This document provides an introduction to vascular access surgery. It discusses the history and development of vascular access methods beginning in the late 19th century. The three primary methods used today are native arteriovenous fistulas, prosthetic arteriovenous grafts, and intravenous catheters. Arteriovenous fistulas are preferred when possible due to their longer lifespan and lower risk of complications compared to grafts and catheters. The document outlines considerations for patient evaluation, access selection, creation of arteriovenous anastomoses, maturation of fistulas, post-dialysis hemostasis, and frequent complications.

1. INTRODUCTION TO
VASCULAR ACCESS
SURGERY
Dr. Ali Mujtaba
(Resident Urology)
Department of Urology
SIUT , Karachi

2. OBJECTIVES
 What is vascular access?
 How it all started?
 Ideal vascular access
 Methods to gain vascular access
 Properties of Vascular access
 Risk of AVF primary FALIURE
 Selection and placement
 Preparation for permanent HD access
 Arteriovenous anastomosis
 AVF maturation
 Post dialysis Haemostasis
 Vascular access complication

3. WHAT IS VASCULAR ACCESS?
 Vascular access refers to a rapid, direct method of
introducing or removing devices or chemicals
from the bloodstream.

4. HOW IT ALL STARTED?
 1896
Jaboulay and Briau (Lyon, France) published an
experimental technique in dogs which consisted of
suturing an artery-end-to-end-anastomosis.

5. Nephrol Dial Transplant, Volume 20, Issue 12, December 2005, Pages 2629–2635, https://doi.org/10.1093/ndt/gfi168
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ANIMAL EXPERIMENTS WITH VASCULAR
ANASTOMOSES BY JABOULAY AND BRIAU,
PUBLISHED 1896

6. 1924
 In October 1924, Georg Haas (Giessen,
Germany) performed the first haemodialysis
treatment in humans which lasted 15 min.
 He first used glass cannula to obtain arterial
blood from the radial artery, which he returned to
the cubital vein.

7. 1943
 Modern haemodialysis therapy started on 17
March 1943
 Willem Kolff, a young doctor in the small
hospital of Netherlands, treated a 29-year-old
suffering from malignant hypertension and
‘contracted kidneys’.

8. 1963
 Thomas J. Fogarty from USA,
invented an intravascular
catheter with an inflatable
balloon at its distal tip designed
for embolectomy and
thrombectomy.
 Essential device even today

9. 1965
 The legendary paper ‘Chronic hemodialysis using
veni-puncture and a surgically created
arteriovenous fistula’ was published by Brescia,
Cimino, Appell and Hurwich .
 Dr Appell was the surgeon in the team. The first
surgically created fistula for the purpose of
haemodialysis was placed on 19 February 1965.

10. 1967
 One year after the article, M. Sperling
(Würzburg, Germany) reported the successful
creation of an end-to-end-anastomosis between
the radial artery and the cephalic vein in the
forearm of 15 patients using a stapler.
 This type of AV anastomosis gained widespread
acceptance.

11. IDEAL VASCULAR ACCESS
 Delivers adequate flow rate
 Long life
 Low rate of complications
 Cannulated easily

12. METHODS TO GAIN VASCULAR ACCESS?
Three primary methods are used to gain access to the
blood:
 Native Arteriovenous fistula (AVF)
 Prosthetic arterio-venous graft (AVG)
 Intravenous catheter
Temporary double lumen cathater
Permanent Cathater

13. FISTULA VS GRAFT

14. PROPERTIES OF VASCULAR ACCESS
HD cath AVG AVF
Immediate use Yes 2-4 Wks No
Primary failure Less Less More
Survival Short Intermediate Long
Obstruction More Intermediate Less
Infection More Intermediate Less

15. RISK OF AVF PRIMARY FALIURE
 Wrist fistulas
 Age > 60 years old
 Obesity
 Diabetic
 Peripheral vascular or cardiovascular disease
 Non white race
 Female sex

16. SELECTION AND PLACEMENT
 AVF: First, if available
 AVG: Next
 HD Catheter : Last, should be avoid
 Location
Placed distally and moved to proximal

17. FREQUENCY
 AV fistulas in at least 50% of hemodialysis
patients
 AV grafts in 40%, and
 Dialysis catheters in no more than 10%

18. PREPARATION FOR PERMANENT HD ACCESS
 Patients with GFR < 30 mL/min/1.73 m2 should
educated on all modalities, including
transplantation.
 In patients with CKD stage 4 or 5, forearm and
upper arm veins suitable for placement of
vascular access.

19.  Patients should have a functional permanent VA at
initiation of HD.
 AVF should be placed > 6 months before start of HD.
 This timing allows for access evaluation and additional
time for revision to ensure working fistula is available at
initiation of dialysis therapy.
 A graft should, in most cases, be placed at least 3-6 weeks
before start of HD therapy.

20. EVALUATIONS FOR PERMANENT HD
ACCESS
 History and physical examination
 Duplex ultrasound of upper-extremity arteries and
veins.
 Central vein evaluation in appropriate patient
known to have a previous catheter or pacemaker.

21. IMPORTANT HISTORY

22. 21
Physical Exam
Look, Listen, and Feel Using;
Eyes
Ears
Fingertips
BEST TOOL/TECHNIQUE?

23. IMPORTANT PHYSICAL EXAMINATION

24. DUPLEX ULTRASOUND OF UPPER-
EXTREMITYARTERIES AND VEINS
 Selection of the most appropriate vein and best
location of the access
 Doppler ultrasonography
 Minimal vein and artery size : venous diameter ~ 2.5
mm, artery diameter ~ 2 mm
 Vein dilation test
During the Doppler study the proximal vein
is occluded Increase in internal diameter of 50% has
been associated with a good fistula outcome

25. ARTERIOVENOUS ANASTOMOSIS
• Easiest
• Highest fistula flow
• Risk for high output
cardiac failure
• Minimize turbulence
• Slightly lower fistula flow
• Twisting of artery during
construction
Side to Side
End to Side

26. • Decrease turbulence
• Highest venous flow
• Minimal venous hypertension
• More difficult than side to side
• Least arterial steal and
venous hypertension
• Lowest flow of the four
configurations
Side to End
End to End

27. AVF MATURATION
 AVF should be matured before cannulation
 Rule of 6s
1. Access flow of 600 mL/min
2. < 0.6 cm below surface of skin
3. Minimal diameter 0.6 cm
 If fistula not matured in 6 wks → fistulogram
for access problem

28. POST DIALYSIS HAEMOSTASIS
 Direct pressure over the site
 Tip of one or two fingers > 10 minutes
 Prolonged bleeding > 20 minutes : Increased
intra-access pressure

29. PATIENT EDUCATION

30. SURVEILLANCE
 Prolong access longevity
 Safe another vessel
 Reduce infection rate from insert double lumen
catheter
 Adequacy of hemodialysis
 Frequency of hospitalization
 Decrease the cost of hemodialysis access
management

31. Vascular access complication

32. AVF OR AVG DYSFUNCTION AND RELATED
COMPLICATION
 Early: Non maturation
 Late: Stenosis and thrombosis
 Other: Hand ischemia (Steal syndrome)
Aneurysm and bleeding
High flow related heart failure
Infection

33. THANK YOU ……..