This lecture is unique as it deals with all aspects of vascular access surgery for patients with end stage renal disease.

2. End Stage Renal Disease
• End stage renal disease (ESRD)
is defined as an irreversible
decline in kidney function,
when renal replacement
therapy (RRT) is needed for
survival.
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3. ESRD
• End stage renal disease (ESRD) has
become a public health concern
worldwide, with recent reports showing
that the total number of ESRD patients
has been growing dramatically.
• The rising prevalence is due largely to
two main factors: the ageing of the
population and the global epidemic of
diabetes.
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IN ESRD
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4. Renal Replacement Therapy (RRT)
Three modalities exist for the treatment of
ESRD:
● Haemodialysis
● Peritoneal dialysis and
● Kidney transplant.
These treatment options are known as RRT.
kidney transplantation is preferred for patients
with ESRD since it offers a longer life span,
superior quality of life, and more cost effective
than long term dialysis.February 19, 2020
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5. ● The ideal and proper treatment
option of ESRD is renal transplantation.
However, many patients do not have the
opportunity to be treated as such or they
need to wait for a variable period of time till
they get this chance.
● Additionally, some patients develop
rejection of the transplanted kidney. Such
patients need to be managed by
haemodialysis.
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6. • Vascular access is vital for patients with
ESRD.
• Exposure of the venous system of the
forearm to systemic arterial pressure results
in the arterializations of veins. Being
subcutaneously located; these veins can be
punctured repeatedly at the time of
haemodialysis.
• Most ESRD patients receive haemodialysis
treatment by being connected 3 times per
week to a dialysis machine for several hours
at a time.February 19, 2020
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7. Methods and Timing of Vascular Access
• ● Though there are many methods
of vascular access for haemodialysis
(AVFs, arteriovenous grafts-AVG-and
central venous catheters-CVCs),
native AVF is the oldest and the best.
● Placement of AVFs should be
initiated when the patient reaches
CKD stage 4, or within 1 year of the
anticipated start of dialysis.VASCULAR ACCESS FOR HAEMODIALYSIS
IN ESRD
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8. History
• In 1924, George Hass in Germany performed the
first haemodialysis treatment in humans. In a 15-
minute procedure, he used glass needles to access
the radial artery and return blood into the cubital
vein. He used an artificial kidney made up of 3 glass
cylinders.
• The native AVF was born in 1966 when Brescia et al.
published their landmark account of 14 side-to-side
anastamoses between the radial artery and
cephalic vein at the wrist.
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IN ESRD
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• In the 1960s the idea of connecting artery and vein with rubber
tubing and a glass cannula was developed. This was originally the idea
of Nils Alwall, Sweden; then developed by Quinton, Dillard, and
Scribner into an AV Teflon shunt. Their first patient, Clyde Shields,
survived for more than 10 years after having this type of shunt in
March 1960. This method of vascular access is no more in use today.

10. Advantages of Native AVF
• Native AVF has the longest patency
rates among the vascular access
options.
• It has low rates of local or systemic
infection.
• It has low rates of thrombosis.
• The delivered dialysis dose is superior to
tunneled cuffed dual lumen catheters
and comparable with grafts.
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12. February 19, 2020
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Anatomy of Upper Limb Blood Vessels.
● Basilic
Vein arises
from the
ulnar side
of the
superficial
venous
network of
the
dorsum of
the hand
and
drains the
medial
side of
upper
limb.
● Cephalic
vein
Originates
from the
radial aspect
of the
superficial
venous
network
of the
dorsum of
the hand and
drains the
lateral side of
the upper
limb.

13. • A basic understanding of anatomy of vessels utilized
to create the vascular access is crucial for proper
handling and care of an access during dialysis
therapy. The venous system of an extremity
includes superficial and deep veins. The superficial
system is most important for access creation. The
superficial vein in the upper extremity that is
preferred and most commonly utilized for AVF
creation is the cephalic vein. The radiocephalic AVF
at the wrist is the first choice haemodialysis access
and utilizes the forearm segment of the cephalic
vein. The brachiocephalic fistula at the elbow
utilizes the upper arm segment of the cephalic vein
and is generally the second choice site for AVF
creation.February 19, 2020
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14. • The other superficial veins in the forearm (the
basilic vein on the ulnar side and the median basilic
vein near the elbow) are occasionally used for AVF
creation. The deep veins in the forearm are not
ideal for AVF creation. The deep veins in the upper
arm are the brachial and basilic veins that run
parallel to the brachial artery. The basilic vein in the
medial aspect of the upper arm is the most
common deep vein utilized for AVF creation. The
basilic vein is mobilized from its usual location and
transposed superficially through the deep fascia in
the upper arm to create the (transposed basilic
vein) AVF. The brachial veins in the upper arm are
used for vascular access as a last resort.
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15. • A physical examination should document blood
pressure differences between the upper extremities
and an Allen test should be performed as the lack of
a well-developed palmer arch predisposes for
vascular steal symptoms in case the dominant
artery is used for the VA creation.
• Ultrasound must be done before surgical
implantation because it can provide information for
maximal surgical success by mapping arteries and
veins; e.g. a preoperative arterial lumen diameter
>2 mm is associated with successful fistula
maturation, while a diameter of <1.6 mm predicts
failure of the procedure.
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● There are 4
configurations
of AV anastomosis.
● End-to-end
anastamoses are
now rarely
performed, since
the complete
disruption of the
artery imposes a
risk for peripheral
ischemia and
thrombosis.

17. Vascular Access Techniques
Radio-cephalic AVF
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18. SNUF BOX AVF
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19. Brachio-cephalic AVF
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20. February 19, 2020
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Proximal Forearm AVF/ Type 1

21. February 19, 2020
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Proximal Forearm AVF/ Type 2

22. Transposed Basilic Vein AVF
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24. February 19, 2020
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25. February 19, 2020
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27. AVF Maturation
• Rule of 6’s
• In general, a mature fistula should:
• Be a minimum of 6 mm in diameter when a
tourniquet is in place.
• Be less than 6 mm deep.
• Have a blood flow greater than 600 ml/min.
• Be evaluated for non maturation 4-6 weeks
after surgical creation.
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28. • AVGs: a graft made of synthetic
material like PTFE is utilized for
vascular access creation if the
native vessels are not suitable
for creating an AVF. The forearm
loop, upper arm straight and
thigh loop grafts are commonly
utilized configurations for
creating a dialysis access.
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29. Forearm Loop Graft Upper Arm AV Graft
VASCULAR ACCESS FOR HAEMODIALYSIS
IN ESRD
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30. Thigh AV Graft
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31. AVGs Advantages
• Grafts have lower
initial non-function
rates than
autogenous fistulae.
• Grafts can be used
earlier
postoperatively
compared with
native fistulae,
usually 2 to 3 weeks
after surgery.
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32. Central venous catheters are either
temporary non-cuffed or permanent
cuffed tunneled catheters.
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33. • Tunneled central vein catheters are often used as
temporary accesses for haemodialysis. Tunneled
catheters can be placed at several sites. The
preferred site is the right internal jugular vein.
Other sites often used are the left internal jugular
vein and femoral vein. Subclavian vein is accessed
only if the possibility of placing an ipsilateral
permanent arteriovenous access in the upper
extremity is unavailable. The risk of developing
central vein stenosis is very high with a subclavian
catheter. For two decades, subclavian placement of
dialysis catheters was the preferred route; however,
this was abandoned after venograms revealed the
frequent presence of severe stenosis or venous
occlusion at subclavian cannulation sites.February 19, 2020
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34. February 19, 2020
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Cuffed Tunneled Catheters.

35. Temporary non Cuffed
Catheters
• More ridged.
• Easy and fast insertion.
• Immediate use.
• Higher infection rate.
• Preferred IJ or femoral.
• Avoid subclavian.
• < 3wks for IJ.
• <5 days for femoral.
• Dacron cuff.
• Softer.
• Sheath for insertion.
• Different holes, length
and material.
• Requires sedation.
• Lower neck insertion
site.
• More bleeding.
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Cuffed Tunneled
Catheters

36. Tunneled R IJV
Catheter
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Catheters
Disadvantages
● Associated with
higher mortality risk
than fistula.
● Thrombosis.
● Infection.
● Central venous
thrombosis.
● Discomfort.
● Cosmetic.
● Shorter expected
using time.

37. February 19, 2020
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38. Complications of AVFs
• Complications may result from
surgical faults and/or an improper
care in the dialysis units.
• Poor or delayed maturation,
haematoma, swing site stenosis,
central vein stenosis, aneurysm,
infection, steal syndrome, HF and
neuropathy.
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IN ESRD
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39. COMPLICATIONS…
MASSIVE INFILTRATION SWING SITE STENOSIS
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Massive infiltration complicating a
right brachiocephalic AVF due to
improper cannulation technique;
resolved after 4 weeks of rest to the
arm.
(Swing Site) stenosis; the
fistulogram shows a long inflow
segment stenosis which was
successfully angioplastied. A: Pre-
angioplasty. B: Waist on the
balloon. C: Post-angioplasty image.

40. ANEURYSM due to vessel trauma
from frequent needle punctures
and/or a proximal stenosis.
CENTRAL VEIN STENOSIS
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BIG HAEMATOMA

41. February 19, 2020
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Steal Syndrome due to ischaemia of the distal
extremity. Upper arm fistulae are more likely
to cause ischaemic symptoms compared to forearm
fistulae. The presence of poor peripheral vasculature
secondary to DM, calcification and peripheral
arterial disease is the primary etiological factor.

42. • To summarize, once the patient is diagnosed with ESRD he
should be referred to a vascular surgeon to create an
elective native AVF.
• The patency of the superficial veins in the upper extremities
should be preserved by avoiding intravenous cannulation or
vein punctures.
• The initial haemodialysis should start with native AVF rather
than central venous catheters that can result in central
venous stenosis and eventual failure of future vascular
access.
• Proper care, cannulation and handling of AVF by the dialysis
unit staff is vital.
• Early recognition and timely referral of patients with AVF
complications. Many of such complications can be managed
by thrombectomy, drug therapy, endovascular interventions
and surgery as a last resort.
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43. • Placement of AVF should be as distal as possible in the upper
limb to avoid the steal symptoms that result from proximal
AVF.
• Elderly patients or those with peripheral arterial disease and
DM may need to start HD via CVC as the chance of success of
native AVF is less than in patients without such co morbidities.
• It is very important to have a multi-displinary approach to
patients who need VA for HD. Nephrologists should refer their
patients to interested expert vascular surgeons. The patients
should be referred at the proper time before their upper limb
veins are destroyed. The follow up of such patients is the duty
of both nephrologists and surgeon together with the ancillary
staffs.
• Meticulous surgical technique should always be stressed.
• The creation of AVF should be carried out by an expert rather
than an uninterested junior member of the surgical team.
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44. ∎ AVF is the best method of vascular access
due to its longevity and lowest morbidity and
mortality.
● Forearm (radio–cephalic or distal AVF).
● Elbow (brachio–cephalic or proximal AVF).
● Arm (brachial–basilic AVF with transposition
or proximal AVF).
● AVGs are the second option.
● CVCs are important adjunct (internal jugular
and femoral veins are preferred).
● Tunneled catheters are preferred over non-
tunneled catheters to minimize infection.February 19, 2020
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45. Take Home Messages
• Urgent haemodialysis can be performed via
central venous catheters ( R IJV is preferred).
• AV shunt is no more in use.
• Once ESRD is diagnosed, the patient should
be scheduled for an elective AVF.
• Always preserve the superficial veins of
upper limbs.
• AVF should be performed by a skilled surgeon
(vascular, urologist or general surgeon).
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46. Take Home Messages…
• Follow the principles of AVF construction (select
best available site and give time for maturation).
• AVG are used only when no more AVF can be
fashioned.
• Best care of AVF should be provided by the
operating surgeon, interventionist and
dedicated nurses).
• Vascular access is a lifeline for ESRD patients. It
is mandatory before renal transplant and
indispensable after failing renal transplant.
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47. Author's publications about vascular
access for haemodialysis
• https://www.academia.edu/8754609/OUTCO
ME_OF_HEMODIALYSIS_AVF_IN_BAGHDAD_I
RAQ
• https://www.academia.edu/8753988/provisio
n_of_vascular_access_for_chronic_uraemic_p
atients_by_subcutaneous_arteriovenous_fistu
la_in_the_upper_extremity
February 19, 2020
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