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    Vascular Access

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    Chenny Menciano
    Vascular access is required to connect patients to hemodialysis machines. The two most common types of vascular access are arteriovenous (AV) fistulas and AV grafts. A multidisciplinary team approach is recommended to manage vascular access. Guidelines from DOQI in 1997 recommend AV fistulas over grafts if possible due to better patency rates and fewer complications. Dr. Soetomo Hospital in Surabaya, Indonesia performed 687 AV shunt surgeries between 1998-2003, with a failure rate around 8%. Proper patient selection and surgical technique are important to reduce failure rates of AV shunt creation.

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    Vascular Access

    Uploaded by

    Chenny Menciano
    397 views47 pages
    Vascular access is required to connect patients to hemodialysis machines. The two most common types of vascular access are arteriovenous (AV) fistulas and AV grafts. A multidisciplinary team approach is recommended to manage vascular access. Guidelines from DOQI in 1997 recommend AV fistulas over grafts if possible due to better patency rates and fewer complications. Dr. Soetomo Hospital in Surabaya, Indonesia performed 687 AV shunt surgeries between 1998-2003, with a failure rate around 8%. Proper patient selection and surgical technique are important to reduce failure rates of AV shunt creation.

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    Vascular access is required to connect patients to hemodialysis machines. The two most common types of vascular access are arteriovenous (AV) fistulas and AV grafts. A multidisciplinary team approach is recommended to manage vascular access. Guidelines from DOQI in 1997 recommend AV fistulas over grafts if possible due to better patency rates and fewer complications. Dr. Soetomo Hospital in Surabaya, Indonesia performed 687 AV shunt surgeries between 1998-2003, with a failure rate around 8%. Proper patient selection and surgical technique are important to reduce failure rates of AV shunt creation.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    397 views47 pages

    Vascular Access

    Uploaded by

    Chenny Menciano
    Vascular access is required to connect patients to hemodialysis machines. The two most common types of vascular access are arteriovenous (AV) fistulas and AV grafts. A multidisciplinary team approach is recommended to manage vascular access. Guidelines from DOQI in 1997 recommend AV fistulas over grafts if possible due to better patency rates and fewer complications. Dr. Soetomo Hospital in Surabaya, Indonesia performed 687 AV shunt surgeries between 1998-2003, with a failure rate around 8%. Proper patient selection and surgical technique are important to reduce failure rates of AV shunt creation.

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    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 47

    Vascular Access For Hemodialysis

    Paul Tahalele, MD, Ph.D, FInaCS, FCTS Professor of Surgery Chief of Surgical Department. Medical School Airlangga University Surabaya, Indonesia

    Definition

    Vascular access is the circulatory site that allows the connection between the patients circulation and the dialyzer
    The two most common types of chronic access used for hemodialysis are :

    Arterio-venous (AV) fistula Arterio-venous (AV) graft

    http://classes.kumc.edu/cahe/respcared/cybercas/dialysis/franvasc.html,

    Last accessed : 2004

    Multidisciplinary Hemodialysis Vascular Access Team

    Began informally in the early 1990s Arteriovenous fistula



    1960

    (Surendra shenoy et al, 2002. In: Dialysis Access, ed. RJ Gray p.10)

    Scribner, Dillard, and Quinton (an internist, a surgeon,


    and an engineer), introcuded first long-term cannulation for artery and vein using Silastic shunt

    1966

    Brescia, Cimino and coworkers reported the autologous


    subcutaneous arteriovenous fistula
    (Brescia MJ, Cimino JE, Appel K, et al. N Eng J Med 275:1089,1966.)

    Types of Vascular Access for Hemodialysis


    a)

    Central Venous Access

    Double lumen catheter (Hickmann cath., Groshong cath., etc) Port A-Cath

    b)
    c)

    External shunt : Scribner shunt Internal shunt :

    AV fistula AV graft

    Double Lumen Catheter

    Groshong catheter

    5 Hospitals in Surabaya 120-140 HD pts per year.

    Hemodialysis

    HEMODIALYSIS PORT

    AV Shunt (Brescia-Cimino shunt)

    Implementation of the Dialysis outcomes Quality Initiative (DOQI) guidelines for vascular access management (1997)
    Multidisciplinary

    approach :

    Nephrologist Surgeon Interventional radiologist

    DOQI guideline
    a) Diagnostic Evalution Prior to Permanent Access Selection
    Preoperative Venography Other imaging studies : USG doppler

    Flow Vein Mapping Mapping upper arm cephalic vein Forearm veins in obese patients

    Anatomy

    DOQI guideline
    b) Selection of permanent vascular access :
    AV Fistula (15%) AV graft (85%) : 1980 - 1990

    1996 2000 : Fistula 30 60%

    RJ Gray. Washington Hospital Center, 2002

    Tabel 1. Incidence of Hemodialysis Vascular Access Placed For the years 1996 - 2000
    Year Fistulae Grafts Total New Access Fistula %

    1996 1997

    21 41

    50 53

    71 94

    30 44

    1998
    1999 2000

    76
    77 75

    82
    77 50

    158
    154 125

    48
    50 60

    RJ Gray. Washington Hospital Center, 2002

    DOQI guideline
    c) Type and location of dialysis AV grafts placement
    Saphenous vein Graft (SVG) Prosthesis Dacron graft

    Preoperative preparation

    Patient :

    Informed consent Nondominant arm Pressure differential < 20 mmHg between arms Patient palmar arch has to be good

    Arterial requirements

    Allen test

    Arterial lumen diameter 2.0 mm at point of anastomosis

    Venous requirements

    Luminal diameter 2 mm at anastomosis

    point Absence of obstruction Straight segment for cannulation Within 1 cm of surface Continuity with central veins

    USG Doppler

    Allen Test
    1.

    2. 3.

    4.

    Position the patient so that he or she is facing you with their arm extended with the palm turned upward Compress both the radial and ulnar arteries at the wrist With the arteries compressed firmly, instruct the patient to create a fist repetitively to cause the palm to blanch When the patients hand is blanched, release your compression of the ulnar artery and watch the palm to determine if it becomes pink. Then release all compression :
    Pale Pink Allen test positive Allen test negative Abnormal flow Normal flow

    5.

    Repeat steps 2-4 for the radial artery

    Allen Test

    Operation Technique

    Prepare the forearm

    Wash the upper and forearm with savlon And desinfects with povidone iodine 10%

    Put the sterile drapping until the 1/3 distal upper arm

    Standard equipment for AV shunt surgery

    Skin Identification of radial artery and cephalic vein pathway

    Skin Identification of brachial artery and cubiti vein pathway

    Local Anesthesia :
    Xylocain or Lidocain 1-2% 10 cc

    Hockey Stick Incision the skin

    Identification of cephalic vein, radial artery & separates it from surrounding tissue

    Oblique Cut the vein after ligation the distal part and lumen dilatation

    Oblique cut the artery after ligation the distal part and lumen dilatation

    End to End Anastomosis

    After anastomosis, release the bulldog clamp

    Thrill Palpation on the vein line

    Suture only the skin

    Bandage the arm

    Complications of AV fistulas for hemodialysis


    Primary thrombosis fistula Secondary thrombosis fistula Proximal venous stenosis-hand hyperaemia Puncture site infection Aneurysm formation Cavernous transformation Left ventricular failure (very rare)

    Complications of subclavian vein catheterization for hemodialysis

    During insertion

    During or between dialysis

    Pneumothoraks Hematothoraks Subclavian artery injury Brachial plexus injury Caval perforation Guide-wire fracture

    Thrombus formation Pulmonary embolus Sepsis

    Exit site Bloodstream Air embolus Haemorrhage Haemopericardium Intrapulmonary haemorrhage

    Disconnection

    Migration

    CLINICAL SIGNIFICANCE

    Severe upper-extremity edema; high-pressure, dilated upperarm veins

    Severe upper-extremity edema; secondary to subclavian lesions in two patients with ipsi-lateral functional arteriovenous dialysis accesses

    Dr.Soetomo Hospital Experience of AV Shunt Surgery


    N : 687 pts.
    Male (474 pts., 69%) ; Female (213 pts., 31%); Age : 19 87 year (51 32)

    Etiology :
    Primary CRF :622 (90,6%) Secondary CRF : 65 (9,4%)

    1998 2003 (6 years)

    Tabel 2. CRF patient with AV shunt surgery at RSU Dr. Soetomo during 6 years (1998s/d2003)
    Year 1998 1999 2000 2001 2002 2003 Total % Male 67 110 67 86 61 63 474 69,0% Female 38 41 24 34 41 35 213 31,0% Total 105 171 91 120 102 78 687 100%

    Tabel 3. Percentage of the AV Shunt Surgery Failure at Dr. Soetomo Hospital during 6 years (1998s/d 2003)

    Year 1998 1999 2000 2001 2002 2003 Total

    1st Operation

    2nd Operation

    105 171 91 120 102 78 687

    6 12 8 12 6 9 56

    % 5,71 7,02 8,79 10,0 5,88 11,54 8,15

    Tabel 4. Correlation between surgeon and failure of the first AV shunt surgery
    Surgeon
    Vascular surgeon Resident

    1st Operation
    331 (48,18%) 356 (51,82%)

    Revition
    18/331 (2,42%) 48/356 (13,48%)

    Total

    687 (100%)

    56/687 (8,15%)

    Strategies & tips for AV shunt surgery

    Check the general condition


    Consciousness ? Restless ? Dyspneu ? Blood Pressure ? Tx : Sedative drugs

    Minimum 140/90

    Check the local condition


    Oedema ? Sign of puncture site residue ? Scleroting or thromboplebitis of the vein ?

    Technique
    Distally as possible (1/3 distal forearm) on nondominant arm
    Dont pass the styloid processus of radius

    If not possible, find the contralateral one


    If there is edema on both side, put the double lumen catheter

    If its still not possible, try the cubiti region. Next if not possible, try the graft surgery (autologus or prosthesis) Still fail, do the shunt on femoral region between great saphenous vein and femoral artery The last is Port A-Cath

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