VASCULAR ACCESS

• the vascular access is the Achilles heel for the hemodialysis (HD)
patient
• All vascular accesses are subject to the development of stenosis that
contributes to inadequate blood flow and a shortened life span from
thrombosis
• KDOQI guidelines and
Surveillance: use of instruments to measure blood flow or intra-access
pressures
Monitoring: using physical examination (PE) or clinical indicators to
detect vascular access stenosis
Vascular Access : Types

• AV fistula
• AV graft : AV bridge made up of polytetrafluoroethylene (PTFE)
• Venous Catheters
Cuffed
Non-cuffed
Maturation of Fistula: 6 to 8 weeks

Increased Blood Flow

Dilatation of artery & vein

• Dilatation of vein ease cannulation

Pressure and flow induced thickening of vein

• Strengthens the fistula
• Prevents tearing and extravasation

A well-functioning fistula remains the preferred access compared to a graft due to a

fistula’s lower incidence of infection, higher patency rates, and overall better patient
survival.
Neointimal hyperplasia : AV Graft
• Hyperplasia at the venous anastomosis  obstructs the lumen of the
downstream vein  poor flow & prolonged bleeding  THROMBOSIS

• Occurs due to
turbulence downstream to the graft–vein anastomosis
compliance mismatch rigid (graft) and flexible (vein)
Fistula First Policy (KDOQI, 2006)
• Fistula First” initiative to promote construction of AV fistulas,
targeting at least 68% use in prevalent patients on dialysis

• After implication of the policy incidence of AV Fistula 26%  61%

• “Fistula first and Catheter last” policy : urgent start peritoneal dialysis

• KDOQI 2018 Update : ESKD Life Plan

VESSEL PRESERVATION
• minimize venipunctures and placement of peripheral infusion lines in
the upper extremity, especially in the cephalic and antecubital veins
of either arm. The veins on the dorsum of the hand should be used
whenever possible
• risk of subsequent central vein stenosis, the subclavian vein should
not be cannulated

• Wristbands bearing the inscription: “Save Veins • No IV / LAB Draws.

ARTERIOVENOUS ACCESS PLANNING
• CKD patients with eGFR: <30 mL/min : Counselling for RRT
• AV Fistula : 6 months prior to anticipated HD initialtion
PREOPERATIVE EVALUATION
• h/o : previous central vein catheterisation
• Exam
• All peripheral pulses
• BP in both arms normal if <10 mm Hg, borderline if 10–20 mm Hg, or
problematic if >20 mm Hg USG Doppler
• Allen Test
 Venous mapping
• Doppler Ultrasound  Minimum Vein Diameter: 2.5 mm
 Minimum Arterial Diameter : 2.5 mm
• Venography  Vein Dilatation Test : 50% Dilatation after tourniquet
 Artery Dilatation Test
• Arterography
In elderly patients with poor blood
vessels getting the perforating vein
elbow fistula, fistula patency rate
at 24 months was an impressive
78%.
• AV Fistula in leg : Rare

 Superficial Femoral Artery Femoral Vein

Popliteal Artery Saphenous Vein to the

• Steal due to fistula on the same side as an internal mammary artery–

coronary artery bypass graft.
OPERATIVE PROCEDURE FOR AN AV
FISTULA
Side (artery) to Side (vein) Side (artery) to End (vein)

Transfer of higher pressure to distal vein

RED HAND SYNDROME
Venous Hypertension : distal vein preserved Venous Hypertension: Less: distal vein
ligated

• modified “piggyback SLOT technique: Less juxtaanastamosis stenosis

• The radial artery normally has a flow rate of 20–30 mL/min, and this flow increases to
200–300 mL/min immediately after creation of the anastomosis
PERIOPERATIVE CARE AND FISTULA
MATURATION
RULE OF SIXES
perform arm exercises for several weeks prior to surgery
Maturation 6 weeks
Following surgery, the arm should initially be kept elevated Vein Diameter 6 mm
Tight circumferential dressings should be avoided Below The Skin 6 mm
Hand exercises (e.g., squeezing a rubber ball or a soft handgrip device) may help Blood Flow 600 mL/min
increase fistula blood flow and pressure, and are believed by some to assist with the
Straight Segment 6 cm
maturation of an AV fistula; a concept that has never been confirmed in a randomized
trial.
For Cannulation

The fistula should never be used for venipuncture. Fistula blood flow should be
checked daily
fistula maturation
• premature attempts to cannulate it can be associated with infiltration,
compression of the vessel, and permanent loss of the fistula
• Primary maturation failure of an AV fistula can result from an
atherosclerotic artery, inadequate anastomosis, or an inability of the
artery and/or vein to dilate due to vessel damage, multiple tributary
branches in the vein draining the AV fistula
• If a fistula cannot be cannulated or support dialysis therapy ≥6 weeks
after placement, an imaging fistulogram should be obtained to
determine the source of the problem.
INITIAL TRIAL CANNULATION OF A
NEW AV FISTULA
• initial trial cannulation should be done on a nondialysis day: Obviates heparin use

• Wet needle” technique: To ensure that the needle is placed properly, needle placement should be
confirmed with a normal saline flush before connecting the needles to the blood pump and starting
the pump

• Needle with a “backeye.” A needle with a backeye should always be used for the arterial needle to
maximize the flow from the access and reduce the need for flipping the needle

• Needle size selection: 17G or a 16G needle

• Prepump arterial pressure should not exceed −250 mm Hg. Based on performance of the fistula
using a 17G needle,
Initial cannulation procedure
• Apply a tourniquet to the access arm.
• Disinfect the access site per unit protocol.
• Attach a 10-mL syringe filled with 8 mL of normal saline solution to the needle, but do not prime the needle
until immediately before the cannulation.
• Grasp the needle by its butterfly wings and prime the needle with normal saline until all the air has been
purged. Clamp the needle closed. Remove the protective cap and immediately proceed with the cannulation.
• Carefully cannulate the fistula using a 25° insertion angle. When blood flashback is observed (the needle may
need to be unclamped to see the blood flashback), flatten the angle of the needle, parallel to the skin, and
advance it slowly into the fistula lumen.
• When the needle is in the vessel, remove the tourniquet and tape the needle securely per unit protocol. If blood
flashback is visible, aspirate back 1–5 mL with the 10-mL syringe.
• Flush the needle with the normal saline solution and clamp. The syringe must aspirate and flush with ease.
Monitor for signs or symptoms of infiltration. Patients usually experience immediate sharp pain upon infiltration
of saline or blood into the tissues.
• Repeat steps 1–7 for the second needle unless blood return via a venous catheter is planned
• One needle technique with return using a venous catheter
For the first 2 or 3 treatments, the blood can be returned via the
venous catheter
• The manner in which needles are inserted affects the long-term patency and
survival of AV fistulas.
• The “ladder” or rotational approach uses the entire length of the access
without localizing needle sticks to any two areas. Grouping needle sticks in
one or two specific areas can weaken the wall of a fistula, producing an
aneurysm
• Buttonhole cannulation tips:
The AV fistula is always punctured through a limited number of sites, the use
of which may be rotate
The needle must be placed precisely through the same needle tract used
previously
• Buttonhole cannulation requires strict adherence to proper infection control measures as well as
technique to prevent serious infection and technique-related complications

• Employ proper buttonhole cannulation procedure steps (skin prep, proper scab removal, re-prep of the
skin, and proper use of blunt needles

• Use the needle wings to help guide the needle gently into the skin and vessel or conduit—excessive
pressure prevents feedback to the cannulator’s fingers to feel resistance

• Always cannulate the buttonhole under consistent conditions; if a tourniquet was used to establish the
buttonhole, it should be used consistently, as otherwise the tissues in the buttonhole tract may not align
• Consider the patient as a self-cannulation candidate. Benefits can include patient empowerment, less
pain, and ease of cannulation, as the patient has to master cannulation of only his or her own specific
access
Hemostasis postdialysis
• Following needle removal, direct pressure over the site, usually with
the tip of one or two fingers pushed firmly but not so hard as to
occlude flow, is the best method for achieving hemostasis
• One must prevent hematoma formation at the access site while
controlling bleeding at the skin exit site.
• Pressure must be held for at least 10 minutes before checking the
needle site for bleeding. Adhesive bandages should not be applied
until complete hemostasis has been achieved.
• Prolonged bleeding (>20 minutes) may indicate increased intra-access
pressure due to an unsuspected outflow stenosis
AV Fistula: Exam
• The purpose of the vascular access examination is to detect immaturity
or dysfunction so that early referral for correction can be made
• Delayed diagnosis of dysfunction often leads to inadequate HD and
complications such as hematoma formation, development of large
aneurysms, and thrombosis
• Only a small portion of the arteriovenous fistula (AVF) circuit is
available for PE (5–10 cm)
• The circuit begins in the left heart carrying blood through the arteries
feeding the AVF and blood is returned through the draining veins to
end up in the right heart
• Beathard method of PE of the vascular access can be conveniently
divided into
inspection (look),
palpation (feel), and
auscultation (listen)

• The best time to do a PE is before HD prior to cannulation of the AVF

• The AVF is arbitrarily divided into the inflow, body, and outflow
segments.
• The inflow consists of a portion of the feeding artery adjacent to the
anastomosis, the artery–vein anastomosis, and the juxta-anastomotic
segment (2 cm downstream from the arterial anastomosis)
• The body is the next 5–10 cm (7–12 cm from the arterial anastomosis)
from the inflow segment and is the portion cannulated for HD
• The outflow segment is the remaining portion of the AVF extending
from the body of the AVF to the central veins. This segment is usually
deep, and lesions here are located proximal relative to location in the
arm
• Aneurysms are significant dilations or bulges in the AVF at least three
times the size of a minimal AVF diameter of 6mm (>18mm). They are
true aneurysms when the wall of the aneurysm is the vein wall and
pseudo-aneurysms when blood exits from the AVF through a
perforation with soft tissue over the AVF forming the aneurysm wall

• Accessory veins exit the AVF in the inflow or distal segment of the AVF
and are of such caliber (one third to half the AVF diameter) that they
compromise AVF maturation
• An immature AVF is defined as not reaching minimal Doppler
ultrasound criteria (diameter >5 mm, Doppler ultrasound blood flow
>500 mL/min) or cannot be used for HD for reasons such as difficult
cannulation or the inability to achieve adequate blood flow
Inspection
 Swelling arm  ipsilateral subclavian vein stenosis
chest and arm on the side of the
 Swelling of the arm and face  ipsilateral BC vein stenosis
AVFs
 Swelling of both arms and face  SVC stenosis

Long scars in the forearm or upper arm  transposed AVF

Arm Raising Test: Complete collapse  No significant outflow stenosis

: No collapse  Outflow stenosis / High flow AVF
: Partial collapse  Stenosis at the junction of the collapsed and prominent segments of the AVF

ANEURYSM: Body of AVF

Unstable Aneurysm: Pain, Enlargement, and Skin  Risk for Rupture  Surgical Intervention

Ipsilateral hand and fingers: R/o access-related ischemia

Constant hand pain, numbness, discoloration, cyanosis, gangrene of the finger tips, and digital contractures
Palpation
• Start Arterial end  Veinous end
• Pulsatile AVF suggests a stenosis in the outflow segment
• Pulsatile immature AVFs should not be cannulated as they form
significant hematomas when the HD needles are removed due to high
intra-access pressure
• Thrill: No thrill or a short systolic thrill will be felt in the pulsatile
portion of the AVF, and a continuous systolic–diastolic thrill will be felt
beyond the stenotic segment.
Augmentation Test
• Compression of the distal segment of the AVF 2–3 cm proximal to the
arterial anastomosis and palpation between the arterial anastomosis
and the occluding finger should result in the arterial pulse being
transmitted into the AVF resulting in normal augmentation of the
pulse
• Poor augmentation in an immature AVF suggests a juxta-anastomotic
or arterial stenosis
• The “1-min” AVF exam combines the Arm Raising Test and
Augmentation Test to detect outflow and inflow stenoses,
respectively
• Some immature AVFs have large accessory veins that emerge from the segment of
the AVF close to the arterial anastomosis and divert blood from the main access
channel
• In the obese, the veins are deep and cannot be seen

Sequential Occlusion Test is done to detect accessory veins

• The AVF is sequentially occluded from the arterial to the venous end at 1-cm
intervals followed by palpation between the occluding finger and the arterial
anastomosis. The AVF will be pulsatile when the occluding finger is distal to the
accessory vein and no thrill will be felt by the palpating finger. Once the occluding
finger is proximal to the accessory vein, the palpating finger will feel a thrill
suggesting the presence of an accessory vein.
Auscultation
• The normal mature AVF has a continuous bruit that can be heard in
systole and diastole. The bruit is loudest near the arterial
anastomosis. The presence of a stenosis results in a high-pitched
predominantly systolic bruit distal to the stenosis followed by a return
of the normal bruit proximal to the stenosis

• https://videopress.com/v/jESwLNba
AV GRAFT

1. Made from PTFE: 4. Long Term Patency Low

Polytetrafluoroethylene

2. Early Use/ 2–3 weeks

Short maturation time

3. Surface area for Large

cannulation
PTFE hYbRiD
VENOUS CATHETERS
• Bridge till a permanent access.

• the potential acceptability of venous catheter access for chronic

dialysis in some elderly patients, especially those with comorbidities
and limited expected life span (Drew and Lok, 2014).

• Infection rates with venous catheters in elderly patients (>75 years)

are relatively low, one-third that in younger patients (Murea, 2014).
Adherence to hand washing and catheter-care protocols
 INDICATIONS
Uncuffed Acute setting Temporary HD: AKI/PD/Tx
(Few weeks Infections) overdose or intoxication
Cuffed (Dacron)/Felt Low catheter migration Plasmapheresis
Low risk of infection CKD needing urgent hemodialysis

Antiseptic impregnation

NO SUBCLAVIAN

Central Venous Stenosis: 40%

subclavian artery perforation
brachial plexus injury
pneumothorax
FEMORAL PREFERRED

• acute pulmonary edema

• PS Infection risk with femoral catheters is increased in obese patients
(BMI > 28 kg/m
• When femoral catheters are used, the length must be sufficient
(usually at least 20 cm) so that the tip is in the inferior vena cava to
permit better flow and to minimize recirculation.
Complications of a venous catheter
Infection
Poor Flow
Thrombosis
Central Venous Stenosis
Catheter adhesion
Post clamp fracture
INFECTION EXIT SITE TUNNEL CLABSI/CRBSI
Site Limited to exit site Tunnel Systemic symptoms
T/t Topical antibiotic IV Antibiotic IV Antibiotic
Oral antibiotic
Removal Not Required Required Required
Catheter-related bloodstream infection
(CRBSI)
• Patients present with signs and symptoms of systemic infection.
• Mild (fever or chills), Severe (hemodynamic instability)
• Patients may develop septic symptoms after initiation of dialysis,
suggesting systemic release of bacteria and/or endotoxin from the
catheter.
• There can be signs of metastatic infection, including endocarditis,
osteomyelitis, epidural abscess, and septic arthritis
• Gram-positive organisms are the causative organisms in the majority
of cases, but gram-negative infections occur in a very sizeable minority
Ix C/s Catheter Removal t/t

Blood drawn from 2 sites • Peripheral Vein Coagulase(-) Not necessary 10-14 days
• Catheter hub Staph
• Blood line during dialysis Gram negative Not Necessary 10-14 days
• Catheter tip (distal 5 cm)
CRBSI If C/S from both positive for a single Staph aureus Remove 3 weeks
organism (If TEE negative)
Fungal Guidewire 14 days after
exchange culture negative
Persistent
Infection

CATHETER REMOVAL INDICATIONS

• Septic Thrombosis
• Endocarditis
• Osteomyelitis
• Severe Sepsis With Hypotension
Empirical

• Vancomycin plus gentamicin

Vancomycin 20mg/kg (load) f/b 500mg after each HD session
Gentamycin: 1mg/kg

• Ceftazidime: 1 g iv after each session

• Cefazolin (Methicillin sensitive Staph):
20 mg/kg iv after each session

Antifungal
• Caspofungin/micafungin
70 mg iv loading dose followed by 50 mg iv daily

• Fluconazole (200 mg orally daily) or

• Amphotericin B
Antibiotic Locks

Antibiotic lock should not be used alone; instead, with

systemic antimicrobial therapy, with both regimens
administered for 7–14 days

Dwell times for antibiotic lock solutions should generally not

exceed 48 hr before reinstallation of lock solution

The antibiotic lock is used only for the duration of systemic

antibiotics, after which a standard heparin or citrate lock is
resumed

Complications

Endocarditis
Follow up Blood Culture
Osteomyelitis
Suppurative Thrombophlebitis • After 72 hrs of t/t
Spinal Epidural Abscess
• 1 week after completion (R/O Recurrence)
ASPIRIN AND CRBSI

• Reduced incidence of S. Aureus–related CRBSI

• Reduced symptoms of infection and size of vegetations on

cardiovascular implantable electronic devices

• This finding needs to be confirmed, and use of aspirin to limit

infection incidence in tunneled venous catheters is not recommended
CATHETER DYSFUNCTION: POOR
FLOW
• failure to deliver a blood flow rate of at least 300 mL/min at a
prepump pressure that is less negative than −250 mm Hg

• Can lead to

inability to aspirate blood freely from the catheter lumens,

frequent pressure alarms not responsive to patient repositioning or
catheter flushing
Initial (early) dysfunction Late dysfunction
Kink Fibrin sleeve (1-2 wk)
Compression within the catheter tunnel from edema Mural Thrombus
Malposition : the azygous or hemiazygous veins T/t :
Mural thrombus: tPA
Improper tip placement Fibrin Sleeve: Balloon angioplasty
THROMBOSIS

Intraluminal thrombosis instillation of tPA for 1 hour

Central vein or intracardiac thrombosis systemic anticoagulation ( for 6 months or longer)
Embolic complications catheter removal
Catheter assisted fibrinolytic therapy
CENTRAL VENOUS STENOSIS thrombectomy
CENTRAL VENOUS STENOSIS
• from endothelial injury at the sites of catheter–endothelial contact
through the release of a variety of growth factors

RISK FACTORS PRESENTATION

Nonsilicone catheters
Subclavian approach (angular stress)
Previous catheter-related infections
History of multiple catheter insertion
Prolonged duration of such catheters
Venous hypertension: swelling of the breast, shoulder, neck, face
vascular access dysfunction: Inadequate dialysis
superior vena cava syndrome
T/t :
Ligation/Balloon angioplasty/Stent placement/axillary vein to
internal jugular vein bypass