Chronic kidney disease
Stage 5 subdivided further into 2 sub-stages the:
1st: treated conservatively without dialysis
2nd: follows the initiation of renal replacement therapy (RRT) in
the form of dialysis or transplantation, required to sustain life
Definitions
Primary VA: Creation of a functioning VA for the 1st time
Secondary VA: Ordinary VA creation with AVF or AVG at any
location after a failed primary VA (tertiary VA excluded)
Tertiary VA: VA using great saphenous vein (GSV) or femoral
vein (FV) translocated to the arm or leg. Unusual VA
procedures such as upper or lower limb arterio-arterial loops
are included in this category
Transposition: Relocation of an autogenous vein to a new
(more superficial) position in the soft tissues of the same
anatomical area (e.g. an upper arm AVF with transposition of
the basilic vein)
Translocation: The prepared vein is completely disconnected
and inserted in a new anatomical area to create an AVF
Superficialisation: The index vein is transposed in the
subcutaneous tissue and positioned closer to the skin
Treatment options for ESRD
Hierarchy of haemodialysis access
Snuffbox: dorsal branch of the radial artery and the cephalic vein
Radial-cephalic: radial artery to cephalic vein at the wrist
Brachial-cephalic: brachial artery to cephalic vein (the most
common overall) at the cubital fossa
Brachial-basilic: brachial artery to basilic vein (more complicated
than the cephalic because the vein is deep and so requires full
mobilization to a superficial position to be needled) at the cubital
fossa
Brachial-axillary graft: when arm vein options are exhausted.
Brachial artery in the cubital fossa to axillary vein
More complex (‘tertiary’) procedures, such as:
Popliteal artery to femoral vein using LSV
Axillo-femoral
Axillo-axillary
Christos Argyriou, George S. Georgiadis, Miltos K. Lazarides
Democritus University, Alexandroupolis, Greece Vascular Access
Guidelines: Do We Need Better Evidence?
Majority of recommendations
stated as level C, statistically
significant compared with
recently published guidelines
(Fig.1)
Heikkinen et al.: “the projected
workload for vascular
procedures in 2020 is estimated
to be greater for access than for
AAA”
Characteristics of AVF
AVF configuration
It is preferred an end to side (vein to artery)
anastomosis
For RCAVFs an end to end anastomosis has
been advised by some to prevent steal
syndrome
AVF should be performed at the most distal
site possible in order to preserve as many
vessels as possible
Proximal AVFs have higher risk of VAILI
Inner radial arterial diameter < 2.0 mm
and/or cephalic venous diameter < 2.0 mm by
US measurement => consider an alternative
site for access
If there is an indwelling CVC/ pacemaker the
VA should be created in the opposite arm
because of the risk of central venous stenosis
and reduced access patency
AVF configuration
Prefer basilic vein transposition AVF to
AVG because of its improved patency
and reduced risk of infection
Lower limb VA : prefer femoral vein
transposition to AVG due to lower
infection rate
Presence of infection: prefer a
biological graft to a synthetic one
Absence of bruit or thrill => good
predictor of AVF thrombosis
bruit
Perioperative complications
Haemodialysed patients: bleeding tendency, abnormal
bleeding times
Post-operative infection: Peri-operative infections (within
30 days of creation) have a low incidence (0.8%) and
account for only 6% of all VA site infections
Non-infected fluid collections: seromas (frequent in AVG,
rare in AVF)
VAILI
Early thrombosis occurring within 30 days of VA
Access maturation
Maturation is usually assessed by the presence of:
1. adequate venous diameter
2. soft easily compressible vein
3. continuous audible bruit
4. palpable thrill near the anastomosis
the rule of 6’s: at least 6 mm vein diameter and 600 ml/min
flow and less than 6 mm vein depth
Cannulations techniques
Ultrasound assisted cannulation
Rope ladder: uses the entire length of the cannulation
segment and results in moderate vessel dilatation over a long
vein segment
Area: repeated cannulation in the same site
dilatation + stenosis in adjacent regions
aneurysmal
Buttonhole: demands the cannulation at exact same site,
cannot be performed in AVGs
Surveillance of VA
Late vascular access complications
1. True and false access aneurysm
2. Infection
3. Stenosis and recurrent stenosis
i.
ii.
Inflow arterial stenosis
Juxta-anastomotic stenosis
iii. Venous outflow stenosis
iv. Cephalic arch stenosis
4. Thrombosis
5. Central venous occlusive disease
6. VAILI and high flow vascular access
7. Neuropathy
8. Non-used vascular access
True and false access aneurysm
Access site aneurysms may be
the effect of repeated needling in
the same area
Up to 17% of AVFs may
develop true aneurysms
(aneurysmal dilatation of all
layers of the vessel wall) and
they are entangled with:
1. Pre/ post-aneurysm
stenosis which may
to pulsation of the distal
vein and reduced/
missing thrill proximally
2. Wall-adherent thrombi
producing local signs of
aseptic thrombophlebitis
3. Necrosis of the overlying
skin + the risk of
spontaneous rupture/
bleeding
7 % of AVGs may develop
false aneurysms (wall defect)
after graft destruction
Infection
Stenosis and recurrent stenosis
1. Inflow arterial stenosis
2. Juxta-anastomotic
stenosis
3. Venous outflow stenosis
4. Cephalic arch stenosis
Thrombosis
Final complication after a period of:
i.
ii.
iii.
VA dysfunction
Progressive stenosis
Hypotension
Central venous occlusive disease
Clinically may appear as asymptomatic, or with upper extremity/ facial/ breast swelling,postcannulation bleeding, AVF aneurysms
May
to:
i.
VA loss
ii.
Preclude future VA creation in the ipsilateral limb
Causes:
i.
CVCs use (25-50%)
ii.
↑ Blood flow
iii.
Extrinsic compression
“Steal syndrome”
VA Induced Limb Ischaemia (VAILI) replaced the
term steal syndrome: Extremity malperfusion
after VA creation which can be classified in 4
stages:
Stage
Symptoms
1
Slight coldness, numbness, pale skin, no
pain
2
Loss of sensation, pain during HD/
exercise
3
Rest pain
4
Tissue loss affecting the distal parts of
the limb, usually the digits
VAILI and high flow vascular access
VAILI and high flow vascular access
a)
Flow reduction by banding of the vein close to the anastomosis
b)
Flow reduction by creating inflow from a distal artery with smaller diameter (RUDI
procedure)
c)
Flow reduction of a RCAVF by proximal ligation of the radial artery
d)
Improvement of distal perfusion in a RCAVF by ligation of the distal radial artery
e)
Improvement of distal perfusion by distal revascularisation interval ligation (DRIL)
with a vein bypass and ligation of the brachial artery distally the arteriovenous
anastomosis
f)
Improvement of distal perfusion by creating a more proximal inflow of the AVF
(Proximalisation of the AV anastomosis; PAVA)
Neuropathy
Axonal ischaemia in peripheral nerves that can lead to severe
and non-reversible limb dysfunction
Radial nerve
↓ collateral flow in vessels to major nerves in the antecubital
fossa, most often after BCAVFs, with
ischaemic axonal or
reversible demyelinating injuries
Clinically as post-operative sensory/ motor loss in the distribution
ΔΔ: true VA induced ischaemia, post-operative oedema/ carpal
tunnel syndrome
It should be treated by immediate VA closure
Non- used VA
Tertiary vascular access
3 Groups:
i.
ii.
iii.
upper limb, chest wall and translocated autogenous vein from the
lower limb
lower limb
VA spanning the diaphragm, and other unusual VA procedures
including upper and lower limb arterio-arterial loops
Antiplatelet and anticoagulation therapy in VA
Imaging in vascular access
Imaging in pathological vascular access findings
Antibiotic therapy in VA
Vascular access: Guidelines
Complex of tertiary
haemodialysis vascular access
Thanks for your
attention!!!
1. Christos Argyriou, George S. Georgiadis, Miltos K. Lazarides
Democritus University, Alexandroupolis, GreeceVascular Access
Guidelines: Do We Need Better Evidence? Eur J Vasc Endovasc
Surg (2018) 56, 608-609
Literature
review
2. Editor’s Choice e Vascular Access: 2018 Clinical Practice
Guidelines of the European Society for Vascular Surgery (ESVS)
Jürg Schmidli , Matthias K. Widmer , Carlo Basile, Gianmarco de
Donato , Maurizio Gallieni , Christopher P. Gibbons , Patrick Haage
, George Hamilton , Ulf Hedin, Lars Kamper, Miltos K. Lazarides ,
Ben Lindsey, Gaspar Mestres , Marisa Pegoraro , Joy Roy , Carlo
Setacci , David Shemesh , Jan H.M. Tordoir , Magda van Loon ,
ESVS Guidelines Committee b, Philippe Kolh, Gert J. de Borst,
Nabil Chakfe, Sebastian Debus, Rob Hinchliffe, Stavros Kakkos,
Igor Koncar, Jes Lindholt, Ross Naylor, Melina Vega de Ceniga,
Frank Vermassen, Fabio Verzini, ESVS Guidelines Reviewers c,
Markus Mohaupt, Jean-Baptiste Ricco, Ramon Roca-Tey
3. https://www.semanticscholar.org/paper/How-to-improve-vascularaccess-care.Loon/b07f8be606ceace8a7bb57adf723eb4e0266469b