Hemodialysis Access Planning

• It is well established that dialysis cannot be provided without
access.
• The attainment and maintenance of a single reliable, long-
lasting dialysis access with minimal complications continue to
be challenging.
• Achievement of such an access is associated with optimal
patient clinical outcomes, superior quality of life, and minimal
costs.

• Dialysis access planning should start in CKD stage IV (glomerular filtration
rate [GFR] 15–30 mL/min), when education about CKD and modalities of
RRT should be discussed.
• The rate of decline of GFR over time is perhaps the best predictive guide to
timely referral and access placement.
• The components required for patient-focused access planning are as
follows:
1. Timely and appropriate referral;
2. Education (above);
3. Patient history and physical examination;
4. Supportive investigations.

Hemodialysis Access
Dialysis access refers to the creation of an
entrance way into the bloodstream so that the
blood can be cleansed by the dialysis procedure.

Types of Hemodialysis Access
• Fistula (arteriovenous fistula)
• Graft (arteriovenous graft)
• Venous catheter:
• 1. Cuffed
• 2. Uncuffed

Types of Hemodialysis Access:
Among 4,07,811 U.S. end-stage
renal disease patients undergoing
hemodialysis :
64.2% are dialyzed through AVFs
18.5% through AVG
19.5% through hemodialysis
catheters
https://www.ajronline.org/doi/full/10.2214/AJR.15.14650

Change in type of vascular access during the first year of dialysis among ESRD patients
starting via hemodialysis in 2013 quarterly:
(a) type of vascular access in use (cross-sectional)
(b) longitudinal changes in vascular access use and other outcomes,
Data Source: Special
analyses, USRDS ESRD
Database. Data from
January 1, 2013 to May
30, 2016
CROWNWeb, Consolidated
Renal Operations in a Web-
enabled Network; ESRD, end-
stage renal disease; HD,
hemodialysis; PD, peritoneal
dialysis.
2017 Annual Data Report Volume 2, Chapt

Preparation for Hemodialysis Access:
Ideally before dialysis an venous access should be made:
• – Fistula should be placed 6 months prior to start dialysis
• – Graft should be placed 3-6 weeks prior to start dialysis
• – Venous catheter can be used instantly

What is a fistula or AVF?
 An arteriovenous fistula is a connection between an artery and a vein
surgically created for hemodialysis by the vascular surgeon.
 It is the preferred access of all the types of hemodialysis access and is
often referred to as the “gold standard.”
 This access results in an extra pressure and extra blood to flow into the
vein, which helps to enlarge and strengthen the vein.

Preparation for Access
Before an access is made, patient is evaluated by a vascular surgeon
for
– vein mapping with an doppler ultrasound
– Vessel with a 2-2.5 mm and above diameter are acceptable for
fistula.
– US also help to determine course of the veins
– Blood lab tests for anesthetic and surgical fitness

Main Features Addressed by Duplex Ultrasound Vascular
Examination
Arterial System
• Artery size from the axilla to hand including the palmer arch
• Dual arteries in upper arm, i.e., high bifurcation
• Degree of arterial wall calcification
• Arterial stenotic lesions
• Blood flow at defined segments
Venous System
• Detailed venous anatomy in arm and leg as needed
• Vein size mapping from wrist to axilla
• Vein patency and presence or lack of stenosis
• Patency and flow pattern of subclavian vein
• Presence of diving venous branch at antecubital fossa

What is an arteriovenous fistula?
An AV fistula allows a higher rate of blood to flow
back and forth from the vein to a dialysis machine.
Untreated veins cannot withstand repeated needle
insertions, because they would collapse under
strong suction.

Hemodialysis Access
• There are only about ten sites
in the body where an AV fistula
or graft can be made.
They are commonly located in
the
• – Arm (non-dominate forearm
or upper arm)
• – Leg
• – Neck

Types of Arterio-Venous fistula

Different fistula: Radiocephallic
 End to side anastomosis of radial artery and
forearm cephalic vein, Brescia- Cimino fistula
(proximal forearm).
 Original fistula created by Dr. James Cimino in
1966.
 Technically simple
 Distal patency rates at one year are
approximately 50% to 80%.
 The use of this distal access site preserves
more proximal vessels for subsequent attempts
at creating a fistula.
Ref: Types of Arteriovenous Fistulas Michael Segal; Erion Qaja. Last Update: March 16, 2019.

Proximal forearm AVF:
• Anastomosis between
proximal radial artery and
median antecubital vein

Proximal forearm AVF:
• Anastomosis
between
perforating
vein and
proximal radial
artery

Brachiocephalic AVF:
• Anastomosis between Cephalic
vein and Brachial artery

Transposed brachio basilic fistula
• Anastomosis between
Basilic vein & brachial
artery

Maturation of the fistula:
Rule of 6s includes:
– The flow should be greater than 600 mL per minute
– Greater than 6 mm diameter
– Less than 6 mm below the skin
– At least 6 cm of the vein for cannulation
– expected maturation at 6 weeks
_
Ref: Types of Arteriovenous Fistulas Michael Segal; Erion Qaja. Last Update: March 16, 2019.

Examination
of Vascular
access

Assessment of AV Access by Physical Examination
• Pulse:
• Thrill:
• Arm elevation: to assess the outflow tract(if fails to collapse-
indicates -the downstream stenosis)
• Pulse augmentation: to evaluate the inflow segment(if pulse does
not augment –indicates accessory outflow pathway)

AV Fistula: Advice to the patients
Listen – Check for Bruit
Feel – Check for “thrill.”
Ask the patient –
– not to squeeze an access arm with elastic, a
watch, or by carrying something across it.
– To visit whenever there is chills or a fever.

Caring for Your AV Fistula
• Daily care of AV fistula is essential for it’s proper functioning
• Look – Check for
– signs of infection, such as
• – swelling,
• – redness,
• – warmth and
• – drainage, as well as
• – bleeding, peeling of the skin over the access or bulging areas.

NKF Recommended AVF cannulation Policy
Clinical exam by an experienced nurse has been able to predict AVF
maturity 80% of the time.
Fistula First Initiative advises 3 level of Cannulation competence
(CCHT, PCT III)
Only an expert cannulator is authorized to cannulate a new AVF.

Advantages of AVFs
The gold standard for vascular access because –
– it provides adequate blood flow,
– lasts a long time, usually 20 plus years
– has a lower complication rate than other types of access.
It is done as minor outpatient surgery
Usually take 6 to 12 weeks to develop
Fewer infections & thrombus than grafts and catheters
Pt can take Bath

Disadvantages of AVFs
May require another temporary type of access during the
healing and maturation phase
Maturation may be delayed, or it may fail to mature
Visible as a bulge under the skin
Not always possible for all patients
Needles are required to access the AV fistula for
hemodialysis

“ Fistula First, Catheter Last”
Goal
Increase AVF rate in appropriate HD patients to 60% by
2009
Decease long term(>90days) catheter rate to <10%
AVF is most cost effective, lasts longest, needs less
intervention and has lowest complication.

K/DOQI recommendation
Care under a Nephrologist.
Dialysis education at CKD 4( GFR <30).
Avoid phlebotomy/BP check in the non-dominant arm once CKD 4.
Fistula placement 6-12 months before anticipated HD.

Primary Failure
• HD fistula maintenance study (Prospective observational study) primary failure 40%
• AVF 47-60% VS. AVG. 19-40%
• BC 32%
• BB 21%
• Upper arm AVF 15%
• In one retrospective study on >16K patients , 27% of AVF group VS 17% of AVG group needed
another access, in one year.

AVF or Graft
5year patency for AVF and
AVG are similar
Higher patency for AVF after 2
years.
AVF less successful than AVG
in elderly female and with DM.

Does
fistula
Exercise
help?
Hemodialysis International, Oct 20,2015 by
Nestor Fontsere.
After one month by clinical exam 94.7% in the
exercise group VS 80.6% ( p-0.009)in non-
exercise group had a more mature fistula.
After one month by Doppler, 81.6% in exercise
group versus 74.2% in non-exercise group (p-
0.459) had a more mature fistula.

Catheter
Once a catheter is placed, needle insertion is not necessary.
Though Catheters are not ideal for permanent access, but they
are useful to start hemodialysis immediately & will work for
several weeks or months while fistula / graft matures.
Catheterization should be carried out in operating theatre or
high-dependency care areas, always using a fully aseptic
technique.

Catheter
Dialysis catheters are
artificial indwelling
transcutaneous
conduits that
are used to access the
venous space for renal
replacement therapy
(RRT).
Ref: http://meditechdevices.com/duraflow-acute-hemodialysis-catheter/

Sites
• – Right Subclavian
Vein
• – Internal Jugular
vein
• – Femoral Vein

Complications
The main problems associated with venous catheters are
1. Infection
2. Poor catheter flow (catheter dysfunction)
3. Thrombosis
4. Central venous stenosis
5. Catheter adhesion
6. Port clamp fracture

https://www.health.qld.gov.au/data/assets/pdf_file/00 25/444670/icare-haemodialysis-guideline.pdf (queensland, Australia)

Advantage of Catheter
Dialysis can be performed immediately after
placement
Easy to remove and replace

Disadvantage of
Catheter
Highest infection rate
Direct line to the heart contributes to more serious life
threatening infections
Clots more frequently
Often difficult to obtain sufficient blood flow to allow for
effective removal of waste materials through dialysis
Bathing and swimming are not recommended due to infection
risks

Complication during jugular /
subclavian catheterization:
• Common :
Minor hematoma formation at
insertion site
Local infection
Arterial (carotid, subclavian,
vertebral) puncture
Arrhythmias,

Complication during jugular /
subclavian catheterization:
• Rare Complications:
 Major hematoma compressing
airway
 Major trauma to large vessels
with hemorrhage
 Cardiac perforation with
tamponade
 Pneumothorax or hemothorax
(diagnosis via chest radiograph)
 Thoracic duct injury, usually associated with
left subclavian
or internal jugular approach (diagnosis
established by the
 presence of chyle in pleural fluid)
 Sepsis
 Venous air embolism
 Nerve injury
 Venous thrombosis and pulmonary emboli

EQUIPMENTS :
• Haemodialysis kit
containing:
• Seldinger needle
• 5/10 cc syringe without
lure lock
• Guidewire
• Dilator
• central venous catheter /
Haemodialysis catheter
• anchoring clips.

EQUIPMENTS :
• Other instruments:
• Sterile mask, gloves, and
gown
• Sterile drapes
• Monitors (ECG, pulse ox
imeter & BP)
• Peripheral IV with infusion
• Suture material
• Scalpel / BP blade – 15 no
Sterile gauze
Syringes
Disinfectant (2% chlorhex idine, iodine
solution)
Gallipot
0.9% normal saline
Heparin
Needle holder
Sponge holding forceps

EQUIPMENTS :
• Seldinger needle :
designed for single wall
puncture
• – small in diameter,
• – thin walled,
• – short beveled
• – very sharp.
• – Hub clear

Procedure:
 Obtain informed written consent
 Choose the site for insertion
 Position the patient
 Put on your gloves and gown.
 Clean and drape the site: The iodine solution should be applied vigorously to an area
of skin approximately 30cm in diameter, in a circular motion from centre to
periphery for at east 30 seconds. Do not use a forward and backward movement.
 repeat this step three times using a new swab for each application
 allow the antiseptic to air dry, do not wipe or blot

Procedure:
Draw 5 ml of lidocaine; raise a bleb on the skin with a 27-gauge
needle.
Infiltrate local anesthetic all around the site, working down
toward the vein. Pull back on the plunger before injecting each
time to ensure that you don’t inject into
the vein.
open the dialysis catheter Kit, Flush each port of the catheter
with saline or heparinized saline (1:10), and close off each line

Procedure:
The length of the catheter planned to be
inserted should be noted prior to insertion
and documented
Attach a syringe to the 18/19 G needle,
keeping the beveled surface along Numeric
marking on syringe.
Catheterization with tip at desired position
Dressing

Anatomical consideration
 Rt Femoral vein catheterization:
 Find the arterial pulse and enter
the skin 1 cm medial to this, at a
45° angle to the vertical and
heading parallel to the artery.
Advance slowly, aspirating all
the time, until you enter the vein

Anatomical
consideration
• Rt subclavian vein
Catheterization:
Pt positioning
Selection of puncture site
Puncture
Wire advancement with
angled tip toward the heart

Anatomical consideration (IJV & CA)
• Relation of internal carotid artery with internal jugular
vein

US view of the Internal Juvular vein
& Carotid artery

Procedure:
Catheter tip
position in
RA

Follow up X-
ray:
• Catheter
tip is at rt
upper
atrium.

The white tube of DEATH
• 9% bacteremia annually ($22-45K/episode)
• 30% complications/yr. ( malfunction )
• 51% annual mortality in patients who exclusively use CVC
• Increase MI, CHF, PVD, CVA
• Lower flow rate, poor Kt/V
• Poor quality of life
• Up to 40% central venous stenosis ( Subclavian 50%, IJ 10%), may preclude
future AVF.

Graft
AV graft is the second most common vascular access of
choice in hemodialysis patients
Arteriovenous graft is a surgically created anastomosis
between an artery and vein via prosthetic conduit. The
conduit can be straight or looped and placed
superficially under skin for easy cannulation
The graft becomes an artificial vein that can be used
repeatedly for needle placement and blood access during
hemodialysis

AV Graft
Location: Grafts can be placed in arm or leg but most are
placed in the forearm
Grafts can be used after 3-6 weeks of placement
Indications –
• – Small, weak or hypoplastic peripheral vein
• – obesity
• – severe arterial occlusive disease .

AV Graft material:
 Biological
 Synthetic – polytetrafluorethylene (PTFE) , Dacron, silicon, and
polyurethane.
 Polytetrafluoroethylene (PTFE) grafts are preferred over
biological and other synthetic grafts due to low thrombosis risk,
longer patency, ease of implantation, and low risk of disintegration
with infection.
Ref: Comparative study of use of Diastat versus standard wall PTFE grafts in upper arm hemodialysis
access.Almonacid PJ, Pallares EC, Rodriguez AQ, Valdes JS, Rueda Orgaz JA, Polo JR Ann Vasc Surg. 2000
Nov; 14(6):659-62.

AV Graft material, newer options:
• The HeRO Graft
(Hemodialysis Reliable
Outflow) HeRO Graft is
the only fully
subcutaneous AV access
clinically proven to
maintain long-term
access for catheter-
dependent patients with
central venous stenosis.
Ref: Merit Medical dialysis devices

AV Graft material, newer options:
• TEVG (Tissue Engineered Vascular Graft)
:
• Built to tolerate hemodynamic loads, heal
and remodel in response to needle sticks,
resist infection, no post operative
maturation period.
• Currently the major draw back is cost
effectiveness.
The Tissue-Engineered Vascular Graft—Past, Present, and Future; Tissue Eng Part B Rev. 2016 Feb 1; 22(1): 68–100.
doi: 10.1089/ten.teb.2015.0100

Types of AVGs depending on
location:
• Straight
forearm
(radial
artery to
cephalic
vein)

Looped forearm Graft
(brachial artery to cephalic vein)

Straight upper
arm (brachial
artery to axillary
vein)

Looped upper arm
(axillary artery to
axillary vein)

ePTFE Graft
Thrombosis
Identified by flow, pressure, duplex scan
RCT failed to show usefulness of preemptive
angioplasty .
High frequency of early AVG restenosis after
angioplasty.
Stent grafts prevent AVG restenosis better than
balloon angioplasty, but do not prevent AVG
thrombosis.

Advantages of Graft
Implanted during minor outpatient surgery
Can be used within 3-4 weeks
Initial high blood flow rates
Less primary failure than AVFs

Disadvantages of Graft
Usually only lasts 3-5 years
More likely to get infected than AVF
More likely to have infection & blood clots than an AVF
Longer bleeding time than an AVF after dialysis needles
are removed

• Failure of maturation
• Infection
• Emboli
• Thrombosis
• Hemorrhage
• Ischemia/obstruction
• Aneurysm
• Stenosis
• Stent complications
• Compartment syndrome
• Seroma, lymphocele
• Edema
• Carpal tunnel syndrome
• Cardiac failure
• Wound

• Infectious:
• Non-infectious:

The Centers for Disease Control Core Interventions
for Dialysis Bloodstream Infection (BSI) Prevention

Variations in clinical definitions of CRBSIs:CDC
• Clinical manifestations and at least one positive peripheral blood culture and no
other apparent source, with either positive semiquantitative (>15 CFU/catheter
segment) or quantitative (>10 CFU/catheter segment) culture, whereby the same
organism is isolated from the catheter segment and a peripheral blood sample.
Simultaneous quantitative cultures of blood samples with a ratio of ≥3 : 1 (catheter
vs. peripheral). A differential period of catheter culture vs. peripheral blood culture
positivity of at least 2 hours.
OR
• The isolation of the same organism from semiquantitative or quantitative culture
segment and from blood with accompanying symptoms of bacteremia and no other
apparent source of infection.

Variations in clinical definitions of CRBSIs:IDSA
• Bacteremia or fungemia in a patient with an intravascular catheter with at least one
positive blood culture and with clinical manifestations of infections and no apparent
source for the bacteremia except the catheter.
AND
• One of the following must be present:
i) A positive semiquantitative (>15 CFU/ catheter segment) or quantitative (>103
CFU/catheter segment) culture whereby the same organism is isolated from the
catheter segment and peripheral blood.
ii) Simultaneous quantitative blood culture with a >5 : 1 ratio catheter versus
peripheral.
iii) Differential time period of catheter culture versus peripheral blood culture.

Variations in clinical definitions of CRBSIs: KDOQI
• Definite: Same organism from a semiquantitative culture of the catheter
tip (>15 CFU/catheter segment) and from a blood culture in a symptomatic
patient with no other apparent source of infection.
• Probable: Defervescence of symptoms after antibiotic treatment with or
without removal of the catheter in the setting where blood culture
confirms an infection, but the catheter tip does not or vice versa in a
symptomatic patient with no other apparent source of infection.
• Possible: Defervescence of symptoms after antibiotic treatment or after
removal of catheter in the absence of laboratory confirmation of
bloodstream infection in a symptomatic patient with no other apparent
source of infection.

Journal
Food and Drug Administration Task Force. Precautions
necessary with centralvenous catheters. FDA Drug
Bulletin, July 1989:15– 16.
Scott WL. Centralvenous catheters: an overview of Food
and Drug Administration activities. Surg OncolClin North
Am 1995; 4:377–392.
Oncology Nursing Society. Access Device Guidelines:
Recommendations for Nursing Practice and Education.
Pittsburgh, PA: Oncology Nursing Press, 1996.
NationalAssociation of Vascular Access Networks.
NAVAN Position Statement. J Vasc Access Devices
1998;3:8–10
Inference:
“the catheter tip should not be placed in or
allowed to migrate into the heart”
a catheter tip should not be positioned
within the right atrium.
the tip of a PICC should be positioned within
the lower third of the superior vena cava
(SVC), close to the junction of the SVC and
right atrium

Journal:
Infusion Nurses Society. Standards of
Practice. J Intrav Nurs 2000; 23(suppl):6S
NationalKidney Foundation. K/
DOQI Clinical Practice Guidelines for
Vascular Access. Am J Kidney Dis 2001;
37(suppl1):S137–S181.
Central Venous Catheter Tip Position: A
Continuing Controversy
J Vasc Interv Radiol 2003; 14:527–534
Inference:
“central catheters should have the distal tip dwelling in the vena
cava”
· for tunneled (cuffed) catheters - states that the tip should be
positioned at the SVC/right atrial junction or into the right
atrium to ensure optimal blood flow.
· For nontunneled hemodialysis catheters, position the catheter
tip at the SVC/atrial junction or in the SVC.
The majority of central venous catheters used for routine
applications should be positioned with the distal tip in the SVC.
However, to achieve optimal performance of a hemodialysis or
pheresis catheter, it may be necessary to position the tip within
the upper right atrium

Recommended HBV precaution and isolation practices

That’s all ……..
Thank you!!!!

Catheter exit site review:
CVCs should be reviewed for signs of infection at each
haemodialysis treatment or whenever accessed
The insertion site should be examined by the clinician
for erythema, exudate, tenderness, pain, redness,
swelling, suture integrity and catheter position

Hemodialysis
• Hemodialysis circulates blood through a machine
outside the body to remove toxins and excess fluid &
then pumps the cleansed blood back into the body.

Hemodialysis Access Planning

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