surgical management of dialysis access

SURGICAL MANAGEMENT OF DIALYSIS ACCESS

STEVE WORATYLA, MDSURGICAL SPECIALISTS OF LANCASTER

TYPES OF ACCESS FOR DIALYSIS

1. CENTRAL VENOUS CATHETERS TEMPORARY TUNNELLED (CUFFED)

2 ARTERIAL VENOUS GRAFTS PROSTHETIC

PTFE (GORTEX) VECTRA (immediate access) HeRO graft

BIOPROSTHESIS BOVINE CAROTID ARTERY

3. ARTERIAL VENOUS FISTULAS

4. PERITONEAL CATHETERS

THE CREATION AND MAINTENANCE OF A DIALYSIS ACCESS IS CRUCIAL TO THE ONGOING CARE OF A

PATIENT WITH END-STAGE RENAL DISEASE

Peritoneal Dialysis

Historical Background

Era of modern dialysis began in the 1960’s with the creation of the radio-cephalic av

fistula

Modern hemodialysis access consists of a well created autologous AV fistula

Use best vein and best artery available Usually upper extremity (vein map preop) Cephalic vein and Basilic vein Radial artery and Brachial artery Start distal and work proximal in the arm

Requires 6-8 weeks for maturation Allows vein to dilate and thicken 80-85% success rate (supports dialysis)

May be improved with aggressive followup program Physical exam, ultrasound, Fistulogram

Maturation Process

National Kidney FoundationKidney Disease Outcome Quality Initiative

1997 and 2006

2/3’s of Hemodialysis patients should have AV fistula

Lower cost Lower morbidity Lower mortality

Types of AV Fistulae Nomenclature : Artery-Vein

Radial-Cephalic Radial-Basilic Brachial-Cephalic Brachial-Basilic Brachial-Brachial

Transposing Vein to more superficial and accessible location Basilic Veins Deep Veins

Radial-Cephalic AVF

Brachial Cephalic AVF

Brachial Basilic AVF

Surgical Technique

AV Grafts Brachial artery to

antecubital vein Forearm loop graft

Radial artery to antecubital vein

Brachial artery to Axillary vein

Axillary artery to Axillary vein

Dialysis Catheters

Dialysis Catheters(HeRO Catheter)

How Does Hemodialysis Work

How Does Hemodialysis Work

AVF Complications/Problems

Thrombosis Stenosis Pseudoaneurysm Infiltration Infection Bleeding Poor maturation Tortuosity Depth of AVF Steal syndrome

AVF Maintenance

AVF Maintenance

Steal Syndrome

Steal Syndrome

Conclusions Autologous AV Fistula is best

Requires good communication and planning between Nephrologist, Patient, and Surgeon

Peritoneal dialysis catheter is viable alternative to hemodialysis in most patients Requires more active patient involvement

Avoid CVC’s and PICC’s Central venous stenosis is achilles heel of

upper extremity AV access