INTRODUCTION TO VASCULAR ACCESS SURGERY

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 ……..