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

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

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

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