Arteriovenous fistula, vascular access

FIGURE 45-1. The predominant types of vascular access for chronic dialysis patients are (A) the arteriovenous fistula and (B) the synthetic arteriovenous forearm graft. The first primary arteriovenous fistula is usually created by the surgical anastomosis of the cephalic vein with the radial artery. The flow of blood from the higher-pressure arterial system results in hypertrophy of the vein. The most common AV graft is between the brachial artery and the basilic or... 

Catheters are placed when there is a clinical need for repeated sampling, injection, or vascular access, usually on a temporary basis. In kidney failure, catheters allow emergent blood access for hemodialysis and hemofiltration (Canaud, 2000), and provide temporary access as more permanent sites such as arteriovenous fistulas or grafts mature rerotola, 2000). Placement of a catheter or access port is routine for the administration of chemotherapeutic agents and intravenous nutritional supplements. Catheters are often placed when frequent, repeated doses of medication are to be injected. 

The number of percutaneous femoral arterial catheterizations has increased exponentially in recent years with several million procedures performed worldwide annually. A direct consequence of that explosion in number of percutaneous diagnostic and interventional catheterizations is the increasing number of vascular complications due to the percutaneous creation of that vascular access mainly using the femoral artery. Potential complications are pseudoaneurysm, arteriovenous fistula, uncontrollable groin and/or retroperitoneal bleeding, in situ arterial thrombosis, and peripheral embolization. In order to deal with these complications, there is an increasing need for quick and optimal diagnosis and for efficient and, by preference, minimally invasive treatment. 

Jemcov TK Morphologic and functional vessels characteristics assessed by ultrasonography for prediction of radiocephahc fistula maturation. J Vase Access 2013 14 356 363. Ferring M, Henderson J, Wilmink T, Smith S Vascular ultrasound for the pre-operative evaluation prior to arteriovenous fistula formation for haemodialysis review of the evidence. Nephrol Dial Transplant 2008 23 1809-1815. 

In patients with vascular access, the probability of dialysis access-related infection is considerably less for patients with native arteriovenous fistulae than for those with synthetic grafts [36]. Postoperative wound infection as well as poor aseptic technique at dialysis may cause infection of the fistula silent infec-... 

Special attention in such patients focuses on the presence and function of preexisting arteriovenous fistulae, hemodialysis central venous catheters, or access for peritoneal dialysis. Arms with vascular accesses are kept free from blood pressure cuffs, pulse oximeters, tourniquets and peripheral venous cannulae. 

Considerable morbidity exists when dealing with vascular access (VA) creation. Native arteriovenous fistulae (AVF) are the desired VA for patients on dialysis due to their comparably low morbidity and fairly good long-term patency. However, they are also at risk for nonmaturation, stenosis, thrombosis, infection, aneurysm formation, and steal syndrome [ 1 ]. Fistula success is dependent on the center of access creation. Hence, the vascular surgeon s skills and decisions are key [2]. Furthermore, success is also determined by preoperative, technical, and postoperative factors that will be discussed in this chapter (fig. 1). 

Ilhan G, Esi E, Bozok S, Yurekli I, Ozpak B, Ozelci A, Destan B, Gurbuz A The clinical utility of vascular mapping with Doppler ultrasound prior to arteriovenous fistula construction for hemodialysis access. J Vase Access 2013 14 83-88. 

Dialysis vascular access is currently the lifeline for hemodialysis patients. Unfortunately, due to the many complications associated with dialysis vascular access, it is also the Achilles heel of hemodialysis. A relatively ignored aspect of dialysis vascular access pertains to patient safety. The first part of this chapter will describe patient safety issues in the traditional context of arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs) and tunneled central venous catheter (tCVC). In the second half of this chapter, however, we will make the case that a nontraditional approach which emphasizes (a) individualization of care, and (b) patient preferences and patient involvement maybe our best opportunity to improve patient safety in hemodialysis patients. 

Check after creation of an arteriovenous fistula or arteriovenous graft (AVG) for palpable thrill or a bruit The presence of a strong pulse in the draining vein without a thrill or bruit indicates a proximal venous stenosis. Patients need an instruction when checking their vascular access (VA) daily for bruit and thrill. 

Saran R, Elder SJ, Goodkin DA, Akiba T, Ethier J, Rayner HC, Saito A, Young EW, Gillespie BW, Merion RM, Pisoni RL Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients results from the Dialysis Outcomes and Practice Patterns Study. Ann Surg 2008 247 885-891. 

---