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Dialysis > Dialysis Access > Flashcards

Dialysis Access Flashcards

1
Q

What AVFs have the best patency

A

Upper arm (brachial-basilic or brachial-cephalic)

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2
Q

What medical treatment improve patency?

A

CCB - Primery patency of AVG
Aspirin - Secondary patency of AVG
ARBs - improves AVG patency.

Ace-i - Primery Patency of AVF
ARBs + Antiplatlets - patency of AVF.

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3
Q

What medical treatment reduce patency?

A

Warfarin reduces AVG Primery Patency.

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4
Q

What 3 arterial factors improve AV success rate and patency?

A

No pressure differance between hands
Diameter of 2mm or above
Patent palmar arch

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5
Q

What venous factors improve AV success rate, matoration and patency?

A

Diameter of 2.5-3 is good of success and early maturation.
3mm is optimal.

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6
Q

What are the advantage of upper extremities shunt over lower extremities?

A

Lower infection rate.
Better and more comfortable access.

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7
Q

What are the main principals in planning and selecting shunt type and location?

A

Non dominant hand first.
Start as distal as possible.
Prefer autologous shunt
Prefer type of fistula by this order: Direct anastemosis, Venous transposition, Venous translocation, Prosthetic.

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8
Q

What is the preferred vein for fistula in the Forarm?

A

Chephalic

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9
Q

What is the order of seletction of arteries for anastomosis in the Forarm?

A

Posterior branch of Radial (Snuffbox)
Radial
Ulnar
Proximal Radial
Brachial

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10
Q

What is the chalange of using basilic vein in the the Arm and Forarm?

A

The vein is medial and always requieres transposition.

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11
Q

In case of no autologous vein in the Forarm, what is the next choice?

A

Translocation of Saphenous or femoral vein.
Prosthetic graft is the last choice as a bridge to AVF in the Arm.

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12
Q

What are the risk of too meny endovascular salvage treatments to AVF?

A

Can damage the venous outflow.

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13
Q

What is the preferred vein for fistula in the Forarm?

A

Chephalic

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14
Q

What is the order of seletction of arteries for anastomosis in the Arm?

A

Proximal Radial
Brachial

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15
Q

When would you prefer a two stage transposition access surgery over one stage surgery?

A

When the vein in less than 4mm

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16
Q

After how long can you use AFG?

A

2 weeks.

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17
Q

What is the avarge time to maturation of AVF?

A

12 weeks.

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18
Q

What is the disadvantage of Balloon assisted maturation (BAM)?

A

Patency equals prosthetic graft but more expensive.

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19
Q

What Graft-arterial ratio is abnormal?

A

>0.75

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20
Q

What Graft-venous ratio is abnormal?

A

<0.5

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21
Q

What is the 1 year primery and secondary partency of AVF?

A

Primery 85%
Secondary 90%

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22
Q

What is the 2 year primery and secondary partency of AVF?

A

Primery 69%
Secondary 75%

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23
Q

What is the 1 year primery and secondary partency of AVG?

A

Primery 54%
Secondary 65%

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24
Q

What is the 2 year primery and secondary partency of AVG?

A

Primery 30%
Secondary 60%

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25
Q

AVF - P vs. S - 1 vs 2 years
AVG - P vs. S - 1 vs 2 years

A

85, 90, 70, 75
55, 65, 30, 60

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26
Q

What is the most common way to measure fistula function?

A

Urea clearance > 1.2

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27
Q

What are the 3 craiteria for fistula maturation?

A

6 rule
6mm depth
6 mm diameter
> 600ml/min flow volume

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28
Q

What is recirculation?

A

Outflow blood contains inflow blood.

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29
Q

What is the flow volume requiered to avoid recirculation?

A

1000-2000ml/min

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30
Q

What is the influance of AVF/AVG on Cardiac Function?

A

Access creation increase Pulmonary hypertension and CO.
Hance patients with Pulmonary HTN or Heart faliure will have a diteriaration in their basic condition.

The High access flow (Qa) increase the preload and the extraction of flueids increase the CO.
If the heart can’t compensate and increase CO it will decline and also cause recirculation.
The danger zone (Q/CO >0.3) for developing CHF increase when CO decline.

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31
Q

What is considered abnormal Venous Pressure in dialysis?

A

50% above mean arterial pressure

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32
Q

Steal syndrome grading?

A
  • Grade 0: No symptoms - “physiologic steal”
  • Grade 1 Mild: Cool extremity, few symptoms, flow augmentation with access occlusion
  • Grade 2 Moderate: Intermittent ischemia only during dialysis, claudication
  • Grade 3 Severe: Ischemic pain at rest, tissue loss
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33
Q

Risk factors for Steal syndrome?

A

DM
PAD
Coronary Artery Disease
Brachial-based access (proximal)
Female
History of steal syndrome
mulltiple previous access procedures

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34
Q

What grade of steal syndrome need intervantion?

A

Grade 3 and somtimes 2.

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35
Q

Treatment Algoritm of steal syndrome

A
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36
Q

What are the surgical methods for steal syndrome?

A
37
Q

What is Ischemic Monomelic Neuropathy?

A

Acute pain or anastesia developed hours after surgery.
Occur in 0.5% of cases.
Delayed recognition/intervention leads to irreversible neurologic deficits.
Treatment is ligation.

38
Q

What is the 1-year mortality for patients on HD?

A

22%
mean life expectancy 5.8y

39
Q

What are the SVS guidelines for starting HD?
For using AVF?

A

Cr clearance <25ml/min

autogenous should mature for 6 months (4-6weeks ok)
prosthetic 3-6weeks
would be constructed before initiation of HD

40
Q

Why wait >4-6 months before initiation of HD?

A

lower risk of death and sepsis compared to <1 month

41
Q

Does plavix help keep AVF open?

A

there is no evidence to support that

42
Q

What are catheter options for dialysis?

A

short term
double lumen, non-tunneled, noncuffed, <6 months)

43
Q

What bacteria are associated with catheter infection?

A

S.Aureus, CONS, enterococcus, pseudomonas

44
Q

How do you clinically exam UE for AVF and important hx?

A

Neuro
derm
CHF, dominance, IV/central lines, trauma
pulses
edema
tourniquet to assess veins for continuity and size
tap
chest wall collaterals

45
Q

What are ideal vessel sizes for UE AVF?
How does vein size affect maturation/patency?

A

artery 2mm
vein 3mm

if 2.5 maturation 90%, 80% 1 year patency

46
Q

Why is cephalic better then basilica vein?

A

easier to access for HD puncture
minimal dissection

47
Q

What is the order of forearm AVF?

A

Snuffbox/posterior radial branch-cephalic
radio-cephalic (Brescia-Cimino-Appel) (if PRB non palpable)
radio-cephalic transposition (if cephalic too far way)
ulnar-cepahlic (if radial not palpable)
Brachial-cephalic forearm looped transposition (if radial/ulnar pulse not palpable but brachial is)
autogenous radial-basilic forearm transposition OR
autogenous ulnar-basilic forearm transposition OR
autogenous brachial-basilic looped transposition (all if cephalic not adequate)

48
Q

Once forearm options exhausted what are other options?

A

can consider prosthetic to exhausted forearm before moving to upper arm. can extend dialysis 1-3 years
6mm PTFE no rings

distal arterial inflow
radial-ac straight
brachial-ac forearm loop

49
Q

What are upper arm AVF options?

A

brachial(or prox radial)-cephalic
autogenous brachial-cepahlic transposition (if cephalic too far away)
autogenous brachial-basilic transposition (if cephalic no good)
brachial-brahcial transposition OR GSV/femoral vein translocation if either vein no good)

50
Q

What is femoral vein and SVG latency in UE AVF?

A

SVG not known, tends not to dilate
femoral vein 94% at 2 years

51
Q

What is preferred vein and artery for LE AVF?
What size should anastomosis be?

A

GSV, femoral artery
4-6mm

52
Q

Why are LE AVF bad?

A

high infection rates, higher likelihood of steal, higher rates of PVD

53
Q

What are possible configurations for LE AVF?

A

autogenous femoral-GSV transposition (loop or straight)
autogenous tibial-GSV direct access
Femoral-femoral transposition
prosthetic femoral artery-femoral vein

54
Q

What are possible configurations for body wall AVF?

A

venous outflow axillary, jugular, common femoral vein
prosthetic ax-ax chest
prosthetic ax-ax chest loop
prosthetic ax-common fem vein chest

55
Q

How should grafts be surveilled post-op?

A

no clear benefit in surveillance
clinical monitoring by skilled personal is adequate
32% reduction in overall cost but mostly in prosthetic
seem more reasonable in prosthetic

56
Q

What are clinical signs of distal graft stenosis for autogenous graft?

A

palpable pulse ar arterial end, failure to collapse with arm elevation, discontinuous bruit, complete access collapse proximally, persistent edema, venous collaterals on ipso chest wall, continued bleeding

57
Q

What is static venous pressure?

A

turn dialysis pump off and equilibrate circuit. venous (efferent) needle pressured is measured. if >50% of MAP considered abnormal or if begins to increase over time

58
Q

What three features make maturation more likely?

A

rule of 6
600ml.min flow

59
Q

What flow rate is indicative of autogenous graft dysfunction?

A

< by 25%

60
Q

What can cause failure of maturation? (4)

A

too deep (may need to retunnel)
non-ligated side branches
poor venous outflow
(distal stenosis, vein too small)
insuff arterial inflow

61
Q

What can be done to accelerate maturation?

A

balloon access maturation (BAM)
2,46, weeks progressively larger balloons

62
Q

What are AVF complications?

A

thrombosis
intimal hyperplasia
failure to mature
infection
seroma
pseudoaneurysm
aneurysm
steal
IMN

63
Q

What is most common complication? how to deal with it?

A

thrombosis
early and late
prosthetic does better then autogenous
tpa 2-4mg
oen thrombectomy

64
Q

How does intimal hyperplasia cause AVF complications? How to manage?

A

>90% graft failure
venous anastomosis stenosis
if >50% should be treated

patch, endovascular

65
Q

what are RF associated with graft failure

A

age, DM, vein diameter <2mm, CHF, female

66
Q

What are clinical features favouring use of a prosthetic?

A

imminent need of HD
short life expectancy
morbid obeisty
unfavorable vascular anatomy

67
Q

What is the benefit or pre-op non-invasives studies?

A

no difference in primary patency but lowers initial failure rate and improved primary assisted patency
not SVS recommendation

68
Q

Describe the two stage approach to the brachia-basilic AVF?

A

incision prox ac and anastomosis
once dilates to 6mm, skip or continuous incisions over course of the vein and dissect.
either elevate vein or disassemble anastomosis
simply elevating makes accessing difficult because courses medially

69
Q

What nerves runs over basilic vein?

A

medial antecubital nerve so if elevate vein either transect nerve or transect anastomosis.
sensory medial cutaneous aspect of arm

70
Q

what is the average life for autogenous and prosthetic?
infection rate?

A

3, 2 years
1-10%

71
Q

What causes recirculation?

A

if dialysis flow exceeds AVF flow
venous outflow stenosis
arterial inflow stenosis
needles too close

72
Q

What causes pseudoaneurysms? How to treat?

A

multiples punctures at same sites
tx reserved if enlarging

73
Q

What causes autogenous access aneurysm? what is tx?

A

usually a result of outflow stenosis
can’t continue cannulation must fix
relocate more proximally

74
Q

What are features of a seroma? how to manage?

A

not uncommon for prosthetic
usually resolve without intervention
usually near arterial anastomosis
may be associated with low grade infections
usually occur within first month
new tunnel usually best management

75
Q

When does stew occur?
what is the cause?

A

usually immediately but can happen up to a year
prox or distal stenosis

76
Q

What is the grading system for steal?

A

0: no steal
1: mild-cool extremity, flow aug with access occlusion
2: moderate-intermittent schema only during dialysis, claudication
3: severe-ischemic pain at rest, tissue loss

77
Q

What are RF for steal?

A

hx of steal
elderly
multiple prior access
PVD
DM

prosthetic
brachial artery

78
Q

What is treatment for steal?

A

DRIL procedure
banding
ligation
RUDI (revasc using distal inflow)
Proximalization of anastomosis

79
Q

What is target DBI and pressure for banding ?

A

DBI 0.6 or pressure 50mmhg

80
Q

What are three types of neuropathy patients with HD can get?

A

systemic disease neuropathy (ureic)
mononeuropathy from compression (carpel tunnel) HD patients get it more frequently
iscchemic monomelic neuropathy

81
Q

What is IMN? What re the RF?

A

acute vascular compromise to the median, radial, ulnar nerves

DM, from brachial, older, PReexisting neuropathy

not seen distal to brachial

82
Q

What are symptoms associated with IMN? tx?

A

pain, weakness, paralysis of muscles of forearm often with sensory loss within hours
hand is warm, palpable pulses, no muscle ischemia

surgical emergency with ligation or revasc

83
Q

What is aetiology of IMN?

A

AC region is watershed for vasa vasorum of the three upper limb nerves

84
Q

What are signs of outflow stenosis on dialysis?

A

High static venous pressure
Low flow rates
Urea clearance

85
Q

What kind of balloons do you use for venous angioplasty?

A

High pressure
Usually stm 24-28

Sustained inflation

86
Q

What stents are best used for venous stenting?

A

Covered stent
Hyperplasia can come through bare metal

87
Q

Where does the DRIL proximal anastomosis need to be?

A

Proximal to the anastomosis by 5-7cm because otherwise there is a pressure drop just distal to the proximal bypass anastomosis

88
Q

Why does proximalization of the anastomosis work for steal?

A

It lengthens the anastomosis so the resistance of the avf.
Same for RUDI

89
Q

What is the cutoff for DBI for ischemia?

A

0.3-0.4

Dialysis (2 decks)

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