Practical Guide to Surgical and Endovascular Hemodialysis Access Management

Case Based Illustration

Jackie Pei Ho, Kyung J Cho, Po-Jen Ko, Sung-Yu Chu, Anil Gopinathan

• Editorial: WSPC
• Año: 2015
• ISBN:
  9789814675369
• Categoría: Medicine
• Categoría: Surgery & Surgical Medicine

The renal failure and hemodialysis dependent population is increasing worldwide. Hemodialysis access is the life-line of these patients. Hemodialysis access related surgical and interventional procedures form a major demand to the healthcare services in many developed and developing countries. As such, the proper clinical decision, planning and performance of these procedures will greatly benefit the hemodialysis patients and reduce unnecessary healthcare costs.

This book is a practical guide for clinicians and nurses creating, treating or managing hemodialysis accesses for renal failure patients. Basic principles to manage common or difficult situations of hemodialysis access are discussed and illustrative clinical cases are shown as examples. This book is an essential reading material for healthcare professionals in their early phase of developing the hemodialysis access program, while providing useful tips and tricks to established clinicians that will broaden their armamentarium.

The renal failure and hemodialysis dependent population is increasing worldwide. Hemodialysis access is the life-line of these patients. Hemodialysis access related surgical and interventional procedures form a major demand to the healthcare services in many developed and developing countries. As such, the proper clinical decision, planning and performance of these procedures will greatly benefit the hemodialysis patients and reduce unnecessary healthcare costs.

This book is a practical guide for clinicians and nurses creating, treating or managing hemodialysis accesses for renal failure patients. Basic principles to manage common or difficult situations of hemodialysis access are discussed and illustrative clinical cases are shown as examples. This book is an essential reading material for healthcare professionals in their early phase of developing the hemodialysis access program, while providing useful tips and tricks to established clinicians that will broaden their armamentarium.

Contents:

• General Principles of Hemodialysis Access Creation (Jackie P Ho)
• Algorithm of Assessment and Planning of Hemodialysis Access Creation in Challenging Conditions (Jackie P Ho)
• Creation of Vascular Access (Jackie P Ho)
• Challenges in Tunnelled Catheter Insertion (Anil Gopinathan)
• Assessment of Vascular Access Maturity and Long Term Performance (Jackie P Ho)
• CO 2 Angiography: Application and Caution (Kyung J Cho)
• Strategies to Assist Fistula Maturation and Successful Use for Hemodialysis (Jackie P Ho)
• Endovascular Salvage for Failing Hemodialysis Access (Jackie P Ho)
• Endovascular Salvage for Thrombosed Hemodialysis Access (P J Ko and S Y Chu)
• Surgical Management for Failing and Failed Hemodialysis Access (Jackie P Ho)
• Strategies for Central Vein Obstruction (Kyung J Cho)
• Prevention, Diagnosis and Management of Steal Syndrome (Jackie P Ho)
• Management of Aneurysm, Pseudoaneurysm and Infective Complications of Hemodialysis Access (Jackie P Ho)
• Vascular Access for Desperate Situations (Jackie P Ho)
• Multi-Disciplinary Team Approach for Optimal Hemodialysis Access Care (Jackie P Ho)

Key Features:

• This book provides an overall principle of hemodialysis access management strategy, discussion and illustration on various hemodialysis access creation and maintenance, review of treatment for various challenging access conditions
• The authors are vascular surgeons and intervention radiologists dedicated to hemodialysis access service. This book has a comprehensive coverage of surgical and intervention management of various conditions of hemodialysis access
• This book consists of large number of clinical photographs, schematic diagrams, operative and interventional images, and clinical decision flow chart for easy reading and understanding

CHAPTER 1

General Principles of Hemodialysis Access Creation

Jackie P. Ho

Overview on ESRF and Hemodialysis Access

The prevalence of end stage renal failure ESRF patients is increasing Worldwide.¹ Japan, Taiwan, USA, Portugal, Singapore and Mexico are some of the countries having the highest ESRF prevalence. Hemodialysis is the modality of renal replacement therapy adopted by the majority of patients.² The hemodialysis access has become the life-line of many ESRF patients.

Different from treatment of various vascular diseases, hemodialysis access management involves creation of an abnormal vascular passage that will constantly and repetitively interact with the external hemodialysis devices. This passage can be in the form of a tunnelled catheter inserted into a large sized central vein, CVC, or a new connection between an artery and a vein using either patient’s native superficial vein (arteriovenous fistula, AVF) or synthetic graft (arteriovenous fistula graft, AVG).

On the other hand, many patients do have existing cardiovascular diseases which will interfere with the choice, success, risk and durability of hemodialysis accesses.

The creation and maintenance of hemodialysis access require both open vascular surgical technique and endovascular wire and catheter technique. The planning and monitoring of hemodialysis access also require specific knowledge and skill sets. This book aims to provide an all compassing coverage of these aspects. Before going into a specific area, let us take a closer look at the center of hemodialysis access service — the patient and the access users.

Understand Your Patients and the Access Users

Diversity: Renal failure hemodialysis-dependent patients have a wide spectrum of medical risk, cardiovascular conditions, psycho-social and financial status. Their age range from pediatric to octogenarians. Some have low surgical and anesthetic risk while some have extremely high risk. Some are young, mobile and working with long life expectancy. Some are old and frail, who require a caregiver to attend clinics and treatments. There are a variety of illnesses leading to ESRF. Chronic medical co-morbidities are common among the hemodialysis population. Because of the multiple long-term medical problems, psycho-social and financial problems are frequently seen among the patients, rendering hemodialysis access service delivery more difficult. Depression and depressive symptoms are not uncommon in hemodialysis patients.

Service goal: The hemodialysis access serves as the life-line of those patients. Patients may require hemodialysis access for a couple of years to few decades. Hemodialysis access program therefore should not look to providing a one-off service but a long-term committed care with strategic planning. Due to the wide variation of their medical, surgical and psycho-social issues,^3,4 hemodialysis access strategy also needs to be tailored to suit individual’s problems and needs. The aim is to enable patients to have hemodialysis access with longest duration, least number of surgical and interventional procedures and least access-related morbidity. The service should be set to minimize the disturbance of patients’ and their caregivers’ daily activities. Day procedure therefore is a more preferable model. Clinicians have to be sensitive to patients’ emotion and psychological status. A friendly and caring healthcare team is one of the key elements for a successful hemodialysis access service.

End users: The end user of the hemodialysis access is not the nephrologist, surgeon, or interventional radiologist. The end users are the patient and the nursing staff of the dialysis center who needle the access few times a week. Unfortunately, the healthcare team and dialysis nurses rarely work side-by-side in the same facility. Many patients are unable to understand their access condition thoroughly or to convey the message between the two parties. A clear and standardized format of communication between the healthcare team and dialysis nurses can greatly facilitate the hemodialysis access service.⁵ Dedicated patient education on access assessment and daily care will engage patients well in maintaining a functional access. In the long journey of maintaining a hemodialysis access, the patient himself/herself is an important team player.

Patient expectation: Currently surgically created vascular accesses for hemodialysis are being addressed as “permanent access”. The term “permanent” may cause some confusion. These accesses are permanently created onto the patient’s body. However, most accesses degenerate and develop stenosis with time and may not work permanently. Patients will become disappointed and frustrated when vascular access become blocked, which is against their expectation of “permanent”. Therefore, patients should be counselled that the vascular access is only of “long-term” and not “permanent” use. Vascular access, especially AVF, may be perceived as a minor and simple operation. Patients may expect a straight forward process from creation to needling. Again, emotional upset may arise if the access failed to mature or require secondary procedures to enhance the maturation. Proper patient counselling and patient education help manage the expectation of the patients and avoid unnecessary frustrations.

General Principles

There are benefits and disadvantages for both hemo- and peritoneal dialysis. Make sure the patient has been well counselled on both dialysis modalities and had made an informed decision for themselves before creating a vascular access.

The three essential components of a hemodialysis access (except tunnelled CVC) are:

Good inflow — clinician has to find an artery which is easily accessible, reasonable in size, good flow and ensure creating a fistula on it will not compromise the end organ blood supply.

Good outflow — An outflow vein that drains well ultimately into right atrium.

Good conduit — Either native superficial vein or a synthetic graft that can easily be cannulated.

There are several general principles on surgical dialysis access:

(1) Patient’s native vein arteriovenous fistula (AVF) in general is preferable to synthetic graft arteriovenous fistula graft (AVG)^6–8

Usually, AVF has better patency and fewer septic complication than AVG, provided the native vein size and quality is satisfactory.

(2) Use the most distal native vein first⁶

This is to preserve more proximal vein for future use when the distal AVF failed. Distal forearm cephalic vein will be considered first, followed by mid-forearm cephalic vein and antecubital vein. Basilic vein of the arm, situated medially, usually deeper in subcutaneous tissue and next to medial antebrachial cutaneous nerve, will be chosen when cephalic vein is small or exhausted. Basilic vein of the forearm may also be used for AVF creation if the size is good.

(3) Choose non-dominant or less functional upper limb for access creation

Patients will have reduced functionality of the upper limb bearing the vascular access during dialysis for about 4 hours in 2–3 days every week. After dialysis, they also need to avoid exertion of that limb for half a day to minimize re-bleeding. It is more convenient for the patient if the vascular access is situated on the non-dominant or less functional limb. This is particularly true if the patient had suffered a previous stroke and there is weakness in one of the upper limbs. Bearing in mind the vein of the weaker limb may shrink in size and contracture may present, vascular access creation or subsequent cannulation in the weaker limb could be more challenging.

(4) It is more preferable to place dialysis access on upper limb than lower limb

There are both medical⁹ and social disadvantages of placing the vascular access in the lower limb compare to upper limb. Venous stenosis and deep vein thrombosis symptom in the lower limb are more likely to cause problems than in the upper limb. Hygiene in general, is better for the upper limb and therefore will have less septic complications. The social embarrassment of exposing the upper limb for cannulation is also less than the lower limb, especially for female patients.

(5) Avoid or minimize the duration of percutaneous tunnelled CVC

Disadvantages of percutaneous tunnelled CVC include line sepsis, social inconvenience and induce central vein stenosis or thrombosis (risk increase with duration). Certainly, tunnelled CVC has to be avoided or its duration minimized for patients with reasonable life expectancy. On the other hand, the advantages of tunnelled CVC are no needling pain on every dialysis session, no risk of steal syndrome and no surgery required. A long-term tunnelled catheter may be the best hemodialysis access option for some patients, e.g. patients with very limited life expectancy (terminal malignancy or terminal medical conditions), patients with extensive arterial atherosclerosis involving both upper and lower limbs, patients with hematological diseases whose bleeding risk will worsen in future.

In some clinical situations, the principles may conflict with each other. Clinicians have to weigh the importance of these principles based on individual patient’s specific conditions. Some examples are discussed below.

A 63-year-old petite lady, with tunnelled CVC inserted via the right internal jugular vein IJV eight months ago, attends your clinic for vascular access creation. Besides diabetes and hypertension, she also suffers from depression. She has marginal sized left forearm cephalic vein clinically as well as on ultrasound study (average 2.2 mm). Antecubital vein over left elbow is prominent and measures 2.8 mm on ultrasound. Brachial, radial and ulnar pulses are all palpable. Diameter of her radial artery measures 1.8mm on ultrasound study. A small radial artery together with a marginal sized vein, the chance of maturation failure of a left RC AVF is high. To avoid prolonging the tunnelled CVC duration and inducing disappointment, a more reasonable approach would be to use the more proximal antecubital vein for BC AVF creation as the first attempt.

A 57-year-old morbidly obese lady (Fig. 1) with history of diabetes, sleep apnoea and heart failure (ejection fraction 35%) had tunnelled CVC via right IJV two months ago and then blocked one week ago required change of the catheter to the right femoral vein. On examination, left forearm cephalic vein is not visible, antecubital vein is palpable and of reasonable size over the cubital fossa. Ultrasound study confirmed the left forearm cephalic vein is small (average 1.5 mm). The left arm cephalic vein size averaged 2.9 mm but the subcutaneous fat above the arm cephalic vein measured 15–20 mm. All the pulses over left upper limb are palpable and strong.

The option for this lady would either be left BC AVF and a subsequent superficialization procedure of the cephalic vein fistula, or a forearm loop BC AVG. There are pros and cons for either strategy. Left BC AVF and superficialization bears a higher risk of wound compli...