Chapter 176 - Hemodialysis access - complex Flashcards
Rate of access creation outside of the upper extremity
7%
Patency of central venous angioplasty or stenting 1 year
29% angioplasty
70% stenting
Autogenous femoral vein transposition requirements
1) vein > 3mm
2) patent noncalcified fempop artery
3) No significant obesity of the thigh
Prosthetic loop fem-fem access requirements
1) patent FV, noncalcified SFA CFA
2) No obese patients
Prosthetic chest wall access requirements
1) patent axillosubclavian artery and vein
2) patent central vein
Tunnelled dialysis catheter requirement
Patent central vein
Hemoaccess reliable outflow vascular access device requirement
1) guide wire access to patent central vein
2) brachial artery > 3 mm
3) no active infection
4) SBP > 100 mmHg
5) EF > 20%
GSV forearm translocation secondary patency at 1 and 2 years
50-96% 1 year
66-84% 2 year
Infection rate of GSV forearm translocation
4%
FV translocation patency and issues
67-100% secondary patency at 18 months
Steal at 27%
DRIL using contralateral GSV
Arm composite autogenous vascular access (ACAVA)
GSV and FV both used to limit steal
81% secondary patency at 12 months
Brachial vein tranposition secondary patency
1 year 40-92%
2 year 55%
GSV transposition key points
size necessary
delay before cannulation
1) skip incisions or endoscopic harvest to reduce morbidity
2) > 3mm needed
3) cannulation after 6 weeks
4) not useful if morbidly obese
FV transposition issues
32% limb ischemia
ABI drop 0.21
Primary and secondary patency of FV transposition
91%
84%
2 years
FV transposition key points
1) 5 mm anastomosis
2) ABI > 0.85
3) palpable pedal pulse
Types of chest wall/cervical AV access
1) Axillary-ipsilateral axillay loop
2) Necklace: axillary-contralateral axillary/jugular loop
3) brachial-jugular
Necklace access first described by
McCann 1996
Necklace access patency
Primary 72%
Secondary 89%
1 year
Brachial jugular access tunnelling track
Ventral aspect of shoulder
Over mid clavicle
Brachial jugular access patency
70-93% secondary patency 2 year
Rate of steal in chest wall access
0
even if previous forearm steal
Rate of infection in chest wall access
4-15%
better than LE
Tunnelling axillary axillary loop key points
1) reverse trendelenburg to keep breast in dependent position
2) Counterincision cephalic to areola
3) venous limb placed laterally
4) venous limb parallel to vein
5) arterial limb perpendicular to artery
6) access 2-3 weeks
HeRO graft components
1) graft: 6 mm PTFE with titanium coupler
2) venous outflow 19F silicone catheter with nitinol braid
HeRO graft key points
1) counterincision in deltopectoral groove
2) use in catheter-dependent patients with central venous stenosis/occlusion
HeRO patency 1 year and steal rate
Primary 22%
Secondary 59%
Steal 6.3%
Super HeRO adapter
Allow connection to an early cannulation graft (Accuseal
LE prosthetic AV access types
1) Fem-GSV
2) fem vein loop
3) popliteal -GSV
4) fem vein straight AV access
patency of LE prosthetic AV access
1 year 71%
2 year 60%
secondary patency
Infection rate of LE prosthetic AV access
8-41%
Rate of limb loss in LE prosthetic AV access
1-3%
General orientation of LE grafts
Arterial limb lateral
Venous limb medial
Unconventional chest or abd wall access procedures
1) Bypass to right atrial appendage through 3rd intercostal space (minipericardiotomy)
2) right SFA-SVC prosthetic access
3) femoral transposition with iliac vein to SVC bypass
4) axillary artery to left renal vein
5) external iliac to left renal vein
6) right axillary artery to right atrium
Arterial-arterial access procedures
1) Axillary-axillary PTFE
2) femoral-femoral PTFE
3) SFA-PFA PTFE
Salgado SFA transposition for vascular access steps
1) transection of sartorius
2) mobilize SFA
3) close subcutaneous tissue beneath artery with sartorius
4) close skin over artery
Issues with arterial-arterial access
1) no medication infusion
2) pressure 20 min for bleeding to stop
3) low flow only to avoid recirculation and arm pain
Unconventional tunnelled dialysis catheters
1) transthoracic SVC catheter (hemothorax/pneumothorax)
2) Inside-out central venous access technique (IOCVA)
3) translumbar IVC catheters
4) transhepatic IVC catheter
Preferred renal replacement in pediatric population (< 20kg)
1) renal transplant
2) PD
Rate of kidney transplant in pediatric patient with ESRD
38% in 1 year
