Vascular access surgery

Mepivacaine toxicity has been studied in 10 patients with end-stage chronic renal insufficiency undergoing vascular access surgery (74). These patients represent a high-risk... 

Before vascular access surgery, physical and noninvasive examination by duplex ultrasonography of vessels is mandatory. 

Local anesthesia and regional blocks, commonly used in vascular access surgery, may affect vein diameter and fistula blood flow rates, which are important predictors of fistula failure. Regional block anesthesia (brachial plexus block) is associated with vasodilation in both the cephalic and basilic veins and with increased fistula blood flow. 

After vascular access surgery, benefits and risks of antithrombotic medications should be considered. The aim of such treatment is increasing the access duration, but its suitability for needling is also an important outcome to be considered. 

Cardiac Safety in Vascular Access Surgery and Maintenance... 

Patients requiring vascular access surgery are frequently multimorbid, and surgery is often nonelective. Efficient preoperative planning requires communication of accurate data, dates and details of schedules and procedures. This includes planned location and type of vascular access, patient preparation and positioning, use of grafts or distal perfusion, etc. 

The overall aim is to predict a patient s tolerance to the perioperative stress of his/her specific surgical procedure. Whereas peripheral reconstructive vascular surgery carries a particularly high risk of perioperative cardiac morbidity and mortality, peripheral vascular access surgery is classified as low or moderate risk surgery. 

Impaired kidney function is a robust indicator of increased perioperative risk. Patients with end-stage renal disease (ESRD) requiring vascular access surgery are thus usually ASA class 3 or 4, related to their overall health status. ASA classification does not take surgical risk into consideration this needs to be categorized separately using appropriate scoring systems [5]. 

Preoperative assessment of coronary status and cardiovascular function is based on clinical evaluation, noninvasive and invasive diagnostic testing. Physical performance is evaluated according to simple exercise tasks (e.g. walking up stairs), and is quantified by grading their metabolic equivalent (MET, table 1). At a performance of 4 MET or more, the patient is usually fit for vascular access surgery in locoregional anesthesia (ERA) without further cardiac evaluation [6]. 

Patients with moderate to severe pulmonary disease requiring vascular access surgery will benefit most from a LRA technique. General anesthesia (GA) with intermittent positive pressure ventilation (IPPV) and use of muscle relaxants impairs respiration more than LRA with maintained spontaneous breathing. IPPV may cause dynamic overinflation or barotrauma to lungs, promote atelectasis and impair mucociliary clearance [7]. This may be associated with increased pulmonary morbidity, prolonged hospital stay, resource utilization and cost. 

An increasing number of patients present for vascular access surgery carrying a CIED (e.g. internal pacemaker, defibrillator ICD, or cardiac resynchronization therapy) [14]. In these patients, the surgeon needs to brief the team ahead of time about the use of electrocautery. If monopolar cautery is needed, the pathway of the cautery current should be directed far away from the CIED, and the device should be reprogrammed or deactivated temporarily. Depending on the device and indication, the pacemaker function maybe adjusted to a reasonable rate and mode of action [15]. 

As a consequence, use of ultrasound guidance for anesthesia preparations is strongly recommended as an important safety feature in vascular access surgery. 

GA is suitable for all procedures in vascular access surgery patients. Renal insufficiency affects clinically relevant pharmacokinetics of some hypnotics, analgesics and relaxants. 

Safe induction of GA for vascular access surgery should take specific risk constellations among these patients into account ... 

LRA is ever gaining popularity for vascular access surgery due to its sympatholytic and venodilatory effect, overall cardiovascular stability and safety, and a potentially positive impact on surgical outcome [20]. The incidence of vasospasm and early thrombosis may be reduced [21]. The site of the regional block needs to be selected such as to adequately anesthetize the projected vascular access site (table 4). For vascular access surgery on the upper extremity, supraclavicular, infraclavicular or axillary nerve blocks are typically performed. 

Allogenic blood product transfusion should be unnecessary in vascular access surgery with adequate preoperative preparation and surgical technique. Transfusion indications should be restrictive and take patients preoperative chronic stable baseline into consideration. A valid transfusion trigger should combine hemoglobin concentration with the presence of clinical indicators of critical anemia or risks for critical end-organ ischemia (e.g. coronary or cerebrovascular disease [25-28]). 

Shemesh D, Raikhinstein Y, Orkin D, Goldin I, Olsha O Anesthesia for vascular access surgery. J Vase Access 2014 15(suppl 7) S38-... 

O Hare AM, Bertenthal D, Walter LC, et al When to refer patients with chronic kidney disease for vascular access surgery should age be a consideration Kidney Int 2007 71 555-561. 

Mayers JD. Markell MS, Gjhen LS, et al Vascular access surgery for maintenance hemodialysis. Variables in hospital stay. ASAIO J 1992 38 113-115. 

Becker BN, Breiterman-White R, Nylander W, et al Care pathway reduces hospitalizations and cost for hemodialysis vascular access surgery. Am J Kidney Dis 1997 30 525-531. 

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