This document discusses vascular access for hemodialysis and a programmatic approach. It covers the multidisciplinary care team involved, background on chronic kidney disease and end stage renal disease in the US, and options for vascular access at initiation of dialysis. The document reviews guidelines promoting arteriovenous fistulas over catheters, quality standards, and complications associated with different access types. It also discusses strategies for a systems approach to access management, including timing of access creation and cannulation, monitoring access, and interventions for access issues.
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Vascular access
1. Vascular Access for Hemodialysis
A Programmatic Approach
Lee Kirksey MD MBA
Assistant Professor of Surgery Case Western Lerner School of
Medicine
Department of Vascular Surgery
The Cleveland Clinic Foundation
kirksel@ccf.org 216.296.3209
216.445.8079, 4508
2. Care of ESRD patient
⢠CKD team NPs, Physicians
⢠Vascular surgery team
⢠Dialysis center team
Nursing
Physicians
Technicians
⢠Access maintenance service
3. Background
⢠CKD/ESRD is the 9th
cause of death in the
US.
⢠One in ten Americans have some level of
CKD
⢠341,000 patients on hemodialysis.
⢠107,000 new ESRD patients in 2010
4.
5. Vascular Access at initiation of HD
⢠43% of incident patients had no prior
nephrology contact
⢠80% begin HD with a CVC
⢠16% AVF
⢠3% AVG
6. Vascular access use at initiation
and on day of eligibility, 2010
Figure 1.18 (Volume 2)
Incident hemodialysis patients, July-December, 2010
7.
8. Background
⢠Adjusted individual first year mortality for
newly initiated HD patient is 24%
compared to 5-7% annually for ensuing
years
⢠20% annual mortality for prevalent
population
16. Non maturation rates for AVF
reported between 50-60%
Dialysis Access Consortium DAC Dember et al. JAMA
2008:299:2164-71.
Allon et al. Kidney Int 2002;62:1109-24.
Dhingra et al. Kidney Int 2001;60;1443-51.
17. Access Maturation Definition
⢠Rule of 6âs (Anatomic)
â 6 mm diameter
â 600 ml/min flow
â 6 cm accessible
â < 6mm depth
⢠6 consecutive uses of new dialysis
18. Whatâs the goal: clinically
significant vs insignificant variables
⢠Patency
⢠Maturation
⢠Consistent Cannulation that permits
removal of tunneled catheter
23. ESRD-chronologic stages of
Management
⢠Diagnosis of CKD: acute or chronic time course
⢠Initiation of referral for access creation: when to
whom
⢠TDC placement-initiation of dialysis
⢠Creation of Access: fistula/graft/PD/Txplt
⢠Maturation and initiation of dialysis per access-
when/who determines/--âfish or cut baitâ
24. Timing of access
⢠GFR of 30 ml/min should prompt referral and
site protection.š
⢠Access should be created 6 months in advance.š
⢠Maturation of AV fistulas ideally requires 6 to 8
weeks.
⢠Incorporation of AV grafts takes 3 to 6 weeks.
1 KDOQI guidelines
25. Discussion Topics
⢠Barriers to timely access
⢠Find your vascular access champion. Vascular
access should not be second tier importance
⢠Hold your proceduralist accountable both for
quality and service
⢠216.444.VEIN
26. OR> 3 wks> 6wks> Maturation> Cannulation
Stratify catheter dependent
/Low GFR patients relative
priority when OR access is
limited
Does 2 Staged approach add time
to access? NoâŚ..But
27. Discussion Topics
⢠Barriers to timely access
⢠When/how do we cannulate
⢠I release the fistula at 2/3 weeks post op with
visit/exam and prescription
⢠I reserve button hole for reliable home
cannulator/ limited access length in facility
⢠Cannulation team trainingâIâm happy to visit
and discuss anatomy
29. Discussion Topics
⢠Barriers to timely
access
⢠When do we
cannulate
⢠When do we abandon
a fistula
⢠How do we monitor
the fistula? exam,
flows, angio,
nihilism
You must have a good
access maintenance
teamâAfter surgery,
the work has just
begun.
Limited use of stents
216.445.vein
30. Discussion Topics
⢠Barriers to timely
access
⢠When do we
cannulate
⢠When do we abandon
a fistula
⢠How do we monitor
the fistula? exam,
flows, angio, nihilism
⢠Alternative sites in the
challenging pt
31. Preferred Access Sites
⢠Radiocephalic AV fistula.
⢠Brachiocephalic AV fistula.
⢠Basilic vein transposition.
⢠Forearm AV loop graft.
⢠Upper arm AV graft.
⢠Unconventional sites
â Chest wall, legs, right atrium
⢠Cuffed tunneled catheters should NOT be used as
definitive accessâŚ.except in?
43. Products listed may not be available in all markets.
GOREÂŽ
, and designs are trademarks of W. L. Gore & Associates. Š 2011, 2013, 2014 W. L. Gore & Associates, Inc.
Accuseal Graft
44. Tri-Layer Design
⢠Outer Graft Layer
ď Expanded polytetrafluoroethylene
⢠Middle Graft Layer
ď Elastomeric membrane
⢠Inner Graft Layer
ď Expanded polytetrafluoroethylene
⢠CBASŽ
Heparin Surface
CARMEDAÂŽ
and CBASÂŽ
are trademarks of Carmeda AB, a wholly owned subsidiary of W. L. Gore & Associates.
Products listed may not be available in all markets.
GOREÂŽ
and designs are trademarks of W. L. Gore & Associates. Š 2011, 2013, 2014 W. L. Gore & Associates, Inc.
45. May Reduce Risk of Seroma/Aneurysm
Experienced
in Standard ePTFE grafts*
Seroma capsule
Ultrafiltration (fluid leakage) through the graft wall
Products listed may not be available in all markets.
GOREÂŽ
, and designs are trademarks of W. L. Gore & Associates. Š 2011, 2013, 2014 W. L. Gore & Associates, Inc.
* Data on file
47. Brachial Access with Femoral Vein
⢠Primary patency 79% 12 mo
⢠Secondary patency 100% 12 mo
⢠Steal 27%
⢠23% vein harvest site
complications.
⢠Indicated for vascular access
associate arm infection
48. General Principles
⢠Obtain complete access history.
⢠Delineate anatomy of the inflow and outflow
(venography).
⢠Exhaust upper extremity options.
⢠Anticipate/reduce complication
⢠Favor the use of autogenous conduits via
transposition and translocation.
49. Axillary-Axillary Grafts
⢠24 month 40-80%
patency.
⢠Preserves contralateral
access.
⢠The venous limb should
be lateral.
⢠Not associated with
steal.
50.
51.
52. Femoral Vein Transposition
⢠2 year primary patency of 75%.
⢠2 year secondary patency of 94%.
⢠High risk of steal. Limit
anastomosis to 4-5mm.
⢠Patients with PVD are not
candidates.
⢠High flows (2000 ml/min) may
exacerbate CHF.
53.
54.
55. Caveat for leg access
⢠Exhaust all upper extremity-Last ditch
means last ditch
⢠Objective documentation of arterial
perfusion, pvrs with toe pressures
⢠Preserve CFV, profunda femoris
⢠Mild Chronic limb swelling is common
⢠Anticoagulate 3-4 months
⢠Amputation is not absolute
contraindication to leg access
56. SFA-SFV Grafts
⢠Comparable patency.
⢠21% infection rate.
⢠Avoids some of the
pannus and lymphatics.
⢠Preserves more proximal
access.
⢠Complications are easier
to manage.
61. Femoro-Femoral Grafts
⢠60% secondary
patency at 2 years.
⢠8 to 41% infection
rate.
⢠Higher complications
in obese patients.
62. Axillary/Brachial- Jugular Grafts
⢠60% secondary
patency at 2 years.
⢠No incidence of steal.
⢠4-15% incidence of
infection lower than that
of thigh access.
⢠Difficult control in the
setting of
complications.
63. Arterial Interposition Grafts
⢠87% secondary
patency at 3 years.
⢠5% ischemia rate.
⢠Ischemia better
tolerated in the upper
extremity.
⢠May have a role in
CHF.
⢠Higher risk of bleeding.
68. Features of FlixeneFeatures of Flixene
⢠The graft has the sliderThe graft has the slider
capability with acapability with a
polyethylene clear, slidepolyethylene clear, slide
sheath that allows ease ofsheath that allows ease of
tunneling.tunneling.
⢠It has a pre-attachedIt has a pre-attached
tunneler tip.tunneler tip.
69. Features of Flixene:Features of Flixene:
Improved StrengthImproved Strength
⢠High Radial Tensile StrengthHigh Radial Tensile Strength
â Greater resistance to cannulationGreater resistance to cannulation
⢠BenefitBenefit
â Withstand repetitive cannulationsWithstand repetitive cannulations
â Fewer revisions and less pseudoaneurysmsFewer revisions and less pseudoaneurysms
74. Computational Fluid Dynamics (CFD)**
** CFD 600 mL / min, 4.8 mm 30°, t = 0.4s
Conventional End-to-side Anastomosis
Endoluminal Anastomosis with the GOREÂŽ
Hybrid Vascular Graft
* Data on file
75. ESRD stages of Management
⢠Cannulation technique: button hole/rope ladder
⢠Removal of catheter
⢠Monitoring of access
⢠Thrombosis of access- 2/month
⢠Maintenance intervention of access
83. Discussion Topics
⢠Barriers to timely
access
⢠When do we
cannulate
⢠When do we abandon
a fistula
⢠How do we monitor
the fistula? exam,
flows, angio, nihilism
⢠When do we abandon
the fistula
84. Discussion Topics
⢠Barriers to timely
access
⢠When do we
cannulate
⢠When do we abandon
a fistula
⢠How do we monitor
the fistula? exam,
flows, angio, nihilism
⢠When do we abandon
the fistula
⢠Alternatives to
prosthetic
106. Catheter events
& complications
Figure 5.48
Prevalent hemodialysis patients age 20 and older, ESRD CPM data; only includes patients who are also in the USRDS
database. Year represents the prevalent year & the year the CPM data were collected. Access is that listed as âcurrentâ
on the CPM data collection form.
107. Short-Term Catheters
Hohn Hemocath
Single lumen = 5 Fr
Double lumen = 7 Fr
Dual lumen 11 Fr
Short-term pheresis
PICC
Single or double lumen
4, 5, or 6 Fr
( Non-Tunneled Catheters )
114. The Problem
The rapid, progressive development
of intimal hyperplasia at the anastomosis
of hemodialysis fistulae and grafts.
anastomotic
stenosis
PTFE graft anastomotic
stenosis
AV fistula
116. â A well performed fistulogram is the
foundation for all percutaneous interventions â
Thorough evaluation of the entire vascular access circuit
including the graft, native veins, and inflow arteries
123. .
In Search of an Optimal Bedside Screening
Program
for Arteriovenous Fistula Stenosis
Nicola Tessitore,* Valeria Bedogna,* Edoardo Melilli,* Deborah
Millardi,* Giancarlo Mansueto,â Giovanni Lipari,âĄ
William Mantovani,§ Elda Baggio,⥠Albino Poli,§ and Antonio
Lupo*
Clin J Am Soc Nephrol 6: 819â826, 2011. doi: 10.2215/CJN.06220710
125. Selecting the Appropriate Angioplasty Balloon
⢠Length
⢠Diameter
In general, high pressure balloons are used
for angioplasty of neointimal hyperplastic stenoses
Primary selection criteria :
126. 5.3 cm
4.5 cm
4.0 cm
DialEase
Arrow
Inner Lock
Vascular sheaths are color-coded
Vascular Sheaths for
Hemodialysis Access
Interventions
⢠short length
⢠high-flow sidearm
⢠¹ stopcock
127. The length of the angioplasty balloon should
extend ~ 5mm beyond each end of the stenosis.
PTFE
graft
3cm
Use 4cm length balloon
Minimize the length of balloon within normal vein.
Angioplasty damage the venous endothelium
and can incite neointimal hyperplasia.
129. If angioplasty fails, stents may be useful
in the following situations:
Indications for Stents
⢠Angioplasty-induced venous rupture
⢠Surgically inaccessible lesions
- central venous stenoses
136. Problem with Vascular AccessProblem with Vascular Access
⢠Not all patients are candidates for fistulas.Not all patients are candidates for fistulas.
⢠It has been reported that 30% of AVIt has been reported that 30% of AV
fistulas never mature or are able to befistulas never mature or are able to be
cannulated.cannulated.
⢠There are still a number of problemsThere are still a number of problems
associated with grafts.associated with grafts.
137. The Problem with GraftsThe Problem with Grafts
⢠Traditional vascular grafts are often complicatedTraditional vascular grafts are often complicated
by weeping during implantation.by weeping during implantation.
⢠Pseudoaneurysm formation after repeatedPseudoaneurysm formation after repeated
needle sticks, and poor or incomplete healingneedle sticks, and poor or incomplete healing
are common occurrences.are common occurrences.
⢠Ordinarily, grafts are cannulated anywhere fromOrdinarily, grafts are cannulated anywhere from
2 weeks to a month after implantation.2 weeks to a month after implantation.
138. The Problem with GraftsThe Problem with Grafts
⢠Bovine GraftsBovine Grafts
â Prone to aneurysms.Prone to aneurysms.
â When infected, tend to fall apart.When infected, tend to fall apart.
139. The Ideal Vascular Access GraftThe Ideal Vascular Access Graft
⢠Never clotsNever clots
⢠Never gets infectedNever gets infected
⢠Easy to implantEasy to implant
⢠Easy to cannulateEasy to cannulate
⢠Does not bleed after cannulationDoes not bleed after cannulation
⢠Never forms pseudoaneurysmsNever forms pseudoaneurysms
141. The Attempt to Achieve anThe Attempt to Achieve an
Ideal GraftIdeal Graft
⢠Grafts are now being designed specificallyGrafts are now being designed specifically
for vascular access and dialysis.for vascular access and dialysis.
⢠Advances in design and technology areAdvances in design and technology are
overcoming many of the problems seen inovercoming many of the problems seen in
some of the older grafts.some of the older grafts.
142. What is Flixene?What is Flixene?
⢠FLIXENE* is a next generation âcompositeFLIXENE* is a next generation âcomposite
graftâ.graftâ.
⢠This vascular graft has been engineeredThis vascular graft has been engineered
to overcome the major drawbacks ofto overcome the major drawbacks of
conventional grafts and is projected toconventional grafts and is projected to
become the new graft of choice.become the new graft of choice.
*Atrium Medical Corporation
143. Why Was Flixene Developed?Why Was Flixene Developed?
⢠Grafts are commonly placed in patientsGrafts are commonly placed in patients
who have no veins available for anwho have no veins available for an
autologous fistula because they have hadautologous fistula because they have had
many prior access procedures.many prior access procedures.
⢠Also many have spent inordinate time withAlso many have spent inordinate time with
double lumen catheters.double lumen catheters.
⢠Flixene is designed specifically for theseFlixene is designed specifically for these
patients.patients.
144. Why Was Flixene Developed?Why Was Flixene Developed?
⢠Grafts are usually placed in the forearm,Grafts are usually placed in the forearm,
upper arm or thigh.upper arm or thigh.
⢠What is unique about these areas?What is unique about these areas?
â Higher flowsHigher flows
â More difficult turns and bendsMore difficult turns and bends
â Which leads to more weepingWhich leads to more weeping
145. Why Was Flixene Developed?Why Was Flixene Developed?
⢠There is therefore a need for a graft thatThere is therefore a need for a graft that
will:will:
â Decrease weepingDecrease weeping
â Designed for better incorporationDesigned for better incorporation
â Can be cannulated within 72 hoursCan be cannulated within 72 hours
â Withstand needle sticksWithstand needle sticks
146. Whatâs Unique About Flixene?Whatâs Unique About Flixene?
⢠FLIXENE is a state-of-the-art PTFEFLIXENE is a state-of-the-art PTFE
vascular graft composed of three distinctvascular graft composed of three distinct
layers.layers.
⢠This layered design maximizes handling,This layered design maximizes handling,
strength, and implantation properties ofstrength, and implantation properties of
this graft.this graft.
147. Features of Flixene:Features of Flixene:
Superior ResistanceSuperior Resistance
⢠Compression ResistanceCompression Resistance
â More resistance than any non-helixed graft.More resistance than any non-helixed graft.
â More compression resistant than thin-wallMore compression resistant than thin-wall
ringed grafts.ringed grafts.
148. Features of Flixene:Features of Flixene:
Superior ResistanceSuperior Resistance
⢠Kink ResistanceKink Resistance
â Better than any non-helixed productBetter than any non-helixed product
⢠Torque ResistanceTorque Resistance
â Equal to the best in the industryEqual to the best in the industry
149. Features of Flixene: Non-WeepingFeatures of Flixene: Non-Weeping
⢠It has superior water entryIt has superior water entry
pressure (WEP)pressure (WEP)
⢠This tends to eliminatesThis tends to eliminates
blushing and weeping of theblushing and weeping of the
graft.graft.
150. Features of Flixene:Features of Flixene:
Comparative BenefitsComparative Benefits
0
50
100
150
200
250
300
350
Water Entry Pressure
Flixene
Graft A
Graft B
Graft C
151. Features of Flixene:Features of Flixene:
Improved StrengthImproved Strength
Impact of Cannulation on Radial Tensile Strength of
Vascular Grafts
168
131
113
84
62
46
27 20 15
0
50
100
150
200
0 10 20
Number of Punctures/CM
Lbsofforce
Flixene
Competetor A
Competetor B
152. Features of FlixeneFeatures of Flixene
⢠There is also an extra polyethylene sheathThere is also an extra polyethylene sheath
that covers the entire system and protectsthat covers the entire system and protects
the graft from coming into contact with thethe graft from coming into contact with the
skin and other items (Blue Transferskin and other items (Blue Transfer
Sleeve).Sleeve).
153. Summary:Summary:
The Goals of FlixeneThe Goals of Flixene
⢠Flixene was designed with the mostFlixene was designed with the most
complex dialysis patients in mind.complex dialysis patients in mind.
⢠Itâs layered design helps to minimizeItâs layered design helps to minimize
weeping.weeping.
⢠The graft also boasts excellent kink andThe graft also boasts excellent kink and
compression resistance.compression resistance.
154. Summary:Summary:
The Goals of FlixeneThe Goals of Flixene
⢠Decreased graft complications such asDecreased graft complications such as
seromas and pseudoaneurysms.seromas and pseudoaneurysms.
⢠Studies are in progress to evaluate theStudies are in progress to evaluate the
early stick potential of Flixene.early stick potential of Flixene.
⢠Early cannulation is perhaps the greatestEarly cannulation is perhaps the greatest
advantage for AV grafts.advantage for AV grafts.
⢠This decreases the time and need forThis decreases the time and need for
double-lumen catheter use and itsdouble-lumen catheter use and its
associated complications.associated complications.
164. Change in adjusted all-cause & cause-
specific hospitalization rates, by
modality
Figure 3.1 (Volume 2)
Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2005.
165.
166.
167.
168. Vein Preservation
⢠Do not access cephalic or basilic veins.
⢠Use dorsal hand veins.
⢠Avoid all subclavian access. 50% incidence of
stenosis after 2 weeks.
⢠10% incidence of stenosis with internal jugular
access.
169. Patient Evaluation for Long Term
Access
⢠Expected time of hemodialysis.
⢠Previous venous and arterial access. Previous
pacemaker placement.
⢠Arm dominance.
⢠Physical exam.
⢠Duplex ultrasound and venography.
⢠Minimal diameters:
⢠Artery 2mm.
⢠Vein 2.5mm.
171. Social cues
⢠Know your patient
â Who can/canât accept failure.
â Patient frustration/prior failed attempts in
secondary procedures
â Explain that all access ultimately failsâŚDuh?
â Take ownership of access
Only 25% of patients start HD with a permanent access.
As of 2007, 47% of patients had a fistula first.
R-C AVFâs have good patency, lower incidence of steal, stenosis, infection and perioperative morbidity
Disadvatages include 1-4 months of maturation, lower rate of flow, cosmetic concerns.
Basilic vein transposition has the highest incidence of steal, pain and swelling of all native fistulas.
Little data.
More complications and increased severity of complications.
Still preferable to catheters.
Huber, 30 patients.
Gradman 22 cases Excluded ABI &lt;85% or lack of pedal pulses.
Rule of 6s: 600 ml/min, 6 mm diameter, 6 mm under the skin.