This document discusses novel trends in hemodialysis vascular access. It covers the history of dialysis, current modalities of vascular access including arteriovenous fistulas, arteriovenous grafts and central venous catheters. It also discusses imaging techniques like Doppler ultrasound and guidance for vascular access placement. Novel trends discussed include local drug therapies delivered endovascularly or perivascularly to prevent access failure, as well as bioengineered autologous grafts. Needleless dialysis is also mentioned as a novel trend. The key takeaway message is that vascular access is precious and needs careful handling to avoid access failure which can be a nightmare for patients.

1. Novel Trends InNovel Trends In
Hemodialysis VascularHemodialysis Vascular
AccessAccess
MOATAZ FATTHY MD
Lecturer of Internal Medicine
Cairo University

2. • HISTORY
• MODALITIES
• IMAGING
• NOVEL TRENDS
• WHERE WE STAND
• TAKE HOME MESSAGE

3. • HISTORY
• MODALITIES
• IMAGING
• NOVEL TRENDS
• WHERE WE STAND
• TAKE HOME MESSAGE

4. • A Dutch physician, Willem
Johan Kolff, constructed the
first working dialyzer in 1943
during the Nazi occupation
of the Netherlands.
• He first used glass cannulae
to obtain arterial blood from
the radial artery, which he
returned to the cubital vein.

6. 19661966till nowtill now……

8. • HISTORY
• MODALITIES
• IMAGING
• NOVEL TRENDS
• WHERE WE STAND
• TAKE HOME MESSAGE

9. • A well-functioning vascular
access (VA) is a mainstay to
perform an efficient
hemodialysis (HD) procedure.
There are three main types of
access:
• Native arteriovenous fistula
(AVF)
• Arteriovenous graft (AVG)
• Central venous catheter
(CVC).
Tunneled & non-Tunneled

10. • Acute dialysis
• Bridge to permenant
access
• Superficial venous
insufficiency
• Cardiac insufficiency
• Surgically unfit patients
• Most common
• Durable
• More tolerated by
patients
• AVG more infection
incidence but rapid
use than AVF

11. CVCCVC
• What patients do
prefer ??
• 1% Japan
• 18% in the United States
• 39% Belgium
• 44% Canada

12. CVCCVC
Placement
• Central :
Jugular
Subclavian
• Femoral :
Tunneled iliac
• Abdominal :
IVC (translumbar)

13. CVCCVC
Infection
The relative risk of bacteremia is 7-
fold higher in ESRD patients with
vascular access catheters, than in
ESRD patients with AVFs.
There is a 22 to 38% rate of
metastatic complications,
including endocarditis, septic
arthritis, and epidural abscess or
death

14. CVCCVC
Infection
• Tunneled versus non-tunneled catheters
• Silver-sulfadiazine-chlorhexidine coating had a strong
bactericidal effect.
• Antibiotic Ointments
• Antibiotic lock solution is a high concentration of antibiotic
with or without the addition of an anticoagulant agent, such
as tissue plasminogen activator (tPA) or heparin

15. CVCCVC
Thrombosis
• Anticoagulant coating
• Flushing with
anticoagulant
• Catheter Lock
• Catheter tip design

16. AVFAVF
• The AVF needs to be
planned at least one or
two months before
starting HD, a time
required for the proper
maturation of the VA.
• RCAVF
• BCAVF
• BBAVF

17. AVFAVF
The most frequent complications
related to AVFs are
•Insufficient maturation of the AVF
•Stenosis
•Thrombosis
•Infection
•aneurysm, pseudoaneurysm
•heart failure
•steal syndrome” due to ischemia
and high-rate flow AVF.

18. AVGAVG
• Not last as long as AVFs and
they have higher rates of
infection and thrombosis
• Grafts present a second
choice of VA
• They can be placed any
where
• Straight, curved or loop
configuration
• They may offer a large
surface area for
cannulation.

19. AVGAVG
• AVGs can be cannulated
about 2-3 weeks after
placement, although
• This interval is needed in
order to allow the
surrounding tissue to adhere
to the conduit, to reduce
the postsurgical oedema
and the risk for local
complications such as
perigraft hematoma and
seroma

20. • HISTORY
• MODALITIES
• IMAGING
• NOVEL TRENDS
• WHERE WE STAND
• TAKE HOME MESSAGE

21. DopplerDoppler
PRE POST
• The gold standard to
decide on the type and
location of VA is the duplex
ultrasound scan.
• Superficial venous system
• Deep venous system
• Arterial system
• RULE OF
6

22. DopplerDoppler
MAPPING PRE PUNCTURE

23. DopplerDoppler
Guided Access
There are two different main
approaches, according to the
visualization of the needle during
its entry into the vein, using
ultrasound guidance: in-plane and
out-of-plane, placing the probe
on the vein long axis or short axis.
Recently, it has been shown that
the lateral short axis in-plane
technique has virtually no
limitations, ensuring most benefits,

24. • HISTORY
• MODALITIES
• IMAGING
• NOVEL TRENDS
• WHERE WE STAND
• TAKE HOME MESSAGE

26. This review focuses on therapies to prevent or treat AV access
failure that are delivered locally through endovascular
approaches or perivascular administration

27. Oral administration
• A randomized, placebo-controlled trials found some benefits
on AV graft (AVG) patency of orally administered agents,
dipryridamole plus aspirin
• Another ongoing randomized clinical trial is evaluating short-
term use of orally administered sirolimus on the patency of
AVGs and AV fistulas (AVFs) after clinically indicated
angioplasty (Sirolimus Use in Angioplasty for Vascular Access
Extension (SAVE)

28. Endovascular Approach
• DEB
• DES
• Heparin bioactive graft
• Use of biodegradable stents
• Cryotherapy( NO, -10)
• Brachytherapy.(ionizing
radiation)

29. Perivascular Approach
• Application of biologic or
pharmacological agents to the
adventitial layer of the blood vessel
• During vascular access creation
and also, long after access surgery
through ultrasound -guided
subcutaneous injection
• Repeat application of a sirolimus-
laden polymer gel through
ultrasound-guided injection to the
vein–graft anastomosis
• Cell-Based Delivery : seeding
endothelial cells to AVGs and AVFs
through perivascular administration
at the time of access creation
• Thiazolidinediones induce adipose
tissue production of adiponectin
having vasculoprotective effects,
including inhibition of smooth
muscle cell proliferation and
inflammation.

34. • Bioengineering
approaches have
been used to create
autologous grafts from
dermal fibroblasts and
endothelial cells
obtained through tissue
biopsy and expanded
in tissue culture

39. NEEDLE less DIALYSISNEEDLE less DIALYSIS

40. • HISTORY
• MODALITIES
• IMAGING
• NOVEL TRENDS
• WHERE WE STAND
• TAKE HOME MESSAGE

41. Failed vascular accessFailed vascular access
highlighthighlight
• Training for central
access
• Image guided
• Nurses handling
(puncture, circuit)
• Infection control
• Lack of follow up
• Patient factors
(reluctance)
• Vascular surgeons
(priority)
• Tx waiting list

42. • TAKE HOME MESSAGE
• VASCULAR ACCESS IS A
PRECIOUS ONE AND
NEEDS MORE CAREFUL
HANDLING
• FAILED VASCULAR
ACCESS IS A
NIGHTMARE