Vascular accessComplications Surveillance / Troubleshooting. presented at the Sri Lanka Society of Nephrology (SLSON) Academic Sessions 2021

1. Vascular access
Complications
Surveillance / Troubleshooting
Dr Joel Arudchelvam
MBBS (COL), MD (SUR). MRCS (ENG).
Senior Lecturer, Department of Surgery, University of Colombo,
Consultant Vascular and Transplant Surgeon,
The National Hospital of Sri Lanka, Colombo.

2. Vascular access
• End Stage Renal
Failure - Renal
replacement therapy
o Haemodialysis
o Peritoneal dialysis

3. Haemodialysis
• Arterio Venous Fistula (AVF)
• Arteriovenous graft fistula (AVG)
• Central venous lines

4. Central venous lines
• Complications
o Infection
o Thrombosis

5. Vascular access
Arterio Venous Fistula (AVF)

6. Radio Cephalic AVF

7. Lower Limb AVF

8. Decision making
SUITABLE FOR AVF
YES
SUITABLE VEINS
AVF
NO
THIGH VEIN AV GRAFT
NO
CENTRAL VENOUS
LINE / TUNNELED
LINE

9. Vascular access
Arterio Venous Fistula (AVF)

10. Mature fistula
• When the AVF becomes suitable for
dialysis
o Flow - >600 mL/min,
o Diameter – 6mm
o Depth - < 6mm
o Well visualized and felt
• Usually in 6 weeks

11. AVF Monitoring
• Assess for;
o Limb edema / facial oedema
o Alterations in pulse / thrill characteristics
o Prominent collaterals
o lack of pulse augmentation (inflow stenosis)
o prolonged bleeding
o Finer numbness
o Finger pain
o Signs of infection
• Should be done at least monthly

12. AVF Monitoring
• Duplex scanning
o Flow measurements - less than 400 to 500 mL/min
o Abnormalities
• For inadequate dialysis
o Recirculation indicators
• Static pressures
o Arterial and venous
• Angiography

13. Complications
 Thrombosis
 Stenosis
 Steal syndrome
 Aneurysm

14. Thrombosis
• Causes
o Anastomotic issues
o Venous abnormalities
o Systemic causes
o External compression
• Treatment
o Thrombectomy
o Correction of underlying cause – stenosis, strictures
o Redo AVF

15. Stenosis
• Causes
o Anastomotic stenosis – technical, neo-intimal hyperplasia
o Venous stenosis – past thrombophlebitis, cannulation injury
• Clinical findings
o Reduced thrill / Abnormal thrill (weak and/or discontinuous)
o Reduced pressure during dialysis

16. Stenosis

17. Venous Stenosis

18. Treatment
• Fistulogram and Fistuloplasty
• Open Venous patch angioplasty
• Repositioning of the anastomosis
• Redo AVF

19. Central venous stenosis
• History of previous
venous cannulation
• Swelling of the upper limb
• Facial swelling
• Prolonged bleeding after
needle removal
• Increased venous
pressure

20. Central venous stenosis

21. Central venous stenosis
Management
• Fistulogram and
Fistuloplasty
• Bypass surgery
• Ligation of AVF

22. Central venous stenosis

23. Steal syndrome
• Distal limb and hand ischemia due to poor blood flow to
the limb as a result of AVF
• Incidence - 0.25% to 20%
• Depends on the type of AVF – Proximal / distal

24. Risk factors
o Female gender
o Previous AVF on same limb
o Proximal AVF
o Arterial disease
o Large Arteriotomy during access creation

25. Steal syndrome
• Presentation
o Pain, pallor, numbness,
gangrene of digits
o Reduced absent distal
pulse – appear on AVF
occlusion

26. Steal syndrome

27. Steal syndrome
Stages
1 – cold, pale hand
2- pain with exercise or dialysis
3- rest pain /ulcer/ gangrene

28. Steal syndrome
Management
o Mild - conservative
o Angioplasty of inflow vessels
o Ligation of AVF
o Banding of outflow
o Distal revascularization and interval ligation (DRILL)
procedure
o Proximalisation of arterial inflow

29. DRILL procedure

30. AVF Aneurysms
Abnormal focal dilatation of a segment of AVF
o Anastomotic
o Venous

31. AVF Aneurysms
Causes
o Anastomotic
• Infection
o Venous
• Needle injury during dialysis
• Infection

32. AVF Aneurysms

33. AVF Aneurysms
Complications
• Skin erosion
• Infection
• Rupture and bleeding

34. AVF Aneurysms
• Prevention
o Cannulation techniques
• E.g rope ladder
o Avoid dilated areas

35. Cannulation techniques
• Buttonhole cannulation
• General area cannulation
o In close proximity
– Rope-ladder cannulation
– Along the length of access

36. AVF Aneurysms
Management
• Indications for intervention
o Skin threat
o Rapid enlargement

37. AVF Aneurysms
• Management
o Endovascular
• Stenting
o Surgical
• Resection and graft interposition repair
• Ligation and resection – for infected

38. Summary
• Dialysis access is life saving
• Monitoring and detecting complications early will
help to save the access