This document discusses different types of vascular access for hemodialysis, including arteriovenous fistulas (AVFs), arteriovenous grafts, and catheters. It provides details on: - The anatomy of veins in the upper limbs that are used for access - Types of AVFs, grafts, and catheters - Advantages of AVFs such as longer patency and lower infection rates - Steps for maturation and examination of AVFs - Differences between temporary non-cuffed catheters and cuffed tunneled catheters - Recommendations for fistula creation sites and catheters as adjuncts for hemodialysis access

1. Vascular access

2. Basilic vein
arises from the ulnar side of the superficial venous
network of the dorsum of the hand
Drain medial side of upper limb
Cephalic vein
origin: radial aspect of the superficial venous network
of the dorsum of the hand
Drain laateral side of upper limb

4. Types of vascular access
1 Arteriovenous fistula
2 Areteriovenous Graft
3 Catheter :
* Temporary double lumen catheter
* Permenant catheter

5. Native arteriovenous fistula
*it has the longest patency rates among the 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

6. FISTULA 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

7. These fistulae are typically fashioned to connect
-the radial artery to the cephalic vein
- the brachial artery to the cephalic vein
- the brachial artery to a basilic vein.

8. Native arteriovenous fistula

9. Grafts
Upper-arm loop graft (brachial artery to basilic vein).
*grafts have lower initial nonfunction rates than
autogenous fistulae
*grafts can be used earlier postoperatively compared
with native fistulae, 2 to 3 weeks after the surgery

11. Forearm Loop Arteriovenous Graft

12. Upper Arm Arteriovenous Graft

13. Thigh Arteriovenous Graft

14. Examination of AVF
* LOOK
* FEEL
* LISTEN

15. LOOK
- Vascular access scar site
- Hematoma or signs of infection
(redness, warmth,pain,pus)
- Ischemic signs :
blue or cold hands up to gangrene , pain at rest.
(steal phenomena >> backflow of I blood from the hand to
I fstula)
- Aneurysm -
Arm elevation test > normally collapse if not > outflow -
stenosis in venous side
- collaterals

16. FEEL
- AVF pulse character (normal > soft compressible)
Abn > hyperpulsatile > outflow stenosis
Abn > hypopulsatile > inflow stenosis
- AVF thrill ( normal > continous thrill)
Abn > discontinuous and strong > outflow stenosis
Abn > discontinuous and weak > inflow stenosis

17. FEEL
-Augmentation test : ( normally > pulse
augmentation and absence of thrill)
Abn > no pulse augmentation and no thrill> inflow
stenosis
Abn > no pulse augmentation and still thrill > accesory
vein
-Sequential occlusion test : to detect level of accesory
vein

18. Listen
Bruit ( normal continous thrill )
Abn > discontinuous thrill > loud > outflow stenosis
Abn > discontinuous thrill > soft > inflow stenosis

19. venous catheter
Temporary non Cuffed Catheters
Cuffed Tunneled Catheters

20. 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.

22. Cuffed Tunneled Catheters
Dacron cuff.
Softer.
Sheath for insertion.
Different holes, length and material.
Requires sedation.
Lower neck insertion site.
More bleeding.

24. Catheters Disadvantages
Associated with higher mortality risk than fistula
Thrombosis.
Infection.
Central venous thrombosis.
Discomfort.
Cosmetic.
Shorter expected using time.

25. We had done vascular access assesment on 137 pt (94
males , 42 females ) in our nephrology department on
regular hemodialysis
Assesment include:
*History
(Name -Age - Type of access – date of creation – n. of
previous AVF and past catheter – reasons of access
failure – date of starting HD – aet. of renal failure –
max. blood flow and any problems on sessions )
* Inspection – palpation - auscultation

35. Conclusion
Arteriovenous fistula (AVF), due to the possible long-
term use and low-level complications, is known to be
the best method to perform the process of chronic
hemodialysis.

36. AVF remains the first choice for chronic HD. It is the
best access for longevity and has the lowest association
with morbidity and mortality, and for this reason AVF
use is strongly recommended by guidelines from
different countries.

37. According to the guidelines of the National Kidney
Foundation (NKF-K/DOQI),6 the site order for the
surgical intervention of AVF for HD is the following:
*Forearm (radio–cephalic or distal AVF)
*Elbow (brachio–cephalic or proximal AVF)
*Arm (brachial–basilic AVF with transposition or
proximal AVF).

38. prosthetic fistulae become the second option of
maintenance HD access alternatives.
CVCs have become an important adjunct in
maintaining patients on HD. The preferable locations
for insertion are the internal jugular and femoral
veins.

39. The tunneled cath is preferable than non tunneled
as preventing infection because the tunneling makes
the insertion site away from were it goes into the
vein. The other is just a straight stick into skin.
Vascular surgeon with nephrologist should
assess together the best method and site for fistula
and catheter insertion for the most benefit to the
patient.

40. Thank you