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