the dialysis patient access kidney transplantation anne lally, md surgical director of kidney...

The Dialysis PatientThe Dialysis PatientAccessAccess

Kidney TransplantationKidney Transplantation

Anne Lally, MDAnne Lally, MDSurgical Director of Kidney Surgical Director of Kidney

TransplantationTransplantation

Hartford HospitalHartford Hospital

Dialysis options for renal Dialysis options for renal failurefailure

Dialysis Access Dialysis Access

• CathetersCatheters

• FistulasFistulas

• GraftsGrafts

• Peritoneal Dialysis Peritoneal Dialysis CathetersCatheters

Hemodialysis access Hemodialysis access optionsoptions

Dialysis CathetersDialysis CathetersTemporary and PermanentTemporary and Permanent

Tunneled CathetersTunneled Catheters

Several sites can be used:Several sites can be used: Right / Left Internal jugular veinRight / Left Internal jugular vein Femoral veinFemoral vein Subclavian Vein ( higher central v. Subclavian Vein ( higher central v.

stenosis )stenosis ) Rarely the IVC is accessed through the Rarely the IVC is accessed through the

translumbartranslumbar

or transhepatic approachor transhepatic approach

Perm CathPerm CathRight internal jugular vein Right internal jugular vein

preferred (more direct preferred (more direct route to heart)route to heart)

Perm Cath for Perm Cath for HemodialysisHemodialysis

Vascular AnatomyVascular AnatomyAVF and Forarm loopAVF and Forarm loop

Mature Wrist Mature Wrist Arteriovenous FistulaArteriovenous Fistula

Vein TranspositionsVein Transpositions

Additional ConsiderationsAdditional Considerations Cephalic and basilic veins not suitable on Cephalic and basilic veins not suitable on

mapping, consider the brachial vein. mapping, consider the brachial vein.

If brachial vein is suitable, do a two stage If brachial vein is suitable, do a two stage transposition because of the small size of the transposition because of the small size of the vein and the likelihood of injury.vein and the likelihood of injury.

One stage basilic or cephalic vein One stage basilic or cephalic vein transposition require an extended period of transposition require an extended period of maturation. Plan ahead.maturation. Plan ahead.

Strategies to Increase Autogenous Fistulae

Vein Transposition A-V FistulaeVein Transposition A-V Fistulae

SuperficializeSuperficialize

Safe position for cannulationSafe position for cannulation

Away from incisionAway from incision

Mature Basilic veinMature Basilic vein

Transposition of basilic Transposition of basilic veinvein

Angioplasty, stent Angioplasty, stent placementplacement

Covered intravascular Covered intravascular stentstent

Cryopreserved cadaver femoral vein

Use in patients with multiple failed access

Use in infected patients

Must reverse because of valves

Stenosis tend to be at the venous anastomosis in the cad vein

Cryopreserved cadaver femoral vein

We do not recommend percutaneous thrombolysis for this conduit.

Potential to increase a patient’s PRA and make transplantation more difficult.

Only have to match blood type, no immunosuppression.