Susanna Shin, MD, FACS, RPVI

Assistant Professor of Surgery

Division of Vascular Surgery, University of Washington

University of Washington Medical Center

Hemodialysis Access

DISCLOSURESusanna Shin, MD

• No relevant financial relationship reported

End Stage Renal Disease

• Chronic Kidney Disease– Stages 1-5

• Renal Replacement Therapy– Hemodialysis

– Peritoneal Dialysis

– Kidney Transplant

• Not just numbers– GFR < 15cc/min

• eGFR: calculated from creatinine age, body size and gender

– Weight loss, N/V, itching, fatigue/malaise, H/A, Confusion/LOC, SOB

Hemodialysis

• Renal Replacement Therapy

– Hemodialysis

– Peritoneal Dialysis

– Kidney Transplant

Hemodialysis

• Hemodialysis

– Center (vs Home)

– 3-5hours, 3days/week

– Fluid Removal (decreased BP common)

– Filtration of blood

Hemodialysis Access

• Arteriovenous Fistula (AVF)

– Direct connection between artery and superficial vein

– Superficial vein (cephalic or basilic) accessed with HD needles

• Arteriovenous Graft (AVG)

– Prosthetic material (ePTFE) between artery and vein

– Graft accessed with HD needles

• Tunneled Dialysis Catheter (TDC)

– Usually in Internal Jugular Vein or Common Femoral Vein

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk: AVF < AVG << TDC

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk

– Better long-term patency

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk

– Better long-term patency

– Relies on native veins

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk

– Better long-term patency

– Relies on native veins • Basilic and Cephalic Veins - often scarred

• No PIVs and Blood Draws

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk

– Better long-term patency

– Relies on native veins

– 8-12 weeks minimum usually for maturation

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk

– Better long-term patency

– Relies on native veins

– 8-12 weeks minimum usually for maturation • CKD 4 ESRD?

Hemodialysis Access

• Arteriovenous Fistula

– Less infection risk

– Better long-term patency

– Relies on native veins

– 8-12 weeks minimum usually for maturation

– Mature AVF: • ~6mm diameter

• <6mm from skin surface

• >600cc/min flow

• >6-10cm accessible

Hemodialysis Access

• Normal Anatomy

– Arteries

• Brachial

• Radial

– Superficial Veins

• Cephalic

• Basilic

Hu et al, 2016

Radial

Artery

Brachial

Artery

Basilic

Vein

Cephalic

Vein

Hemodialysis Access

Radiocephalic

AV Fistula

• Arteriovenous Fistula Types

– Radiocephalic

– Brachiocephalic

– Brachiobasilic with Basilic Vein Transposition

Hemodialysis Access

• Arteriovenous Fistula Types

– Radiocephalic

– Brachiocephalic

– Brachiobasilic with Basilic Vein Transposition

Hu et al, 2016

Brachiocephalic

AV Fistula

Hemodialysis Access

• Arteriovenous Fistula Types

– Radiocephalic

– Brachiocephalic

– Brachiobasilic with Basilic Vein Transposition

Hu et al, 2016

Brachiobasilic

AV Fistula,

transposed

Basilic Vein

Hemodialysis Access

• Arteriovenous Graft

– Firmer

– Radial, Brachial, Axillary arteries

– Straight vs Looped

Hemodialysis Access

• Arteriovenous Fistula/Graft Creation Considerations

– Non-dominant vs Dominant Upper Extremity

– Distal vs Proximal

– Cephalic vs Basilic

– >3mm vs <2.5mm

– Arm swelling

– Central vein stenosis

– Pacemaker/Port

– Blood pressure asymmetry/differential

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal • AVF/AVG “steal” blood from hand

• Higher Immediate Risk– Small stature

– Large vein

– AVG

• Symptoms– HAND/FINGER numbness, tingling, pain, cramping, weakness, wounds

• Treatment– Non-operative

– Ligation

– Surgical Revision (DRIL, PAI, RUDI)

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis• Inadequate dialysis

• Decreased Thrill

• Alarms– Low Flow

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis

– Recirculation• Arterial or Venous Stenosis

Hemodialysis

Machine

Arterial

cannula Venous

cannula

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis

– Recirculation

– Venous Stenosis• Pulsatile

• Prolonged bleeding

• High Pressure Alarm

• Aneurysmal AVF

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis

– Recirculation

– Venous Stenosis

– Aneurysm vs Pseudoaneurysm

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis

– Recirculation

– Venous Stenosis

– Aneurysm vs Pseudoaneurysm

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis

– Recirculation

– Venous Stenosis

– Aneurysm vs Pseudoaneurysm

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis

– Recirculation

– Venous Stenosis

– Aneurysm vs Pseudoaneurysm• ? Venous Outflow Stenosis

• ? Transplant

• ? High Flow

• ? Poor access technique

Hemodialysis Access

• Post-op/Surveillance Considerations

– Steal

– Arterial Stenosis

– Recirculation

– Venous Stenosis

– Aneurysm vs Pseudoaneurysm

– Ulceration• Rupture

• Infection

Hemodialysis Access

• Take Home Points

– Minimize time with TDC

– Protect native veins

– Alert Vascular Surgeon• Pulsatile AVF

• Weak thrill AVF

• Ulcerated skin

• Aneurysmal AVF

• Hand weakness, pain, cramping, new wounds

• Pressure alarms

• Prolonged bleeding after dialysis