis & Thrombosis
 3-Infection
 4-Heart failure
 5-Ischemia and Nerve injury
 6-Aneurysms and pseudoaneurysms

24.  Risk of high output failure
◦ (likely when flow > 20% C.O.)
 LVH may worsen
 Difficult to fix

25.  1-Non maturation of the access
 2-Stenosis & Thrombosis
 3-Infection
 4-Heart failure
 5-Ischemia and Nerve injury
 6-Aneurysms and pseudoaneurysms

26.  Steel syndrome
 Paraesthesia
 Coolness
 Muscle atrophy
 Loss of Motor function
 Distal Necrosis
 Requires surgical intervention

27.  1-Non maturation of the access
 2-Stenosis & Thrombosis
 3-Infection
 4-Heart failure
 5-Ischemia and Nerve injury
 6-Aneurysms and pseudoaneurysms

28.  Cause / Sites
◦ Puncture site
 Indication for intervention
◦ Risk of rupture
◦ Available puncture sites limited

29.  1-What is Vascular Access?
 2-Types of Vascular Access.
 3-Indications of different types of Vascular Access.
 4-Complications of vascular access
◦ Data from the US & different countries
◦ Data from El-Minia Governorate.

30. Data from El-Minia Governorate

31.  The goal of work was to determine vascular access
related complications in:
 1-Acute HD prescription (venous catheters).
 2-Chronic HD prescription (AV fistulae). in HD unit,
Minia University Hospital
Goal of the Work

32.  A- Venous catheter group :
 2- Internal Jugular vein Group
120 patients (88 males and 32 females).
Methods

33.  B- AV fistula group:
 Included patients who used AVF for chronic HD
prescription.
They were 160 patients with ESRD on chronic regular HD
thrice weekly for variable intervals, 98 male and 62
female, their mean age ± SD was 43.6 ± 12.2 years
(range 18 – 68 year), their duration of HD was ± SD 4.2
± 3.1
Methods

35.  Color Doppler mode was done for
AV fistula group to estimate hemodynamic
parameters including blood flow volume (Velocity X
cross sectional area together with the automatically
calculated resistivity index of the inflow artery).
The fistula it self was examined for flow velocity, flow
volume and cross sectional area.
Three parameters were done at the fistula site: 1- peak
systolic velocity (m/sec.) 2-fistula flow rate (ml/min) 3-
resistivity index.
Methods

36. Results

37. 
Results
Complications of Internal Jugular vein (120 patient(
Complication Number of patients %
a.Infection 24 20%
a.thrombosis 32 27%
a.Accidental withdrawal 8 6.6%

38. 
Results
Complications in subclavian vein approach :(44 patient(
Complication Number of patients %
a.Catheter dysfunction 14 31.8%
a.Infection 20 45.4%

39. 
Results
Criteria of diagnosis of successful or stenosed fistula
Index Successful
fistula
Stenosed fistula
Flow ml / min 220 – 400 Less than 200
Resistivity
index
> 0.1 Less than 0.1
Peak velocity 0.6 – 1 m /sec > 1.5 m / sec

40.  Clinically we found limb edema in
28 patients, hematoma in 10 patients,
accidental trauma leading to fistula failure in 4 patients.
 30 patients create another AVF during their HD life.
 40 patients create 3 AVF
 4 patients create 4 AVF.
 Mean AVF survival was 30 ±19 months.
Results

41.  Smokers were more likely to have failed Vascular
access.
 Severe anemia, age, diabetes mellitus, and smoking are
the main risk factors of VA failure
Results

43.  There was no significant difference between AVF
survival rates of male versus female (p=0.62).
 AVF survival was better for hypertensive versus
normotensive (p<0.05).
 AVF malfunction correlated significantly with HD
duration (p<0.05). And in anemic versus non anemic
(P<0.05) (anemia was defined as Hb < 11 g/dl).
Results

44. Conclusion

45.  Patients who begin HD With AV fistula
Have better outcome than those who
start HD with venous catheter as they have more
complications & higher mortality .
Conclusion

46.  Our study showed that patients on hemodialysis should
benefit from anemia correction, with a target
hemoglobin level between 10 g/dL and 12 g/dL, without
incurring any increased risk of VA failure
Conclusion

47.  1- Early Referral to Nephrologists
 2- Early referral to surgeons for AVF and
restriction of access procedure to experienced
surgeons as most of the complication were operator
dependent
 3-enhanced tanning of dialysis staff

49. Thank You