VASCULAR

ACCESS
AVF and AVG

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 OBJECTIVES

Upon completion of this topic, the learner will be able to:

1. Describe the advantages and disadvantages of various type of vascular access
2. Identify potential complications connected with each type of vascular access
3. Provide adequate and appropriate education to patients and their significant others.

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Significant Dates in the History of the
Vascular Access

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 AV SHUNT
1960: Scribner and Quinton developed the first permanent access.

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 AV FISTULA
1966: Brescia and Cimino developed the internal arteriovenous (AV) fistula
for repeated venipunctures for maintenance HD.

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 AV GRAFT
1974: Bovine carotid artery graft used for circulatory access
1975: Gore-tex® graft became commercially available for use as AV access for HD
1977: Umbilical cord vein used for AVF graft
1977: Expanded polytetrafluoroethylene (ePTFE) used as AV access for hemodialysis

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Preparing for Vascular Access for
Hemodialysis

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 I. Anatomy of the vascular access for hemodialysis

A. The venous system in the upper extremity includes both superficial and
deep veins. It is superficial system that is most important for access
creation.
B. The radiocephalic AVF at the wrist is the first choice hemodialysis access
and uses the forearm segment of the cephalic vein.

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Anatomy of the Upper Extremity Vessels

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 II. Patient Evaluation
A. Assessment, Evaluation and Preservation

1. Patiet GFR less than 30 mL/min/1.72m² (CKD Stage 4)

2. Early referral for permanent dialysis access.
3. Preservation of veins of the forearm and upper arms.
4. Recommended timeline
1. AVF should be placed 6 months prior to anticipated need
2. AVG should be inserted at least 3 to 6 weeks ahead of anticipated need
5. Nurse play crucial role in educating, explaining and reassuring patients.
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 II. Patient Evaluation
B. Evaluation Prior to Access Placement

1. Helps to optimize access survival while minimizing potential complications

2. Evaluations should include:
1. History and physical examination
2. Dupplex ultrasound of the upper extremity blood vessels

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III. Selection and Placement of the Vascular Access

1. Arteriovenous Fistula
2. Arteriovenous Graft
3. Central Venous Catheter
A. Non Tunneled CVC
B. Tunneled CVC
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NKF KDOQI, 2006, Clinical Practice Guidelines (CPG)

Vascular access should be placed distally and in the upper extremities

whenever possible. Because AVF provides the access with the longest
patency rates and need for fewest interventions; options for AVF creation
should be considered first, followed by prosthetic grafts, if AVF creation is
not possible. Catheters should be avoided for HD and used only when the
previous options are not possible, are contraindicated by the patient’s
condition, or the access for hemodialysis is short term

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The ARTERIOVENOUS FISTULA (AVF)

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Definition:
A surgically created opening between an artery anastomosed to a
juxtapositional (nearby) vein allowing the high pressure arterial
blood to flow into the vein causing:

VEIN ARTERIALIZATION
a. Engorgement
b. Enlargement
c. Wall thickening.

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Types of Anastamosis

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 PLACEMENT OF AVF
(in order of priority)

1. Wrist (radial-cephalic) primary fistula

2. An elbow (brachial-cephalic) primary fistula.
3. An upper arm (brachial-basilic) fistula with vein transposition (surgically
dissecting out and tunneling in a superficial, accessible area)

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Radiocephalic Arteriovenous Fistula

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Snuff-box Arteriovenous Fistula

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Proximal Forearm Arteriovenous Fistula

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Brachiocephalic Arteriovenous Fistula

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Transposed Basilic Vein Arteriovenous Fistula

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 Assessment for Fistula
ALLEN TEST

1. Patient clenches the fist of one hand to 5. Repeat the procedure, but release pressure
produce pallor in the hand on radial artery this time to assess radial
arterial flow to hand.
2. Clinician occludes arterial flow by
compressing both radial and ulnar arteries 6. Repeat procedure with opposite hand.
3. Patient opens clenched fist
4. Clinician releases pressure on the ulnar
artery and counts the seconds required for
color to return to the hand. More than 3
seconds indicates decreased ulnar arterial
supply to the hand if the radial artery is used
for the vascular access

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ALLEN TEST

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 ADVANTAGES OF AVF 1

1. Average problem-free patency period is approximately 3 years.

2. The long-term secondary patency rate:
1. 7 years for forearm fistula
2. 3-5 years upper arm fistula
3. Lowest rate of thrombosis
4. Lower rates of infection than grafts
5. Cost of implantation and access maintenance are the lowest long-term

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 ADVANTAGES OF AVF 2

6. Associated with increased patient survival and lower hospitalization rates.

7. Avoid potential allergic response to synthetic materials
8. Outflow veins are autogenous tissue that seal and heal after cannulation.
9. Can use buttonhole cannulation technique.

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 DISADVANTAGES OF AVF

1. The vein may fail to enlarge or increase wall thickness (i.e., fail to mature)
2. Long maturation time
3. Some individuals, the vein may be more difficult to cannulate.
4. A thrombosed AVF may be more difficult to restore the flow.
5. Cosmetically unattractive
6. Increase cardiac output.

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 RULE OF 6 for AVF MATURATION

• The vessel should be greater than 6mm in diameter

• The vessel should be less than 6 mm from surface
• Flow through the vessel should exceed 600mL per min.
• AVF should be expertly assessed within 6 weeks of creation for maturation

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 ASSESSMENT OF THE FISTULA

LOOK LISTEN FEEL

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 1. INSPECTION - Look

A. Compare the access extremity with the other extremity.

B. Asses the access extremity for:
1. Swelling
2. Presence of collateral veins
3. Change in color or temperature
4. Decreased sensation
5. Limitation of movement
6. Capillary refill time

C. Assess the fistula itself.

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 2. AUSCULTATE - Listen

BRUIT – continuous “whooshing” NORMAL AVF

sound caused by the turbulence at
the anastomosis

• Note change in the sound or character of AVF with STENOSIS

the blood flowing through the fistula.

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 3. PALPATE - Feel

To determine the blood is flowing through the fistula

Thrill – Sensation that felt over the fistula
a) A continuous vibration
b) Result of turbulence created by the blood flow
c) Pulsatile thrill may indicate stenosis

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 PATIENT TEACHING

• Reinforce and expand pre-AVF placement education to avoid

venipunctures and blood pressure measurements in targeted arm.
• Elevate affected arm to decrease post-op swelling
• Exercise for vessel development

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PATIENT TEACHING
• Instruct the ff:
- How to palpate “thrill”
- Avoid sleeping on access extremity
• Avoid wearing anything that would tightly
encircle the access extremity
• Wash area with soap and water before
cannulation
• How to stop bleeding – apply localized
pressure
• How to recognize and report s/s of infection or
absence of thrill / bruit

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The ARTERIOVENOUS GRAFT (AVG)

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 ARTERIOVENOUS GRAFTS (AVG)

• DEFINITON: A synthetic or, less frequently,

biologic conduit implanted subcutaneously and
interposed between an artery and a vein.
• Needles are inserted into the graft (never into the
anastomoses) to remove and return blood during
hemodialysis. The average graft is 6 mm.

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 INDICATIONS of AVG

• Patients who do not have vasculature suitable for AVF

or who have failed AVF in the location of the planned
AVG.
• AVG is second best option for hemodialysis

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 TYPES OF GRAFT

1. Synthetic Grafts
2.Composite/ Polyurethane Graft
3. Biologic Graft

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 ANATOMIC LOCATIONS of AVG

1. A forearm loop graft

2. Upper arm graft
3. Chest wall or “necklace” prosthetic
graft
4. Lower extremity graft.

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FOREARM LOOP ARTERIOVENOUS GRAFT

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UPPER ARM ARTERIOVENOUS GRAFT

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THIGH ARTERIOVENOUS GRAFT

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 AVG Surgery

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ADVANTAGES OF AVG

• Larger surface area for cannulation

• Easier to cannulate
• Time for surgical insertion to
maturation is short
• ePTFE 1-3 weeks prior to cannulation
• Time allows for healing and the
incorporation of the surrounding tissue

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 ADVANTAGES OF AVG

• AVG can be placed in many areas of

the body
• Can be placed in a variety of shape
to facilitate placement and
cannulation
• Graft is easier to repair

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 DISADVANTAGES OF AVGs

1. Higher rate of stenosis and thrombosis

2. Higher rate of infection
3. Higher mortality
4. Shorter length of patency
1. Last 1-2 years before indication of
failure or thrombosis
2. Long-term patency rate with treatment
of stenosis and thrombosis remains at 2
years

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DISADVANTAGES OF AVGs

5. Cannulation sites seal but not heal

6. Allergic response to the material
7. Steal syndrome

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 Patient Teaching

1. Instruct to elevate and abduct extremity and use

the hand normally as much as possible
2. No venipunctures / BP taking in the access arm
3. Avoid sleeping on the access extremity
4. Wash area with soap & water before cannulation
5. Report any s/s of infection and absence of thrill /
bruit

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VASCULAR ACCESS COMPLICATIONS

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 Access Complications

A. BLEEDING
B. INFECTION
C. VENOUS STENOSIS
D.CENTRAL VENOUS STENOSIS
E. THROMBOSIS
F. ANEURYSM / PSEUDOANEURYSM
G.STEAL SYNDROME

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 A. BLEEDING / INFILTRATION
DEFINITION

• Inadvertent administration of fluid into

tissue surrounding the fistula.
• Secondary to improper cannulation
technique
• Can occur before, during or after dialysis

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 A. BLEEDING / INFILTRATION
SIGNS AND SYMPTOMS

• Edema
• Taut or stretched skin
• Pain

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 A. BLEEDING / INFILTRATION
PREVENTIONS

• Monitor closely for signs and

symptoms of infiltration
• Use caution when taping needles
• Monitor arterial and venous pressure
• Proper needle removal

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 B. INFECTION
CAUSES

• Staphylococcus Aureus is the leading cause

• Poor patient hygiene
• Inadequate skin preparation
• Not using aseptic technique
• Seeding from another infected site in the
body

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B. INFECTION
SIGNS AND SYMPTOMS

• Inflammation
• Pain
• Skin break with drainage along the
course of vessel
• Fever

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 C. VENOUS STENOSIS
DEFINITION

Abnormal narrowing of the lumen of the

vessel as a result of injury to the wall,
causing intimal hyperplasia
• Bruit changes to a choppy
• At the site of stenosis, bruit may be
higher pitched
• Pulse will become a harsher, water
hammer feel

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 C. VENOUS STENOSIS
RELATED ABNORMALITIES

1. Reduction in BFR and potential

clotting
2. Increase static venous pressure
3. Access recirculation
4. Unexplained reduction in KT/V

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C. VENOUS STENOSIS
CLUES INDICATING STENOSIS

1. Inability to maintain BFR

2. Increased venous pressure
3. Difficulty cannulation or having
blood squirt out
4. Increase bleeding time post dialysis

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 C. Venous Stenosis
POTENTIAL INTERVENTIONS AND TREATMENT

1. Non invasive technique to

assess a fistula
2. Doppler ultrasound or
fistulogram
• Detect stenosis
• Measure stenosis
3. Baloon angioplasty
4. Stent placement

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D. CENTRAL VENOUS STENOSIS
CAUSES OR CONTRIBUTING FACTORS

• History of multiple central venous

catheter
• Mechanical compression of the
central venous system
• Arterialized high flow in the central
veins
• Some without an identifiable cause

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 D. CENTRAL VENOUS STENOSIS
SIGNS and SYMPTOMS

1. Massive swelling in the upper

extremity
2. Extensive network of collateral veins
3. Pain and discomfort during dialysis
session

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D. CENTRAL VENOUS STENOSIS
POTENTIAL INTERVENTIONS AND TREATMENT

1. Prevention through avoidance of

subclavian inserted catheters.
2. Transluminal angioplasty with
possible stent placement
3. Surgical treatment is very complex
and reserved for extreme situations.

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 E. THROMBOSIS
CAUSES

1. Stenosis of main outflow vein

without collateral circulation
2. Significant hypotension due to
volume depletion
3. Hypercoagulable states
4. Prolonged occlusive compression
5. Supporting heavy objects

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 E. THROMBOSIS
SIGNS and SYMPTOMS

• Vein distended and does not soften

when arm is elevated overhead
• Significant decreased intra-access
blood flow
• Changes in quality of the bruit
• Difficulty or pain with cannulation
• Evacuation of clots

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 E. THROMBOSIS
POTENTIAL INTERVENTIONS AND TREATMENT

• Urgent referral to a surgeon

• Lysing the clot with a thrombolytic
such as tPA
• Thrombectomy
• Anticoagulation therapy

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 F. ANEURYSM / PSEUDOANEURYSM
CAUSES

• Cannulating in the same area

“one-site-itis”
• Outflow stenosis / occlusion
• Persistent hypotension

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 F. ANEURYSM / PSEUDOANEURYSM
SIGNS and SYMPTOMS

• Vessel enlargement
• Dilatation on the weakened
vessel wall
• Possible changes in bruit

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 F. ANEURYSM / PSEUDOANEURYSM
POTENTIAL INTERVENTIONS AND TREATMENT

• Assessing AVF every treatment

• Education of the staff
• Surgery based on severity

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 E. STEAL SYNDROME
CAUSES

• Ischemia of the extremity distal to • Occurs more frequently in patients

arterial anastomosis who:

• Diversion of significant volume of

• Elderly

blood away from peripheral • Have peripheral vascular disease

circulation • Have diabetes
• Have history of multiple access surgeries

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E. STEAL SYNDROME
SIGNS and SYMPTOMS

• Pain distal to anastomosis

• Cold, pale hand
• Impaired hand movement and strength
• Paresthesias: numbness, tingling
• Poor capillary refill
• Progression to ulcerated, necrotic
fingertips

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 E. STEAL SYNDROME
POTENTIAL INTERVENTIONS AND TREATMENT

• Report any abnormal findings

• Surgical reperfusion of the hand using the DRIL
• Banding of inflow to the graft to reduce flow
• Severe ischemia may require urgent ligation of
the access
• Mild ischemia may improved by wearing of a
glove, exercising, and/or massaging

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 References

• Kallenbach, J.; Review of Hemodialysis for Nurses and Dialysis Personnel,

8th Edition. Elsevier Health Sciences, 2012
• Counts, C.; Core Curriculum for Nephrology Nursing, 6th Edition. ANNA
(American Nephrology Nurses Association), 2015
• Vachharajani, T.; Atlas of Dialysis Vascular Access, 2010

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