Discussion: Del Rosario, Ma. Athena C

DISCUSSION
DEL ROSARIO, MA. ATHENA C.

VASCULAR ACCESS
• A surgically created vein used to remove and
return blood during hemodialysis
• A vascular access lets large amounts of blood

flow continuously during hemodialysis
treatments to filter as much blood as possible
per treatment.
National Institute of diabetes and digestive and kidney diseases (NIDDK) – 2014
Ideal Vascular Access
• Easy to construct
• Easy to cannulate
• Long lasting
• Good blood flow in all ports
• Less prone to infection, thrombosis, etc.
NKF KDOQI Clinical Practice Guidelines for Hemodialysis Vascular Access (2006) – 2015 Update
KDOQI Guideline
• FISTULA FIRST
• Avoid using catheters.
• Nontunneled catheters – only for temporary access and

emergency situations
• Catheters have much higher incidence of infection than AV

Fistula and AV Graft.
• Tunneled catheters – used as access while patient is waiting for

fistula to mature (8-12 weeks).
Types of Vascular Access
• Arteriovenous (AV) fistula
– a connection, made by a vascular surgeon, of an
artery to a vein.
• AV Graft
– is a piece of artificial tubing, generally made out of
teflon or fabric, that is attached on one end to an
artery, and the other end to a vein.
• Venous catheter
– a plastic tube which is inserted into a large vein,
usually in the neck
ARTERIOVENOUS (AV) FISTULA
• Preferred dialysis access:
– Provides good blood flow for dialysis
– Longer lasting
– Lower incidence of associated morbidity and
mortality
• Approximately 8-12 weeks are required for an
AVF to mature completely
Anatomy of upper extremity vessels
Vachharajani, TJ. (2010). Atlas of Dialysis Vascular Access. Wake Forest University School of Medicine.
Radiocephalic AV fistula (Brescia-Cimino)
Snuff-box Arteriovenous Fistula
Brachiocephalic AV fistula
Proximal forearm AVF
Transposed Basilic Vein AVF
The common problems associated with an AVF are:
• Poor or delayed maturation

• Infiltration and hematoma formation during hemodialysis secondary
to improper cannulation technique
• Stenosis at the “swing site,” the segment of the vein mobilized for
arterial anastomosis in the creation of an arteriovenous fistula
• Stenosis due to neo-intimal hyperplasia, eventually leading to
thrombosis
• Aneurysmal dilatation either due to vessel trauma from frequent
needle punctures and/or a proximal stenosis
• Infection
• Steal syndrome due to ischemia of the distal extremity
• High output congestive heart failure from large arteriovenous fistula
• Central vein stenosis
Hematoma formation
“Swing site” stenosis

Aneurysm
Central Vein Stenosis
Steal syndrome
Red hand syndrome
ARTERIOVENOUS (AV) GRAFT
• Second best option for hemodialysis
• The forearm loop, upper arm straight and
thigh loop grafts are commonly utilized
configurations for creating a dialysis access
• It can in general be used 2 – 3 weeks after the
operation
• The lifespan of an arteriovenous graft is
approximately 2 - 3 years.
Forearm Loop
Upper Arm Straight
Thigh loop graft
The common problems associated with an AVG:
• Venous anastomotic stenosis from neo-intimal

hyperplasia
• Development of pseudoaneurysms
• More prone to infection and clotting
• Central vein stenosis, especially with history of
multiple central venous catheters
Pseudoaneurysms Venous outflow stenosis
NON TUNNELLED CATHETER
• Emergent temporary
access for hemodialysis
• 3 common sites
– Internal jugular vein
– Femoral vein
– Subclavian vein
EG Clark and JH Barsuk. (2014). Temporary catheters: recent advances. Kidney International. 86: 888 - 895
NONTUNNELED
NONCUFFED CATHETERS
Short and more ridged.
Easy and fast insertion.
Immediate use.
Higher infection rate.
Preferred IJ or femoral.
Avoid subclavian.
© 2013 C. R. Bard, Inc. Used wit h permission. Bard, are trademarks and/or registered trademarks of C. R. Bard, Inc.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology,.ASN. 361-375. 2009
Timing of Dialysis with Temporary Catheters
• KDOQI (Kidney Disease Outcomes Quality

Initiative) guidelines suggest that non-
tunneled hemodialysis catheters should NOT
be used for:
– More than 1 week at the IJ or SC sites
– More than 5 days at the femoral site
TUNNELLED CATHETER
• 3rd choice of access for hemodialysis
– Preferred site: Right IJ vein
– Other sites: left IJ vein, femoral vein
– Subclavian vein rarely used because of inc. risk of
central vein stenosis
• Rarely, tunneled catheters are placed in the
inferior vena cava by translumbar or
transhepatic approach
Left-sided and Right-sided Catheter
Potential complications of venous catheters are:
• Malfunction due to mechanical causes like

– Poor placement technique
– Retraction with or without exposure of the cuff
– Cracked hub or broken clamps
– Thrombosis/Fibrin sheath formation
• Infection
– Exit site
– Tunnel infection
• Central vein stenosis
Kinked catheter Malpositioned tip
Catheter tip Retraction

Thrombosis
Fibrin sheath formation
Exposed cuff
Exit site infection
Catheter vs. AVF vs. AVG
• Incidence of Infection: Catheter >AVG >AVF
• Incidence of Thrombosis: AVG >AVF
Early recognition of venous catheterization complications is important
to prevent:
• Loss of the vascular site if the catheter falls out

• Inadequate dialysis clearance
• Bacteremia- and sepsis-related morbidity and
mortality
Advice vascular access protection:
• Check the access for signs of infection or problems with blood
flow before each hemodialysis treatment, even if the patient is
inserting the needles.
• Keep the access clean at all times.
• Use the access site only for dialysis.
• Be careful not to bump or cut the access.
• Check the thrill in the access every day.
• Watch for and report signs of infection, including redness,
tenderness, or pus.
• Do not let anyone put a blood pressure cuff on the access arm.
• Do not wear jewelry or tight clothes over the access site.
• Do not sleep with the access arm under the head or body.
• Do not lift heavy objects or put pressure on the access arm.

Discussion: Del Rosario, Ma. Athena C

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Discussion: Del Rosario, Ma. Athena C

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DISCUSSION

DEL ROSARIO, MA. ATHENA C.

• A vascular access lets large amounts of blood

• Nontunneled catheters – only for temporary access and

• Catheters have much higher incidence of infection than AV

• Tunneled catheters – used as access while patient is waiting for

• Poor or delayed maturation

“Swing site” stenosis

• Venous anastomotic stenosis from neo-intimal

• KDOQI (Kidney Disease Outcomes Quality

• Malfunction due to mechanical causes like

Catheter tip Retraction

Fibrin sheath formation

Exit site infection

• Loss of the vascular site if the catheter falls out

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