Practical Guide to Surgical and Endovascular Hemodialysis Access Management

The following sections are included:

• Dedication
• Preface
• Acknowledgement
• Authors
• Contents
• Abbreviation

The following sections are included:

• Overview on ESRF and Hemodialysis Access
• Understand Your Patients and the Access Users
• General Principles
• References

The following sections are included:

• Evaluation for First Vascular Access Creation
• Evaluation for Subsequent Vascular Access Creation
• References

Surgically created vascular accesses can be broadly classified as AVF (arterialize the native superficial vein as fistula/conduit) and AVG (artificial conduit to connect between an artery and an outflow vein). This chapter will not be able to cover all aspects of vascular access creation as the knowledge and skill involved are tremendous. We aim to illustrate the basic principle, commonly used access and stress the practical tips and tricks for successful vascular access creation…

The following sections are included:

• Introduction
• Site Selection
• Selecting the Catheter
• Venepuncture
• Subcutaneous Tunneling
• Dilatation of the Entry Track
• Insertion of the Catheter
• Position of the Catheter Tip
• Bleeding from the Track
• Catheterization in Pre-Existing Venous Stenosis
• Conclusion
• References

The following sections are included:

• Access Maturation and Successfully Used for Homodialysis
• Long-term Vascular Access Monitoring and Surveillance
• Mode of Failure of a Vascular Access
• Clinical Assessment
• Hemodialysis Parameter Monitoring (Fig. 6) and Access Flow Surveillance
• Duplex Ultrasound Surveillance
• Simple Ultrasound Study
• References

In the 1950s and early 1960s, carbon dioxide (CO₂) gas was used as an intravenous contrast agent to delineate the right heart for evaluation of suspected pericardial effusion. This imaging developed from animal and clinical studies, which demonstrated that CO₂ use was safe and well tolerated with peripheral venous injections. With the advent of digital subtraction angiography (DSA) in 1980, CO₂ became a useful contrast agent for vascular imaging. Now with the availability of high-resolution DSA, stacking software, and reliable gas delivery system, CO₂ angiography has become widely used for vascular diagnosis and endovascular procedures…

Maturation of AVF is a continuous process. Usually, AVFs are expected to mature between 8–12 weeks. AVFs are considered as “early fistula failure” if they cannot be cannulated and used for hemodialysis three months after creation. The Society of Vascular Surgery/ American Association of Vascular Surgery and the North American Vascular Access Consortium further define:

Early dialysis suitability failure: an AVF for which, despite interventions (radiologic or surgical), was not possible to use the AVF successfully for hemodialysis by the third month following its creation.

Late dialysis suitability failure: an AVF for which, despite interventions (radiologic or surgical), was not possible to use the AVF successfully for hemodialysis by the sixth month following its creation.

Fistula Used Successfully for Hemodialysis (FUSH): an AVF is considered functionally successful for hemodialysis use. The criteria can be percentage of successful two needle cannulation during HD sessions, volume of dialysate flow achieved, or target clearance achieved…

Hemodynamically significant stenosis may develop along the course of vascular access due to intimal hyperplasia or repeated cannulation trauma. Central vein obstruction may also develop due to prolonged central venous catheterization with tunnelled catheter or simply due to presence of vascular access on the ipsilateral limb…

The following sections are included:

• Indication and Timing
• Contraindication
• Anesthesia and Adjuvant Medications
• Pre-Procedure Preparation
• Endovascular Salvage for Thrombosed Graft; Pharmacomechanical Thrombectomy (PMT)
• Endovascular Salvage for Thrombosis of Arteriovenous Fistula
• Mechanical Thrombectomy Devices
• Post-procedure Consideration
• Special Consideration
• Avoidance of Possible Complications
• Illustrative Cases
• References

The following sections are included:

• Surgical Salvage of Thrombosed Vascular Access
• Surgical Thrombectomy for Thrombosed AVG
• Surgical Thrombectomy for Thrombosed AVF
• General Issues of Surgical Salvage for Failed Vascular Access
• Surgical Procedures for Failing Vascular Access
• Surgical Correction of Persistent Stenotic Regions without Vascular Access Downtime
• Creation of a New AVF Using the Outflow Vein of an Existing Access to Avoid any Vascular Access Downtime (Type I Secondary Fistula)
• Creation of a New AVF over Another Limb (Type II Secondary Fistula)
• References

Central vein obstruction remains a significant source of morbidity and mortality in hemodialysis patients. It can usually be suspected on the basis of the clinical presentation and a history of central line placement. Central vein obstruction causes swelling, discomfort and pain of the extremity associated with vascular access and dialysis. Obstruction of the superior vena cava (SVC) causes superior vena cava syndrome characterized by facial swelling, dyspnea and neck vein distention. Endovascular approach is the preferred method for treating symptomatic central vein obstruction. Selection of the proper recanalization equipment, and development of a facile catheterization and recanalization technique are essential in obtaining a successful recanalization of central vein obstruction. This chapter discusses the anatomy, imaging workup and strategies for central vein obstruction in hemodialysis patients.

Dialysis associated steal syndrome (DASS) is a situation when tissue perfusion distal to the vascular access become insufficient, related to blood being diverted to support the access. It is one of the most dreadful complications of vascular access creation. The severity and implication of ischemia can be classified into:

Grade 1. Mild (cool extremity with few symptoms but demonstrable abnormal vasculature by flow augmentation with fistula occlusion), no treatment needed;

Grade 2. Moderate (intermittent ischemia only during dialysis/claudication), intervention sometimes needed;

Grade 3. Severe (ischemic pain at rest/tissue loss) (Fig. 1), intervention mandatory…

The following sections are included:

• Vascular Access Aneurysm and Pseudoaneurysm
• Infective Complications of AVF and AVG
• References

When common sites of upper limb vascular access (RC AVF, BC AVF, BBT, forearm loop AVG, arm AVG, BA AVG) are exhausted, clinicians will need to thoroughly evaluate the patient and consider more complex vascular access.

The following sections are included:

• Multi-Disciplinary Team Approach
• Preservation of Forearm and Arm Vein for Future AVF Creation
• Patients as a Member of the Vascular Access Care Team
• Method of Cannulation
• Prevention and Control of Infection in Hemodialysis Unit
• Hemodialysis regimen — intermittent dialysis versus frequent short day or nocturnal dialysis
• References

The following sections is included:

• Index