Vascular Access for hemodialysis

1. 1

2. VASCULAR ACCESS IN
HEMODIALYSIS
Dr. IRFAN ELAHI
Consultant Nephrologist
Mayo Hospital Lahore
BY

3. 3
Native Arteriovenous fistula (AVF)
Prosthetic arterio-venous graft (AVG)
Cathater
Temporary double lumen cathater
Permanent Cathater
THERE ARE 3 TYPES OF VASCULAR
ACCESS

4. 4

5. 5

6. 6

7. A V GRAFTS
7

8. 8

9. 9

10. 10
Benefits of Arteriovenous Fistula (AVF)
Lowest rate of failures and complications
Longevity
Lowest costs
BENEFITS OF ARTERIOVENOUS FISTULA
(AVF)

11. 11
Definition
Process by which a fistula becomes suitable for
cannulation (ie, develops adequate flow, wall
thickness, and diameter).
FISTULA MATURATION

12. Rule of 6’s
In general, a mature fistula should:
Be a minimum of 6 mm in diameter with discernible margins 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
FISTULA MATURATION
12

13. 13
The fistula should be examined regularly following
surgery. At 4 weeks post surgery, the fistula should be
evaluated specifically for non maturation.
CLINICAL CLARIFICATION

14. 14
Look, listen, and feel the new AVF at every dialysis treatment
After the scar heals, begin assessing AVF using a “gentle”
tourniquet placed high in the axilla area
Instruct patient to start access exercises after healing
Document patient education as well as condition and
maturation of the AVF
DURING AVF MATURATION PROCESS

15. 15
Vessel diameter must be 4–6 mm
Vessel walls should toughen and be firm to the touch
There should be no prominent collateral veins
MATURING FISTULA

16. 16
TOURNIQUET

17. 17
IS NEW AVF MATURE AND READY
FOR CANNULATION?
AVF

18. 18
Vein looks large enough
Vein feels prominent and straight
Vein has a strong thrill and good bruit
IS AVF MATURE AND READY FOR INITIAL
CANNULATION?

19. 19
What diagnostic tools or techniques can be used
to determine if an AVF is ready for cannulation?
Can the same tools or techniques be used to
select the cannulation sites?
FISTULA MATURATION

20. 20
Duplex Doppler study
Physical exam by the:
Nephrologist
Nephrology nurse
Surgeon
Angiogram (fistulogram)
DIAGNOSTIC TOOLS/TECHNIQUES TO
DETERMINE IF AN AVF IS READY

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

22. 22
Physical Exam
Firm, no longer mushy
Vessel wall thickening
Vessel diameter enlargement (to 4–6 mm)
Absence of prominent collateral vein
If in doubt, “Just Say No”
MATURING FISTULA

23. 23
Look for
Changes compared to opposite extremity
Skin color/circulation
Skin integrity
Edema
Drainage
Vessel size/cannulation areas
Aneurysm
Hematoma
Bruising
INSPECTION

24. 24
Temperature Change
Warmth = possible infection
Cold = decreased blood supply
PALPATION

25. Thrill
PALPATION
25
Palpation can be started at the anastomosis
Thrill diminishes evenly along access length
Change can be felt at the site of a stenosis; becomes
“pulse-like” at the site of a stenosis
Stenosis may also be identified as a narrowed area

26. 26
Feel for Size, Depth, Diameter, and
Straightness of AVF
Feel the entire AVF from arterial anastomosis all the way
up the vein
Evaluate for possible cannulation sites = superficial,
straight vein section with adequate and consistent vein
diameter
PALPATION

27. 27
Listen for Bruit
Listen to entire access every treatment
Note changes in sound characteristics (bruit):
A well-functioning fistula should have a continuous,
machinery-like bruit on auscultation
An obstructed (stenotic) fistula may have a
discontinuous and pulse-like bruit rather than a
continuous one—and also may be louder and high-
pitched or “whistling”
Louder at stenosis than at anastomosis
AUSCULTATION

28. 28
Communicate assessment findings with access team,
including surgeon
Check maturity progress every session
Assure evaluation by surgeon 4 weeks post-op
Intervene if there is no progress at 4 weeks or AVF is not
mature and ready for cannulation at 6–8 weeks
POST-OP FOLLOW-UP

29. 29
Must have:
Physician’s order to cannulate
Experienced, qualified staff person who is successful with new
fistula cannulations
Use of a tourniquet or some form of vessel-engorgement
technique (e.g, staff or patient compressing the vein)
BASIC REQUIREMENTS FOR
CANNULATION

30. 30
17-gauge needle is strongly recommended for initial
cannulation
A fistula may appear and feel ready to cannulate, but the
vessel wall may still be fragile and unable to tolerate the
needle puncture
The smaller needle gauge helps to decrease injury to the
vessel and prevents a large infiltration, hematoma,
compression of the vessel, and possible clotting of the AVF
should any cannulation complication occur (ie, infiltration)
NEEDLE GAUGE

31. 31
MATCH NEEDLE GAUGE TO BLOOD
FLOW RATE (BFR)
Needle Gauge Maximum BFR
17-gauge < 300 mL/min
16-gauge 300-350 mL/min
15-gauge 350–450 mL/min
14-gauge > 450 mL/min

32. 32
USE BACK-EYE NEEDLES
Back-eye opening allows
blood intake from both
sides of the needle; can
be used as arterial or
venous needle
Non–back-eye
needle—for
venous use only
Arterial needle Venous needle

33. 33
BACK-EYE NEEDLE FLOW
Allows blood to
enter or exit from
both the bevel and back-eye

34. 34
Always cannulate the venous needle with the
direction of the blood flow
Always cannulate the arterial needle cannulation
toward the blood inflow or with the blood
outflow
NEEDLE DIRECTION

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Venous
needle
directed
back
toward the
heart
Arterial
needle
directed
toward the
arterial
anastomosi
s
(retrograde)
Needle Direction

36. 36
Venous
needle
directed
back
toward the
heart
Arterial
needle also
directed
back toward
the heart
(antegrade)
Needle Direction

37. 37
Always use a tourniquet, regardless of the size or
appearance of vessel
Use of the tourniquet helps to engorge, visualize, palpate,
and stabilize the AVF
Use 20–35° angle for needle insertion for an AVF
NEW AVF CANNULATION PROTOCOL

38. 38
“WET” NEEDLE

39. 39
On removal of needles, for hemostasis:
Use 2-finger compression
Never use clamps
Hold sites for 10 minutes—no peeking
NEW AVF CANNULATION:
ADDITIONAL POINTS

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Check fistula daily for a thrill and bruit
Check for signs and symptoms of infection or other
complications
Write instructions for fistula care
EDUCATION FOR PATIENTS

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Thrill is undetectable
Patient becomes feverish, dehydrated, or
experiences low blood pressure
CALL THE NEPHROLOGIST/PHYSICIAN

42. CANNULATION SITE SELECTION AND
PREPARATION
42

43. 43
Assess AVF before every cannulation
Compare arms for changes in skin color, circulation,
integrity
Inspect
Access extremity for central or outflow vein stenosis
Distal areas of extremity for steal syndrome
Access for vessel size, cannulation areas, infection,
aneurysms
PHYSICAL ASSESSMENT

44. PHYSICAL ASSESSMENT
44
Palpate
Temperature change may mean infection or stenosis
Change in thrill may mean stenosis
Auscultate
Listen to entire access for changes in bruit that indicate
stenosis

45. 45
Look and feel for a straight segment of AVF
Segment must be as long as the needle length (ie, 1″
minimum)
Stay at least 1.5 from the AVF anastomosis″
The arterial and venous needles need to be 1 to 1.5″ ″
apart
Avoid curves, flat spots, and aneurysms to prevent
complications
IDENTIFY IDEAL SEGMENT OF AVF

46. 46
Dialysis patients have more Staphylococcus spp (SA and
MRSA) on their skin and in their nares (nose) than the
general population
Dialysis staff can also have a higher rate of staph carriage
Common route of transmission of staph is from the nose
to the skin to the vascular access = infection
SITE PREPARATION

47. If possible, patient should
wash the access with
antibacterial soap before
coming to the chair
Staph is the leading cause
of infection in dialysis
patients
SKIN PREPARATION
47

48. 48
Proper needle-site preparation by both the patient and
staff reduces infection rates
Once the skin site is properly cleansed, the skin should
not be touched with bare hands or gloved hands
If touched, re-prep the skin
All site selection should be done prior to the final skin
preparation
SKIN PREPARATION

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Wet insertion site for 30 sec
Allow to air-dry for ≈30 sec
Do not blot or wipe
APPLYING CHLORHEXIDINE
GLUCONATE

50. 50
Saturate sterile gauze pad
Clean sites with circular motion
Wait 2 minutes before proceeding
APPLYING SODIUM HYPOCHLORITE

51. 51
Proper needle-site preparation
reduces infection rates
Start where you are going to
place the needle (the black dot)
and cleanse in a circular,
outward motion
Do not touch skin after cleansing
area
PROPER CLEANSING TECHNIQUE

52. 52
KDOQI Says
For all vascular accesses,aseptic
technique should be used for all
cannulation and catheter
incertion procedures (evidence)
SAYS WHO?
1. Locate, inspect and palpate the
needle cannulation sites prior to skin
preparation. Repeat prep if the skin is
touched by the patient or staff once
the prep has been applied, but the
cannulation not completed.
2. Wash access site using an
antibacterial soap or scrub and water.
3. Cleanse the skin by applying 2%
chlorhexidine gluconate/70%
isopropyl alcohol and/or 10%
povidone iodine as per
manufacturer’s instructions for use.
Notes:
 2% chlorhexidine gluconate/70%
isopropyl alcohol antiseptic has a
rapid (30 s) and persistent (up to 48
hr) antimicrobial activity on the skin.
Apply solution using back and forth
friction scrub for 30 seconds. Allow
area to dry. Do not blot the solution.

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Needle fear and pain with needle insertion are
very real issues for many hemodialysis patients
Various pain-control options can be utilized to
make the cannulation procedure less stressful for
patients
ANESTHETIC OPTIONS FOR
PAIN CONTROL

54. 54
Lidocaine injected under the skin and above the
vessel
Advantage: Numbs the area prior to the
cannulation procedure
Disadvantages: Can cause scarring,
vasoconstriction, keloid formation,burning
with injection, and poses a needle-stick risk
INTRADERMAL ANESTHETICS

55. 55
Topical sprays (ethyl chloride) can be used to numb the
skin sites
Advantage: Noninvasive method of numbing the skin
Disadvantages: Nonsterile, requires patient-specific
bottle to prevent cross-contamination, may discolor or
damage skin with long-term use, flammable contents in
bottle
Method: Spray arterial site, prep skin, then insert needle
immediately; repeat for venous site
TOPICAL SPRAYS

56. 56
Wash skin first
Apply 1 hour before dialysis
Cover with plastic wrap
Prior to cannulation, remove cream, wash/prep
skin
USING TOPICAL CREAMS

57. 57
Tourniquet required for all cannulations
Apply tightly enough to engorge vessel
TOURNIQUET USE

58. CANNULATION TECHNIQUES
55

59. 59
Site-Rotation
Also known as:
Rope ladder
Rotating sites
CANNULATION TECHNIQUES
Buttonhole
Also known as:
Constant-site
Same-site

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Take your time
Cannulation is achieved in a gentle manner
Determine the depth of the access during your
assessment—this will determine the angle of entry into
the fistula
IMPORTANT TIPS

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Cannulation sites are rotated up and down the
AVF to use its entire length
Classic technique used in most dialysis centers
SITE-ROTATION TECHNIQUE

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Look for straight areas of at least 1 for each cannulation″
site
If you try to “straighten out” by pulling on the vessel to
cannulate, the vessel will retract into its original position
when released and lead to an infiltration
Avoid aneurysms and flat or thinned-out areas
Stay 1.5 away from the anastomosis″
Keep the needles at least 1.5 apart″
Each treatment requires 2 new sites
LOCATING THE CANNULATION SITE

63. 63
Proper site-rotation
cannulation technique with
rotation of both venous and
arterial needle sites
Venous
site-rotation
cannulation
sites
Arterial
site-rotation
cannulation
sites

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Improper site-rotation
cannulation technique with
rotation of both venous and
arterial needle sites
Poor venous
site rotation
Poor arterial
site rotation

65. 65
“One-site–itis” occurs when
you stick the needle in the
same general area, session
after session
Causes aneurysm and stenosis
formation
“ONE-SITE–ITIS”
Practice of
repeatedly
puncturing
same area,
AKA
“one-site–itis”

66. 66
Caused by sticking needles in the same general area
Aneurysm can also result from stenosis beyond the aneurysm,
causing elevated back pressure
AVF ANEURYSM

67. 67
Watch the orientation of the needle bevel, and avoid
turning your wrist
If the bevel enters sideways, this can cause cutting of
the vessel and/or a sidewall infiltration
Use only a back-eye needle for the arterial needle
The venous needle can be back-eye or
non–back-eye
NEEDLE INSERTION

68. 68
Use of tourniquet should be mandatory
Stabilize vessel
Pull skin taut toward the cannulator
to allow easier needle insertion
(compresses nerve endings,
blocking pain sensation to the brain
for about 20 seconds)
THREE-POINT TECHNIQUE

69. 69
“L” TECHNIQUE
Hold thumb and index
finger as an “L”
Thumb holds
skin taut over fistula
Index finger stabilizes and engorges

70. 70
Rule of Thumb
20–35° angles for fistulae
45° for grafts
ANGLES OF ENTRY
Reality
Not every access fits the rule
of thumb; some AV fistulae
are very shallow and a lesser
angle can be used
You will need to carefully
assess the depth of the access
and adjust the angle of
cannulation accordingly

71. 71
Secure wings Sterile gauze or adhesive
bandage over insertion site
Chevron to prevent dislodging Additional tape as needed

72. 72
Prep skin prior to cannulation
Stabilize the skin and the AVF
PREPARING FOR CANNULATION

73. 73
Use an approximately 20–35°
angle of insertion depending
on the depth of the access
The angle is from the skin to
the needle hub
First, enter the skin and
tissue above the AVF vessel,
then the vessel
INSERTION OF NEEDLE

74. 74
Once the AVF vessel is
entered, the blood
flashback is visible in
the needle tubing
Level out and advance
the needle with very
minimal pressure
ADVANCING THE NEEDLE

75. 75
Do not “flip” or rotate
the bevel of the needle
180°
Flipping can lead to
stretching of the
needle-insertion site
and cause oozing during
the dialysis treatment
PLACEMENT IS CRUCIAL

76. 76
Apply gauze dressing without pressure
Remove needle at insertion angle
Apply pressure with 2 fingers
Do not use excessive pressure
Hold for 10–12 minutes, no peeking
Use stethoscope to check for bruit after applying dressing to stick
site
NEEDLE REMOVAL

77. 77
USE A STETHOSCOPE TO CHECK FOR
BRUIT

78. 78
Apply adhesive bandages
Dispose of needles in biohazard sharps container per
guidelines specified in the Occupational Safety and
Health Act (OSHA)
NEEDLE REMOVAL

79. 79
Pull needle completely from the vein before pushing down on
the needle site
Hold direct pressure for 10 minutes without “peeking”—no
exceptions
Do not use clamps unless absolutely necessary!
POST-TREATMENT HEMOSTASIS

80. 80
Method in which an individual cannulates the AV
fistula in the exact same spot, at the same angle
and depth of penetration every time
A scar tissue tunnel track develops, allowing for
the use of a buttonhole (blunt) fistula needle
BUTTONHOLE TECHNIQUE
Procedure

81. 81
May prolong AVF lifespan
Reduces pain, bleeding, infiltration, infection
Virtually eliminates missed cannulations
Promotes self-care and self-dialysis
Use blunt needles, which require no safety device
ADVANTAGES

82. 82
Requires same cannulator, same angle, same location
Concerns of “one-site−itis”
Difficult with fistula covered by:
Heavily scarred skin
Large amount of subcutaneous tissue
DISADVANTAGES

83. 83
AVF BUTTONHOLE TECHNIQUE
Buttonhole sites

84. 84
TWO BUTTONHOLE SITES
Buttonhole sites

85. 85
Change blunt needles once the track
is formed
Blunt needles prevent continued cutting of
the buttonhole track and new entry site of the AVF vessel
Blunt needles prevent infiltrations, bleeding from around the
needle sites, and resistance to the needle insertion into the
track and vessel
CHANGING TO BLUNT NEEDLES

86. 86
NEEDLES—SHARP AND BLUNT

87. 87
A ridge is starting to develop
A hole is starting to develop
This site is not yet ready for
a blunt needle
A DEVELOPING BUTTONHOLE

88. 88
Needle inserted into the
buttonhole tunnel track,
but the angle is not
aligned with the vessel
flap
The needle can bounce on
the vein and not displace
the vessel flap
BUTTONHOLE: WRONG ANGLE OF
INSERTION

89. 89
Adjust angle to find the
flap
Lift up and down on the
needle to readjust the
angle until the needle
drops into the vessel flap
BUTTONHOLE: ADJUSTED ANGLE OF
INSERTION

90. Causes
BUTTONHOLE: ADJUSTED ANGLE OF
INSERTION
90
Moving needle from angle used to enter the skin, arm
positioning not in routine place, or patient weight gain
or loss

91. 91
It may be possible to speed the development of buttonhole sites
by cannulating the sites every day
It is helpful to switch over to blunt needles as soon as possible
Long-term use of sharp needles will cut adjacent tissues,
enlarge the hole, and cause bleeding along the needle path
HELPFUL HINTS…

92. 92
If it is impossible to have only 1 cannulator, additional
buttonhole sites can be developed at the same time using a
second cannulator
If your patient is hospitalized and the acute hospital renal team
does not know how to access a buttonhole, they can:
Rotate sites using standard sharp needles as long as they stay
¾ away from the buttonhole tracks″
OR
Have the patient self-cannulate (if the patient has been
trained)
MORE HELPFUL HINTS…

93. 93
Plan outreach to the acute team and educate regarding
buttonhole technique
Continue access monitoring and surveillance, even if patient is
dialyzing
at home
Inform patients that laminated procedure cards and videos are
available
STILL MORE HELPFUL HINTS…

94. 94
Bleeding can occur around the needles during dialysis if:
You are using sharp needles and have cut
the track
The track has stretched because of trying to direct the needle
instead of following the track
You have made a new track and torn tissue
TROUBLESHOOTING THE BUTTONHOLE

95. 95
If, after the weekend, you have trouble with blunt
needles, switch to sharp needles for that day, being
careful not to cut the track
If a site is not progressing, it is acceptable to abandon
that site and find another site
TROUBLESHOOTING THE BUTTONHOLE

96. 96
Difficulty re-entering the fistula vein
Can occur when transitioning from sharp to blunt needles
The blunt needle “bounces” on the vessel and will not enter the
vessel
Corrective action: Change the needle angle slightly until the
vessel flap is located and needle drops into the vessel
If it persists, return to sharp needle for a few sessions and then
try blunt needle again
TROUBLESHOOTING THE BUTTONHOLE

97. COMPLICATIONS
95

98. 98
Bleeding during treatment (oozing around needle or
infiltration) = fragile vessel wall or back wall penetration;
don’t flip the needles
Bleeding post–needle removal = fragile vessel wall or
needle trauma or inadequate pressure at puncture sites
Review needle-removal technique. Improper pressure with
needle withdrawal = vessel damage
BLEEDING

99. BLEEDING
99
A pattern of prolonged bleeding post–needle removal
may indicate stenosis or clotting disorder. Evaluate bleeding
after 20 minutes
Educate patients about post-treatment hemostasis and what to
do at home should the needle site re-bleed

100. 100
INFILTRATION = HEMATOMA

101. 101
Don’t flip needle
Don’t lift needle in vein
Flush with NSS
PREVENT CANNULATION
INFILTRATIONS

102. 102
Apply gauze without pressure
Remove needle at insertion angle
Apply pressure with 2 fingers
Hold pressure 10–12 minutes
PREVENT POSTDIALYSIS INFILTRATIONS

103. 103
Elevate arm above heart
Ice 20 minutes on/20 minutes off for 24 hours
Warm compresses after 24 hours
Let fistula rest
Second infiltration: Notify vascular access team
Don’t use AVF until directed
TREATING INFILTRATIONS

104. 104
If the fistula infiltrates, let it “rest” until the swelling is
resolved ( KDOQI Guidelines)
If the fistula infiltrates a second time, the RN should
notify the vascular access team, including the surgeon,
as soon as possible for intervention
Don’t use that AVF until further directed
INFILTRATIONS IN NEW AVF

105. 102
Check for flashback and aspirate
Flush with NSS to ensure the needle flushes with ease
and there are no signs or symptoms of infiltration
Saline causes much less damage and discomfort than
blood if an infiltration occurs
HOW TO PREVENT INFILTRATIONS

106. 106
If bruising or hematoma occurs
after dialysis, the surface skin site
has sealed but the needle hole in
the vessel wall has not
Use 2 fingers per site for
hemostasis
It is crucial to apply pressure to
both the skin and access wall
POST-CANNULATION BRUISING AND
HEMATOMA

107. 107
May be due to location or position of needle(s)
May need to change direction of arterial needle
If poor flow persists after next session despite changing needle
locations, refer to surgeon for evaluation and possible treatment
options
Use tourniquet for cannulation only!
Do not leave in place for entire treatment!!!
POOR FLOW

108. 108
Caused by stenosis as
vessel narrowing increases
“back pressure,” causing vessel
distension and weakening of
vessel wall
May also be causedor
aggravated by frequent
cannulations in the same
area
ANEURYSM

109. 109
Most common complication
Causes:
IV, CVC, lines
Surgery to create AVF
Aneurysms
May be caused by the back pressure associated with
stenosis
Needle-stick injury
STENOSIS

110. 110
Frequent cause of
early fistula failure
Juxta-anastomotic
stenosis most
common
STENOSIS
Stenosis

111. 111
Juxta-anastomotic (most
common stenosis in AVF)
Mid-access
Outflow
Central vessel
TYPES OF STENOSES
Outflow
Central-vein
Mid-access
InflowForearm
AVF

112. 112
CENTRAL-VEIN STENOSIS

113. 113
DISTENDED, OBSTRUCTED LEFT
SHOULDER VEINS INDICATIVE OF
CENTRAL-VEIN STENOSIS

114. 114
Clotting of the extracorporeal circuit 2 or more
times/month
Persistently swollen access extremity
Changes in bruit or thrill (ie, becomes pulse-like)
Difficult needle placement
Blood squirts out during cannulation
Elevated venous pressures
CLUES TO STENOSIS

115. 115
Excessively negative pre-pump AP
Decreased blood pump speeds
Inability to achieve BFR
Changes in Kt/V and URR
Recirculation
Prolonged postdialysis bleeding
Frequent episodes of access thrombosis
CLUES TO STENOSIS

116. 116
Surgical/technical problems
Preexisting anatomic lesions (eg, old IV injury)
Premature use
Poor blood flow
Hypotension
Hypercoagulation
Fistula compression
THROMBOSIS

117. 117
AV fistulas have lowest risk of infection of any vascular access
type. However…
Each pre- and post-treatment exam should include:
Checking for signs/symptoms of infection, including:
Changes of skin over access area
Redness
Increase in temperature
Swelling, hardness
Drainage from incision, needle sites
Tenderness or pain
INFECTION

118. INFECTION
118
Patient complaints without other indications of
Malaise
Fever

119. 119
Prevention
General hygiene
Pretreatment washing of access extremity
Hand washing, before and after cannulation
No scratching, irritation of skin of access extremity
Precannulation
Appropriate skin antisepsis
Sufficient antiseptic-skin contact time
Cannulate while antiseptic is wet or dry, as directed
Cannulation
Maintain needle sterility
Do not cannulate through scabs or abraded areas
PREVENTION OF INFECTION

120. 120
Steal syndrome is a constellation of symptoms related to
ischemia (inadequate blood supply to the hand) caused by
the AVF “stealing” blood away from the extremity
Steal causes hypoxia (lack of oxygen) to the tissues of the
hand, resulting in severe pain and identified by nail bed
discoloration, a cool hand, and a weak or absent pulse
STEAL SYNDROME/ISCHEMIA

121. STEAL SYNDROME/ISCHEMIA
121
Neurological and soft tissue damage to the hand can occur,
resulting in mobility limitations (eg, grip strength, dexterity),
loss of function, ulcerations, necrosis
Steal syndrome/ischemia is estimated to occur in
approximately 5% of vascular access patients, mostly those
with diabetes and peripheral vascular disease (PVD)

122. 122
“CLAW HAND” CONTRACTURE FROM
STEAL SYNDROME

123. 123
Steal symptoms may improve due to the development of
collateral circulation
Procedures, such as the DRIL (distal revascularization-interval
ligation), can successfully treat steal and ischemia
Individuals who are at high risk for developing acute steal are:
Patients with diabetic neuropathy
Patients with PVD
STEAL SYNDROME/ISCHEMIA

124. 124