The Care and Keeping of Vascular Access for Home Hemodialysis ...
Hemodialysis Access - ITurnbull
-
Upload
louis-fortunato -
Category
Documents
-
view
219 -
download
0
Transcript of Hemodialysis Access - ITurnbull
-
7/27/2019 Hemodialysis Access - ITurnbull
1/18
Hemodialysis access
Irene Turnbull
1/31/2007
-
7/27/2019 Hemodialysis Access - ITurnbull
2/18
Hemodialysis access
The number of patients with end-stage renal
disease (ESRD) in the United States has
increased steadily.
2030: 2.24 million patients with ESRD.The creation and maintenance of functioning
vascular access, along with the associated
complications, constitute the most common
cause of morbidity, hospitalization, and cost in
patients with end-stage renal disease.
-
7/27/2019 Hemodialysis Access - ITurnbull
3/18
Vascular Access via Percutaneous
Catheters
useful method ofgaining immediateaccess to thecirculation.
associated withhigher risks.
the use-life of this
type of access isshorter than that ofAVFs.
Noncuffed catheters
Short term:
-
7/27/2019 Hemodialysis Access - ITurnbull
4/18
Vascular Access via Percutaneous
Catheters: cuffed catheters
Cuffed catheters
Patients who will require
long-term access should
have a tunneled catheterplaced.
allow so-called no-needle
dialysis with high flow
rates
eliminate the problem of
vascular steal
placed in a subcutaneous
tunnel under fluoroscopic
guidance
-
7/27/2019 Hemodialysis Access - ITurnbull
5/18
Vascular Access via Percutaneous
Catheters: cuffed cathetersThe Dacron cuff allows tissueingrowth that helps reduce the riskof infection when compared withnoncuffed catheters.
-
7/27/2019 Hemodialysis Access - ITurnbull
6/18
Hemodialysis access: complications
Complications can be divided into thosethat occur secondary to catheterplacement and those that occur later.
The early complications of subclavian orinternal jugular placement includepneumothorax, arterial injury, thoracic ductinjury, air embolus, inability to pass thecatheter, bleeding, nerve injury, and greatvessel injury.
-
7/27/2019 Hemodialysis Access - ITurnbull
7/18
Hemodialysis access: complications
A chest radiograph must be taken after catheterplacement to rule out pneumothorax and injury to thegreat vessels and to check for position of the catheter.
The incidence of pneumothorax is 1% to 4%,theincidence of injury to the great vessels is less than 1%.
Thrombotic complications occur in 4% to 10% of patients
Infection may occur soon after placement (3 to 5 days)or late in the life of the catheter and may be at the exitsite or the cause of catheter-related sepsis.
Rate of infection between 0.5 and 3.9 episodes per 1000catheter-days.
Catheter thrombosis increases the incidence of cathetersepsis.
-
7/27/2019 Hemodialysis Access - ITurnbull
8/18
Vascular Access via Arteriovenous Fistulas
The ideal vascular access
permits a flow rate that is adequate for the
dialysis prescription ( 300 ml/min),
can be used for extended periods,
and has a low complication rate.
The native AVF remains the gold standard
-
7/27/2019 Hemodialysis Access - ITurnbull
9/18
Arteriovenous fistulas
The standard by which all other fistulas are measured, isthe Brescia-Cimino fistula. (2 year patency: 55% to 89%)
radial branch-cephalic direct access
(snuffbox fistula),
autogenous ulnar-cephalic forearm
transposition,
autogenous brachial-cephalic upper
arm direct
access (antecubital vein to the
brachial artery),
autogenous brachial-basilic upper
arm transposition (basilic vein
transposition).
These options should be exhausted before
nonautogenous material is used for dialysis access.
-
7/27/2019 Hemodialysis Access - ITurnbull
10/18
Noninvasive Criteria for Selection of Upper-Extremity
Arteries and Veins for Dialysis Access Procedures
Venous examination
Venous luminal diameter 2.5 mm for autogenous AVFs, 4.0 mm for
bridge AV grafts
Absence of segmental stenoses or occluded segments
Continuity with the deep venous system in the upper armAbsence of ipsilateral central vein stenosis or occlusion
Arterial examination
Arterial luminal diameter 2.0 mm
Absence of pressure differential 20 mm Hg between arms
Patent palmar arch
-
7/27/2019 Hemodialysis Access - ITurnbull
11/18
radiocephalic fistula
(anatomic snuff-box)
radiocephalic fistula
(Brescia-Cimino)
-
7/27/2019 Hemodialysis Access - ITurnbull
12/18
Vascular access via AVFs:
brachiocephalic fistula brachiobasilic fistula
-
7/27/2019 Hemodialysis Access - ITurnbull
13/18
Arteriovenous fistulas: Complications
Failure to mature
Stenosis at the proximal venous limb (48%).
Thrombosis (9%)
Aneurysms (7%)
Heart failure
The arterial steal syndrome and its ensuing ischemiaoccur in about 1.6%: pain, weakness, paresthesia,muscle atrophy, and, if left untreated, gangrene
Venous hypertension distal to the fistula : distal tissueswelling, hyperpigmentation, skin induration, andeventual skin ulceration.
-
7/27/2019 Hemodialysis Access - ITurnbull
14/18
Prosthetic Grafts for vascular access
Upper arm grafts have a high flow rate and a low
incidence of thrombosis.
higher incidence of ischemia in the hand
higher rate of stenosis, sec to endothelial hyperplasia.
-
7/27/2019 Hemodialysis Access - ITurnbull
15/18
Options for treating stealDRIL procedure
distal revascularization-
interval ligation
excision of a portion of the veinplication w/ mattress or
continuous sutures
crossed PTFE band
interposition of a 4 mm PTFE
-
7/27/2019 Hemodialysis Access - ITurnbull
16/18
Treatment of venous access complications.
Venous angioplasty Graft thrombolysis
-
7/27/2019 Hemodialysis Access - ITurnbull
17/18
Contraindications to Thrombolytic Therapy
Absolute
Recent major bleedingRecent strokeRecent major surgery or traumaIrreversible ischemia of end organ
Intracranial pathologyRecent ophthalmologic procedure
Relative
History of gastrointestinal bleeding oractive peptic ulcer disease
Underlying coagulation abnormalitiesUncontrolled hypertensionPregnancyHemorrhagic retinopathy
-
7/27/2019 Hemodialysis Access - ITurnbull
18/18
Hemodialysis
access
Quality of life and overall outcome could be
improved significantly for hemodialysispatients if two primary goals were achieved:
Increased placement of native AVFs: a minimum
of 50% of new dialysis patients should have
primary AVFs. Detection of dysfunctional access before
thrombosis of the access route occurs.
National Kidney Foundation Dialysis Outcome and Quality Initiative (NKF-DOQI)