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The complications of AV access for

H/D
2007 UpToDate
The 2006 NKF/Dialysis Outcomes Quality Initiative (K/DOQI)
guidelines
The 2006 Canadian Society of Nephrology hemodialysis
guidelines
2007-04-09
Ri

Chronic hemodialysis vascular access:


Types and placement

1.
2.
3.

AV fistulas
Synthetic grafts
Tunneled cuffed catheters

AV fistulas

End-to-side vein-to-artery
anastomosis
The 2005 Canadian and 2006
United States K/DOQI guidelines:
1.
2.
3.
4.

radiocephalic
brachiocephalic
brachiobasilic
Brachial artery and median
antecubital vein

Synthetic grafts

Polytetrafluoroethylene (PTFE, also known as


Gortex)
Straight or looped and ranges between 4 to 8 mm
in diameter
Straight forearm (radial artery to cephalic vein)
Looped forearm (brachial artery to cephalic vein)
Straight upper arm (brachial artery to axillary vein)
Looped upper arm (axillary artery to axillary vein)
The 2006 K/DOQI work group prefers a forearm
loop graft

Tunneled cuffed catheters

Internal jugular vein


Right sided catheters malfunction
less than left sided
Subclavian catheters should be
avoided to prevent subclavian
stenosis

COMPARISON

Primary failure:

Secondary failure:

graft > fistula

Time to use:

an access that never provided reliable hemodialysis


fistula > graft

fistula: weeks to 6 months


graft: days to weeks
catheter: intermediate-duration

Recommendation:

fistula preferred

Nonthrombotic
complications

Infection
Heart failure
Distal ischemia
Aneurysm and pseudoaneurysm
Venous hypertension
Median nerve injury
Seroma formation

Infection

Accounts for 20% of access loss


The source of most bacteremia in H/D pt
S. aureus, S. epidermidis
Predisposing factors:

pseudoaneurysms or perifistular hematomas


severe pruritus over needle sites
intravenous drug abuse
secondary surgical procedures

Prophylaxis?

unsuccessful in preventing

The 2006 NKF/Dialysis Outcomes


Quality Initiative (K/DOQI) guidelines:

six weeks Abx for fistula


surgical excision with septic emboli
infected PTFE grafts:

surgical intervention, may require skin flaps,


3 weeks of Abx

Heart failure

Rare, even in pt with cardiac disease


Fistula increase LV hypertrophy
High-output heart failure if fistula flow
>20% C.O
Treatment:

limiting fistula flow by banding


access thrombosis, may not permanently
decrease flow
peritoneal dialysis or cuffed catheter

Distal ischemia

Distal hypoperfusion of the extremity


Shunting ("steal") of arterial blood flow
1-20%, DM and the elderly
Absent pulse or a cold extremity warrant
immediate surgery
Paresthesia, sense of coolness with
retained pulses, improve over weeks
Management:

percutaneous transluminal balloon angioplasty


distal revascularization with interval ligation

Aneurysm and
pseudoaneurysm

Infrequent complications
Repeated cannulation in the same area
Pseudoaneurysm:

If small defect (<5 mm), occlude it!


Options for the evaluation: graft rupture

a particular problem with PTFE grafts, the material


deteriorates after prolonged use

spontaneous bleeding, rapid expansion in size, severe


degeneration in the material

The K/DOQI guidelines for intervention:

The skin overlying the fistula is compromised


a risk of fistula rupture
Available puncture sites are limited

Venous hypertension

Valvular incompetence or central venous


stenosis
S/S:

severe upper limb edema


skin discoloration
access dysfunction
peripheral ischemia with resultant fingertip ulceration

Venous duplex ultrasound, venography


Treatment:

correcting the underlying vascular problem


screening

Median nerve injury

Carpal tunnel syndrome


Local amyloid deposition
Compression of the median nerve

due to the extravasation of blood or


fluid

Ischemic injury by a vascular steal


effect

Seroma formation

Weeping syndrome:

ultrafiltration of plasma across a PTFE graft

A pocket of serous fluid, firm and


gelatinous
Typically at the arterial end of the graft
where intraluminal pressure is higher
Occur at the distal end if there is
significant central venous obstruction
Fistulogram to exclude central venous
stenosis

Thrombotic
complications

Introduction

The most common (80-85%) complication of permanent


vascular access
The cumulative fistula patency rate in most centers:

Expensive to maintain fistula patency, 15% of annual


spending
Predisposing factor:

60 to 70% at one year


50 to 60% at two years

anatomic venous stenosis, 80-85%


arterial stenosis
excessive post-dialysis fistula compression
hypotension
increased hematocrit levels
hypovolemia
hypercoagulable states

A standard definition for stenosis does not exist


Narrowing >= 50%

Pathogenesis

Initiated by endothelial cell injury


Up-regulation of adhesion molecules on the
endothelial cell surface
leukocyte adherence to damaged and
activated endothelium causes the release of
chemotactic and mitogenic factors for vascular
smooth muscle cells
Enhancing smooth muscle cell migration and
proliferation
Activated PLT and inflammatory cells:

secrete oxidants and toxins, injure the vessel wall

PROSPECTIVE MONITORING
K/DOQI guidelines for surveillance of
grafts :

Intra-access flow:

duplex and variable flow Doppler ultrasound


magnetic resonance angiography
dilution based upon ultrasound, urea, or
thermal techniques

Static venous pressure


Duplex ultrasonography
Gadolinium-based MRI should be avoided
due to nephrogenic systemic fibrosis

PROSPECTIVE MONITORING
K/DOQI guidelines for surveillance of
fistulas :

Direct flow measurements


Physical findings suggestive of stenosis:

arm swelling
prolonged bleeding after needle withdrawal
collateral veins
altered features of the pulse or thrill

Duplex ultrasonography
Static pressure

When to refer?

More than one abnormalities


Persistent abnormalities
Access flow rate <600 mL/min for fistula
Access flow rate <400-500 mL/min for
graft
Venous segment static pressure ratio >0.5
Arterial segment static pressure ratio
>0.75

Treatment of venous
stenosis

Percutaneous angioplasty
Endovascular metallic stents
Surgical revision

Percutaneous angioplasty

Corrects over 80% of stenosis

in both native fistulas and synthetic grafts


in both venous and arterial outflow tracts

The 2006 K/DOQI guidelines


recommend angioplasty if:

stenosis in fistula >50%


stenosis in graft >50% + (abnormal physical
findings, intragraft blood flow <600, or
elevated static pressure)

Success with angioplasty varies with the


size of the stenosis
Monitoring:

high recurrence rate (55 to 70% at 12


months)

Recurrent lesions: repeat angioplasty


Summary:

Reduced vascular morbidity


Preserves future access sites

Endovascular metallic
stents

Advocated as a method of
preventing recurrent stenosis after
angioplasty
Variable results

Surgical revision

The gold standard


The lowest recurrence rate
Generally been replaced by
angioplasty:

requiring hospitalization
extending the fistula site further up
the involved extremity

STRATEGIES TO PREVENT
THROMBOSIS

Antiplatelet agents
Systemic anticoagulation
Antiphospholipid antibodies
Fish oil
Other preventive therapies

Antiplatelet agents

Dipyridamole, low-dose aspirin w/ or w/o


sulfinpyrazone, aspirin + clopidogrel
Neither therapy appeared to be
effective, the recurrence rate was 78%
In patients with new grafts, the rate of
thrombosis was reduced by
dipyridamole (relative risk 0.35 versus
placebo).

A surprising finding:

apparent increase in thrombosis with aspirin


one possibility: cyclooxygenase inhibition
shifts arachidonate metabolism toward
nonprostaglandin metabolites (such as
lipoxygenases), promote intimal hyperplasia

The role of anti-PLT agents in preventing


fistula thrombosis is unresolved

Systemic anticoagulation

A paucity of data exists


A multicenter prospective study:

warfarin to patients with newly placed PTFE


grafts
no increasing graft survival
with significant bleeding

We only administer warfarin to pt with


repetitive thrombus but w/o anatomic
stenosis

Antiphospholipid
antibodies

Lupus anticoagulant and anticardiolipin


antibodies
Increased incidence of thromboses
Increase the risk of access thrombosis

A report of 97 patients on hemodialysis


62% versus 26%

Reasonable to screen:

Warfarin is indicated in patients with


thromboses not involving the access

Fish oil

Omega-3 fatty acids


Inhibit cyclooxygenase, may dampen
intimal hyperplasia in vein grafts
Among 24 patients with PTFE grafts:

At 12 months, the primary patency rate


was significantly higher: 77% versus
15%

Other preventive therapies

Endovascular radiation

prevention of vascular access stenosis


gamma radiation: effective in animal models in
inhibiting intimal hyperplasia
catheter-based irradiation: utilized to prevent
restenosis after angioplasty in the coronary circulation
primary patency at 6 months was better: 42% versus
0
no difference in secondary patency at 6 (92% versus
91%) or 12 months (44% versus 57%).

Gene therapy

theoretically effective, result in less systemic toxicity

TREATMENT OF
THROMBOSES
The 2006 K/DOQI guidelines

With grafts and associated


stenosis:

Surgical thrombectomy
Thrombolysis
Mechanical disruption

With fistulas:

no recommend any approach to the


removal of thromboses

Surgical thrombectomy

Outpatient procedure

quick
very low complication rate
initially success in 90%

However, failure to correct the


underlying outflow stenosis leads
to rapid rethrombosis

Thrombolysis

Attempts to fistula thrombosis with


urokinase and streptokinase, originally
yielded disappointing results
Dosing adjustments and technical
advances:

improved the success rate


reduced the incidence of bleeding

Combines thrombolytic therapy with


mechanical clot disruption:

90% patency
50% patency in 1 year

Mechanical disruption

A study showed:

Similar rate of success with surgical


thrombectomy and urokinase
considerably greater long-term patency

The major concern: pulmonary emboli

only 1 of 650 had pulmonary embolus


2 of 650 developed transient chest pain
of undetermined etiology

K/DOQI goals for


treatment

A success rate of 85%:

After percutaneous thrombectomy

defined by the ability to use the graft


at least once post-procedure
40% patency at 3 months

After surgical thrombectomy

50% patency at 6 months


40% patency at 12 months

Summary

Nonthrombotic complications:

Infection: 20%
Heart failure
Distal ischemia
Aneurysm and pseudoaneurysm
Venous hypertension
Median nerve injury
Seroma formation

Thrombotic complication: 80-85%

Thanks for your


attention!!
References:
2007 UpToDate
The 2006 NKF/Dialysis Outcomes Quality Initiative (K/DOQI)
guidelines
The 2006 Canadian Society of Nephrology hemodialysis
guidelines