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Vascular access for haemodialysis prof. ahmed halawa

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Vascular access for haemodialysis prof. ahmed halawa

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Vascular access for haemodialysis prof. ahmed halawa

  1. 1. Vascular Access for Haemodialysis Ahmed Halawa Sheffield Kidney Institute
  2. 2. In Egypt • Poorly planned • Done by a junior surgeon, not usually specialized • At the end of the list
  3. 3. Renal replacement therapy – Haemodialysis – Peritoneal dialysis – Transplantation
  4. 4. Haemodialysis • Need a conduit that can be needled/used frequently – Autogenous arteriovenous fistula – PTFE graft – Tunnelled line
  5. 5. Formation of Fistula • Multiple options – Radial artery to cephalic vein – Brachial artery to cephalic vein – Basilic vein to brachial artery (transposition) – Long Saphenous vein to superficial femoral artery (transposition)
  6. 6. Formation of Fistula
  7. 7. What makes a good fistula? A good fistula has:- • Good long term patency • Size >5mm • Adequate blood flow >350ml/min • Low revision/intervention rate • Low infection rate • Low thrombosis rate
  8. 8. Fistula Maturation • An AVF forms a low resistance pathway • Volume flow through fistula increases due to low resistance • Distal extremity perfusion is maintained by increase in cardiac output • Flow in proximal artery needs to increase to meet demands of the AVF • Normal brachial artery flow 50ml/min
  9. 9. Factors that lead to good fistula • Arterial • Size >1.6 mm • Lack of calcification • Flow pattern
  10. 10. Factors that lead to good fistula • Venous • >2.2 mm without tourniquet • No evidence of stenosis/thrombosis • Depth • Central venous patency
  11. 11. PTFE Graft
  12. 12. PTFE Graft
  13. 13. Brachiobasilic Vein Transposition
  14. 14. Brachiobasilic Vein Transposition
  15. 15. Complications
  16. 16. Steal Syndrome • Severe ischaemia 1-8% of access procedures • Chronic pain • Tissue loss • Non functioning extremity • Graded 0 (no steal) to 3 (severe) • Secondary to • High fistula flow • Poor collateral perfusion (particularly diabetics) • Rarely inflow stenosis
  17. 17. Steal Syndrome
  18. 18. Steal Syndrome Duplex Doppler ultrasound of the left antecubital fossa demonstrating a significant steal syndrome. Blood enters the proximal brachial artery (1) and >70% is shunted through the PTFE graft (3) with <30% flow through the native distal artery (2).
  19. 19. Steal Syndrome
  20. 20. Management of Steal Syndrome
  21. 21. Management of Steal Syndrome
  22. 22. Management of Steal Syndrome • Distal reconstruction and interval ligation (DRIL) • Preferable to use vein • Increased risk thrombosis PTFE • 9 case series • Symptoms resolved 33 to 100% • Improved 17 to 66% • No change 1 series 11% • DRIL patency 86 to 100%
  23. 23. Aneurysm
  24. 24. Pseudoaneurysm
  25. 25. Aneurysm and Pseudoaneurysm Indications for revision/repair of AV fistula aneurysm: • The skin overlying the fistula is (ischemic) compromised • There is a risk of fistula rupture • Available puncture sites are limited indications for revision/repair of pseudoaneurysm formation : • Symptomatic or threatens the viability of the overlying skin • Evidence of infection • Pseudoaneurysm that is enlarging in size or that exceeds twice the diameter of the graft • Limited number of cannulation sites Cannulation through a pseudoaneurysm must be avoided
  26. 26. Venous Hypertension Sign and symptoms: severe upper limb edema skin discoloration access dysfunction peripheral ischaemia with resultant fingertip ulceration. In most cases, the underlying venous pathology follows ipsilateral central venous catheter placement with consequent venous stenosis.
  27. 27. Venous Hypertension
  28. 28. Venous Hypertension Treatment •Angioplasty of the stenosis •Bypass •Disconnection of the fistula
  29. 29. Infection The second most common cause of AV access failure (0-3% in AVF and 6%-25%in AV grafts) Treatment: AVFs: Local drainage and antibiotic therapy for 6 weeks AV grafts: Antibiotic therapy and surgical treatment (in most cases complete excision of prosthetic graft)
  30. 30. Haematoma
  31. 31. Haematoma • Small and not expanding Conserve • Large or expanding Drainage
  32. 32. Buttonhole Technique for Cannulation of AV Fistulae
  33. 33. Buttonhole Structure
  34. 34. Needles – sharp and blunt
  35. 35. Buttonhole Technique • Reuse same sites each treatment with blunt needles • Must follow the track/tunnel of the original cannulation
  36. 36. Doppler Ultrasound Of The Tunnel
  37. 37. Benefits for the patient • Less painful – elimination of anesthetic • Fewer infections • Fewer missed needle sticks • Fewer haematomas • Cannulation of access takes less time
  38. 38. Why to offer the Buttonhole Technique? • Prolong AV fistula life • Decrease hospitalizations related to access infections and complications • Promote patient self-cannulation • Decrease pain associated with needle cannulation
  39. 39. Rope-Ladder Technique for Cannulation of AV Fistulae
  40. 40. Rope Ladder
  41. 41. Buttonhole vs Rope-Ladder Am J Kidney Dis. 2014;64(6):918-936
  42. 42. References • Atlas of Dialysis Vascular Access http://c.ymcdn.com/sites/www.asdin.org/resource/resmgr/imported/atlas%20of%20dialysis %20access.pdf • Field A,Backwell J,Jaipersad A; et al,. Distal Revascularisation with Interval Ligation (DRIL): An Experience. Ann R Coll Surg Engl. 2009 Jul; 91(5): 394–398 • Treatment of vascular steal syndrome Date written: August 2011: Christine Russel. Available from: http://www.cari.org.au/Dialysis/dialysis%20vascular %20access/Treatment_of_steal_syndrome.pdf • van Hoek F, Scheltinga MR, Kouwenberg I et al. Steal in hemodialysis patients depends on type of vascular access. European Journal of Vascular & Endovascular Surgery. 2006; 32: 710-7. • Clinical Practice Recommendations for Use of Buttonhole Technique for Cannulation of Arteriovenous Fistulae. Available from; http://www.britishrenal.org/BritishRenalSociety/files/64/64c14da8-6738-4828-a326- 526c731ff565.pdf • Ben Wong et al,. Buttonhole Versus Rope-Ladder Cannulation of Arteriovenous Fistulas for Hemodialysis: A Systematic Review. Am J Kidney Dis. 2014;64(6):918-936 http://www.wanfang.gov.tw/Upload/WebDownLoadFile1201505141512177.pdf
  43. 43. Thank You

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