indications for haemodialysis, KDOQI guidelines, autogenous accesss configurations, HD catheters, ptfe grafts, HeRO device

1. Haemodialysis Access
Dr SD Sanyal

2. Types
• AV Fistula (autogenous access)
• Prosthetic grafts
• Catheters

3. KDOQI Guidelines

4. Choice of Access

5. Access trends

6. Factors influencing choice of access
1. Long term patency
2. Sufficient flow rates
3. Complications
4. Cosmetic acceptibility
5. Morbidity, mortality & cost

7. Patient evaluation algorithm

9. AV Fistula
(Autogenous & Prosthetic
grafts)

10. Pre-operative evaluation
1. Early referral:
- GFR < 30ml/min
- 06 months prior to anticipated HD
- s.creat < 4m/dl
2. History and physical examination:
- prior access procedures, revisions,
complications, CV thrombosis and arm edema
- Examination of pulses, Allen’s test

11. Pre-operative evaluation
3. Non invasive imaging:
- Doppler ultrasound
- Venous diameter, presence of DVT
- Arterial pressures
- Presence of occlusive disease/ altered anatomy
- Computed CT
4. Invasive
- Arteriography/venography
- Abnormal invasive imaging
- Occlusive disease

12. Access configurations
• Order of preference:
- Radial cephalic
- Brachial cephalic
- Brachio-basilic transposition

13. Vascular requisites
• Arterial:
- Pressure differential < 20mmHg
- Patent palmer arch
- Diameter > 2mm
• Venous:
- Diameter >/= 3mm
- within 10mm of surface
- absence of obstruction
- straight segment for cannulation
- continuity with proximal central veins

14. Fistula maturation
• Rule of 6:
1. Vein diameter of 6 mm
2. Access flow rate of 600 mL/min
3. Access depth of 6 mm below the skin

15. Factors affecting outcomes
• Age
• Diabetes
• Obesity
• Vessel characteristics

16. Radio-cephalic AVF

17. Surgical technique
• A 3-cm incision is made in the distal forearm midway
between the radial artery and the cephalic vein
• Skin flaps created
• Cephalic vein and radial artery are dissected free
• Sufficient length of vein (approximately 3 cm) should
be mobilized to facilitate its transposition onto the
artery
• Vein is transected, gently distended with saline, and
then spatulated to enlarge the anastomosis
• Artery is occluded with two clamps
• 7- to 8-mm arteriotomy is created
• End-to-side anastomosis is performed using a running
6-0/7-0 monofilament vascular suture

18. Brachio-cephalic AVF

19. Surgical technique
• Transverse incision is made across through the
antecubital crease over the brachial artery and cephalic
vein
• The cephalic vein (or median antecubital vein) is
dissected free for sufficient length to facilitate
transposing it onto the brachial artery
• Brachial artery is exposed by incision of the overlying
bicipital aponeurosis
• Sufficient length is dissected free for the anastomosis
and occluding clamps
• 7- to 10-mm incision is created in the artery and a
• Anastomosis constructed

20. Brachio-basilic AVF

21. Surgical technique
- Incision made over ante cubital fossa
- Skin incision and the dissection are
extended proximally to the axilla
- Basilic vein courses adjacent to the medial
antecubital cutaneous nerve in the
upperarm
- Distended vein is then gently draped over the
upper arm in an arc, and the future course of the
transposed vein is marked on the skin
- Brachial artery is dissected at the site of anastomosis
- A tunnel is created along the course marked on the skin
- End to side anastomosis is created

22. AV Prosthetic
Grafts

23. Forearm loop AV access

24. Surgical technique
- Incision over antecubital fossa
- Brachial artery and Median antecubital vein
dissected
- Proposed course of graft drawn on skin
- Graft draped over the skin
- Counter incision given distally
- Graft( 6mm PTFE) passed after passsage of
tunneling device
- Anastomosis created

25. Upper arm AV access

26. Surgical technique
- Incision over the antecubital fossa to expose
brachial artery
- Proximal incision at axilla( not involving
axillary crease) to expose the axillary vein
- 6mm PTFE graft tunneled and anastomosis
performed

27. Complex Access Procedures

28. Salient points
- To be considered only if conventional access
methods have failed
- venography/venous mapping prior to the
procedure
- Autogenous better than prosthetic
- Upper extremity better than lower
- Exotic and complicated but better than
tunnelled dialysis catheter

29. KDOQI Guidelines
• HD with tunneled catheter/ PD as a bridge to
transplant if:
- weight < 20 kgs
- Time to transplant < 12 months

30. Femoral vein translocation

31. Femoral vein transposition/ Composite
graft

32. Femoro-saphenous/Popliteo-
saphenous access

33. Mid thigh loop access

34. Outcomes

35. Complex Thoracic access

36. Complex Thoracic access

37. Arterial-arterial access

38. Post-operative Care
&
Complications

39. Post-op care
• General principles:
- Check Hb, electrolytes
- Consider dialysis if indicated
- Early drain removal and discharge
- Follow up 2 weeks and 4-6 weeks
- Discharge and referral to dialysis unit with a
schematic diagram of AV access

40. Post-op care
• Strategies to promote maturation:
- Imaging to monitor maturation
- Balloon angioplasty maturation(BAM)
- Access elevation
- Accessory branch ligation
- Medical mgt: Clopidogrel/Aspirin/Warfain

41. Complications
• KDOQI Clinical outcome goals:
- Thrombosis rate of 0.25 episodes/patient-year and life
expectancy of more than 3 years for autogenous accesses and
a thrombosis rate of 0.5 episodes/patient-year and a life
expectancy of more than 2 years for prosthetic accesses
- Infectious complication rates should not exceed 1% and 10%
over the functional life of an autogenous and prosthetic
access, respectively

42. Complications
1. Failure:
- Early: A fistula which was never usable for dialysis/
fails within 03 months of creation
- Causes:
a. Inflow:-
Pre-existing – Small calibre, atherosclerosis
Acquired – Juxta-anastomotic stenosis
b. Outflow:-
Side branches
Anatomically small
Stenotic

43. Juxta-anastomotic stenosis

44. Complications
- Late: Occurs after 03 months of creation
- Causes:
a. Venous stenosis:- At pressue points and
bifurcations
b. Arterial lesions
c. Thrombosis

45. Radial artery stenosis

46. Accessory veins and stenosis

47. Complications
2. Steal syndrome:
- Occurs in 1-8% cases
- May lead to severe ischaemia
- Presentation: Chronic pain, tissue loss,
extremity loss
- Pathology:
a. High flow
b. Arterial stenosis
c. Poor collateral perfusion(diabetics)

48. Steal syndrome

49. Steal syndome
Duplex Doppler ultrasound of the left antecubital fossa demonstrating a
significant steal syndrome. Blood enters the proximal brachial artery
(1) and >70% is shunted through the PTFE graft (3) with <30% flow
through the native distal artery (2).

50. Management of Steal syndrome

51. Management of Steal syndrome
Distal reconstruction and
interval ligation (DRIL)/
RUDI
• Preferable to use vein
• Increased risk thrombosis
PTFE
• 9 case series
• Symptoms resolved 33 to
100%
• Improved 17 to 66%
• DRIL patency 86 to 100%

52. Complications
3. Aneurysm and Pseudo-aneurysm formation:
- Indications for aneurysm repair:
a. Skin overlying the fistula is (ischemic)
compromised
b. Risk of rupture
c. Available puncture sites are limited

53. Complications
- Indications for pseudo-aneurysm repair:
a. Symptomatic or threatens the viability of the
overlying skin
b. Evidence of infection
c. Enlarging in size or > than twice the diameter of the
graft
d. Limited number of cannulation sites

55. Complications
4. Venous hypertension:
- Upper limb edema
- Skin discoloration
- Access dysfunction
- Peripheral ischaemia with fingertip ulceration
Pathology:
- Ipsilateral central venous catheter placement with
consequent venous stenosis

56. Complications
• Management:
- Angioplasty
- Fistula disconnection

57. Complications
5. Infections:
- Incidence:-
a. Autogenous: 0-3%
b. Prosthetic grafts: 6-25%
- Present as vasculitis
- May even have septic emboli
- Culture based antibiotic therapy x 06 wks
- Drainage
- Excision of infected prosthetic material

58. Haemodialysis Catheters

59. Catheters
• Indications:
- Acute renal failure.
- Dialysis for overdose.
- ESRD with no access.
- ESRD with failure of access.
- Peritoneal dialysis with complications.
- Cardiac failure patients.
- Plasmapharesis

60. Pre-procedural evaluation
• History & Physical Examiantion:
- H/O previous tunneled catheter, central line,
AVF and pacemaker insertions
- H/o coagulation disorders
- Examination of neck and chest
- Ipsilateral facial and upper extremity edema,
distended veins and collaterals

61. Pre-procedural evaluation
• Imaging:
- Colour flow venous duplex imaging:
First line
Has limited role in the imaging of chest
veins
- Magnetic Resonance venography :
94% sensitivity for > 50% occlusion
Concerns with Gadolinium
- CT Venography:
Readily available
Faster acquisition
Safer contrast
- Catheter based venography:
Gold standard

62. Technical considerations
• Arterial lumen:
- Outflow to HD machine
• Venous lumen:
- inflow from HD machine
• Catheter dysfunction:
- Qb < 300ml/min.
- Art. Pressure <-250.
- Ven. Pressure > 250.
- Unable to aspirate blood freely. (Late sign).
- Frequent pressure alarms

63. Types
• Cuffed / non Cuffed
- longevity
• Luminal design
- Split tip, Step tip, Symmetric tip and Dual
catheters
• Material
- Silicon, Silastic, Polyurethane
• Antiseptic impregnated.

64. Non cuffed catheters
• Short.
• More rigid.
• Easy and fast insertion.
• Immediate use.
• Higher infection rate.
• Preferred IJ or femoral.
• Avoid subclavian.
• < 3wks for IJ.
• <5 days for femoral

65. Cuffed catheters
• Dacron cuff.
• Softer.
• Sheath for insertion.
• Requires sedation.
• Lower neck insertion site.
• More bleeding.

67. Insertion sites
• Rt IJV
• Lt IJV
• Subclavian not preferred due to the venous
stenosis.
• Femoral
• Translumbar
• Transhepatic

68. Recommended duration
• Vascular catheters:
- IJV 2-3wks
- Subclavian 2-3wks
- Femoral 2-5days
• Cuffed tunneled:
- 1 year –Indefinite.

69. Complications
• Peri-operative:
1. Pneumothorax
2. Haemothorax
3. SC haematoma
4. Wire embolism
5. Arrhythmias: Cardioversion 0.9%
6. Cardiac perforation
- due to dilators, guide wires and rigid introducers
7. Thoracic duct laceration
- Small chance
- Cirrhotics are more prone
- Resolves spontaneously
8. Catheter misplacement
- Venous/arterial

70. Complications
• Late:
1. Air embolism:
- Rare but potentially lethal
- Due to disconnection/ cracks
- Sudden haemodynamic collapse
- Left lateral decubitus
- Aspiration
2. Catheter embolism:
- Due to fractures at points of stress
- Diagnosed due to incomplete removal
- Angiographic retrieval

71. Complications
3. Catheter occlusion:
- 30-40% with tunneled devices
-Due to formation of fibrin sheath
- Management:
> Heparin flush(1ml=5000U) 3times/wk
> Warfain
> Aspirin
> rtpa (Alteplase) flush
> Angiographic snare based retrieval
> Catheter change

72. Fibrin sheath

73. Complications
4. Central venous thrombosis:
- Occurs in conjunction with S. aureus
infection
- Facial, neck and arm swelling
- Duplex USS is diagnostic
- Anticoagualtion and arm elevation
- May require catheter removal

74. Complications
5. Central Venous stenosis:
- Due to subclavian cannulation
- Intimal injury
- May involve brachiocephalic and SVC
- Asymptomatic/ Upper limb edema
- Limb elevation
- Presence of ipsilateral access complicates the
scenario
- Angioplasty +/- stent placement
- Multiple procedures

75. Complications
6. Catheter related infection:
- Incidence: 0.6 to 6.5 episodes per 1000 catheter
days.
- Types
a. Exit site: Inflammation confined to the area surrounding the
catheter exit site, not extending superiorly beyond the cuff if the catheter
is tunneled, with exudate culture confirmed to be positive.
b. Tunnel site: The catheter tunnel superior to the cuff is
inflamed, painful, and may have drainage through the exit site that
is culture positive
c. Bacteraemia: Blood cultures are positive for the
presence of bacteria with or without the accompanying
symptom of fever (Blood Cx > 15CFU. From peripheral and catheter)

76. Complications
- Bacteriology:
a. gram-positive (52%-84%), with S.aureus
making up 21% - 43%. MRSA in 12%-38% of
cases.
b. gram-negative: Pseudomonas species,
K.pneumoniae, E.coli and Enterobacter
c. Fungal: Candida

77. Complications
- Treatment:
> Emperical broad spectrum antibiotics
followed by culture specific regimen
> Gram+ve 4-6 wks
> Gram –ve 7-14 days
> Caspofungin/Amphotericin B
> Topical Mupirocin
> Antibiotic lock: Cephazolin, vancomycin

78. Complications
- Complications of catheter related infections:
1. Osteomyelitis
2. Septic arthritis
3. Spinal epidural abscess
4. Endocarditis

79. Advantages
• Universal Application.
• No maturation time.
• Short term Hemodynamic consequence.
• Lower initial cost.
• Provide time for fistula maturation.

80. Disadvantages
• Associated with higher mortality risk than fistula
• Thrombosis.
• Infection.
• Central venous thrombosis.
• Discomfort.
• Cosmetic.
• Shorter expected using time.
• Lower Qb.

81. Haemodialysis Reliable Outflow
(HeRO) Device
• Indications:
- Upper extremity access precluded by central
venous stenosis or occlusion
- Alternative to lower limb access techniques
• Relative contraindications:
- Brachial artery diameter < 3mm
- SBP< 100mmHg
- EF < 20%
- Presence of active infection

82. Haemodialysis Reliable Outflow
(HeRO) Device
• Components:
- Graft: 6mm PTFE
- Catheter: Into RA via SVC/ Subclavian
• Outcomes:
- Lower infection rates
- Higher patency

84. Thank You