Dialysis Vascular Access
Managing Patients with Problematic Vascular Access Sites
Jacob A Akoh, FRCSED, FRCS(Gen)
Consultant General and Transplant Surgeon, Gastroenterology, Surgery and Renal Services Directorate, Plymouth Hospitals NHS Trust, Derriford Hospital
Abstract
The main problems affecting vascular access in patients are infection, thrombosis, steal syndrome, pseudoaneurysms, and central vein stenosis. Complications of vascular access account for 20 % of hospitalizations among hemodialysis patients and can result in loss of access, significant morbidity, and mortality. This article provides an update on the management of patients with problematic vascular access. The functioning native arteriovenous (AV) fistula is the ideal access. To achieve the ideal standard, pre-dialysis care, pre-dialysis access surgery, adequate fistula maturation, and successful fistula cannulation by dialysis staff must be improved. The risk for infection is highest with temporary catheters, high with cuffed tunnelled catheters, medium with AV grafts, and lowest with native AV fistula. Percutaneous strategies are successful in declotting thrombosed access in 67–95 % of patients. Complex access surgery may be required in patients with exhausted conventional access sites. Vascular access management must be given more prominence to ensure trouble-free functional longevity through access monitoring, surveillance, and early therapeutic intervention when necessary.
Keywords
Angioplasty, arteriovenous (AV) fistula, AV grafts, central venous catheter, hemodialysis, infection, primary failure, pseudoaneurysm, steal syndrome, thrombosis, vascular access
Disclosure: The author has no conflicts of interest to declare. Received: November 25, 2010 Accepted: January 16, 2011 Citation: US Nephrology, 2011;6(1):48–55 Correspondence: Jacob A Akoh, FRCSED, FRCS(Gen), Consultant General and Transplant Surgeon, Level 04, Derriford Hospital, Plymouth PL6 8DH, UK. E:
jacob.akoh@phnt.swest.nhs.uk
The commonly used types of vascular access include native arteriovenous (AV) fistulas, prosthetic AV grafts, and central venous catheters (CVC). Complications of vascular access account for 20 % of hospitalizations among patients on hemodialysis (HD) and can result in loss of access, significant morbidity, and mortality. The limited number of available sites makes the preservation of existing access sites important. The longer a patient remains on HD, the greater the challenge to find and maintain access sites. Every vascular access that is lost brings the patient one step closer to a terminal access problem and ultimate death. Problematic access prevents many patients on HD from receiving optimal care. Low access flow rates limit dialysis delivery, extend treatment times, and can result in underdialysis, which, in turn, leads to increased morbidity and mortality.1
Several lessons have been
Despite these lessons, the proportion of patients on HD who have had multiple access procedures, failed transplant(s), or who have exhausted sites of conventional AV fistula or graft is increasing. Consequently, an increasing proportion of such patients are requiring more complex vascular access modalities for long-term HD. This article provides an update on the management of patients with problematic vascular access.
learnt recently in terms of the management of vascular access (see Table 1).2
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Ideal Vascular Access
An ideal vascular access should exhibit a low primary failure rate, low risk for infection or thrombosis, long survival, and trouble-free survival, not requiring frequent or costly intervention to keep it functioning.
Apart from a high primary failure rate, native AV fistulas can loosely be regarded as ideal. Once matured and functional, native AV fistulas have superior longevity, fewer complications, lower mortality, and lower costs compared with AV grafts.3
The ‘fistula first initiative’, while leading
to an increase in the prevalent dialysis population dialysing via AV fistula, has also increased the number of patients with primary non-function and who are using CVC. To achieve the ideal standard, several actions are needed, including improved pre-dialysis care, pre-dialysis vascular access surgery, and adequate fistula maturation.3 Even with these measures, not all patients on HD can achieve a native AV fistula. The indications for prosthetic AV grafts include failed AV fistula and/or exhausted superficial veins, lack of suitable vessels, particularly in elderly patients and those with diabetes, vessels destroyed by indiscriminate venipuncture, late referral for vascular access, and a need for immediate cannulation with avoidance of a CVC.4,5 factors contribute to the increasing use of CVC, including delayed referral
Several © TOUCH BRIEFINGS 2011
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