AV access

SEMANGAATTT SAYAAANGGG
Definition
• Direct connection between an artery and a vein, created surgically or
to provide access for haemodialysis.
Guideline recommendations (hlmn 2290)
• (1) timing of referral to access surgeons,
• (2) operative strategies to maximize the placement of autogenous AV
accesses,
• (3) first choice for the autogenous access,
• (4) choice of AV access when a patient is not a suitable candidate for a
forearm autogenous access,
• (5) the role of monitoring and surveillance in AV access management,
• (6) conversion of a prosthetic AV access to a secondary autogenous AV
access, and
• (7) management of the nonfunctional or failed AV access.(7)
Pre op Evaluation (hlmn 2291-2293)
• History and Physical Examination
• Medical Assesment
• Medications
• Arterial Assesment
• Venous Assesment
Medical Factors Affecting Arteriovenous
Access Patency (hlmn 2291)
Factor Level of Best Evidence Best Evidence Suggests Effect of Patency
Age Meta-analysis Yes
Gender Meta-analysis No
Diabetes Melitus Prospective series Yes
Atherosclerosis Prospective series Yes
Smoking Prospective series Yes
Obesity Prospective series No
Parathyroid hormone Prospective series Yes
Anemia Prospective series Yes
Medications Systematic review Yes
Selection of Access Location (hlmn 2292)
1. Due to easier accessibility and lower infection rates, upper extremity access
sites are used first, with the nondominant arm given preference over the
dominant arm.
2. AV accesses are placed as far distally in the extremity as possible to
preserve proximal sites for future accesses.
3. As long as the patient is deemed appropriate, given their superior patency
rates and lower complication rates, autogenous AV accesses should always be
attempted before a prosthetic AV access.
4. These autogenous access configurations should include, in order of
preference, direct AV anastomosis, venous transpositions, and venous
translocations.
Selection of Access Location (hlmn 2292-93)
Configurations of Arteriovenous Access
Forearm
Autogenous
• Posterior radial branch–cephalic wrist direct access (snuffbox
fistula)
• Radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula)
• Radial-cephalic forearm transposition
• Brachial (or proximal radial)–cephalic forearm looped
transposition
• Radial-basilic forearm transposition
• Ulnar-basilic forearm transposition
• Brachial (or proximal radial)-basilic forearm looped transposition
• Radial-antecubital forearm indirect femoral vein translocation
• Brachial (or proximal radial)-antecubital forearm indirect looped
femoral vein translocation
• Radial-antecubital forearm indirect saphenous vein translocation
• Brachial (or proximal radial)-antecubital forearm indirect looped
saphenous vein translocation
Prosthetic
• Radial-antecubital forearm straight access
• Brachial (or proximal radial)-antecubital forearm looped access
Configurations of Arteriovenous Access
Upper Arm
Autogenous
• Brachial (or proximal radial)–cephalic upper arm direct access
• Brachial (or proximal radial)-cephalic upper arm transposition
• Brachial (or proximal radial)-basilic upper arm transposition
• Brachial (or proximal radial)-brachial vein upper arm transposition
• Brachial (or proximal radial)-axillary (or brachial) upper arm
indirect femoral vein translocation
• Brachial (or proximal radial)-axillary (or brachial) upper arm
indirect saphenous vein translocation
Prosthetic
• Brachial (or proximal radial)-axillary (or brachial) upper arm
straight access

Adapted from Sidawy AN, Gray R, Besarab A, et al. Recommended standards for
reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg.
2002;35:603-610.
Algorithm (hlmn 2294)
Forearm Access (hlmn 2293-94)
• Cephalic Vein

• Basilic Vei

• Basilic Vein
• Alternate Vein
When the cephalic and basilic forearm veins are not felt to be adequate for autogenous
AV access, translocations of the femoral and saphenous veins are appropriate alternatives.
Forearm Access
• Prosthetic Graft
Upper arm Access (hlmn 2295-96)
• Cephalic Vein

• Basilic Vein
• Alternate Vein
When the cephalic or basilic veins are felt to be inadequate for
upper arm autogenous access, brachial vein transpositions as well as
femoral and saphenous vein translocations are appropriate
alternatives.
• Prosthetic Graft
Technique for Permanent Access (hlmn 2296)
Autogenous Acces
• 1. After identification of the vein, the distal end is transected and flushed with heparinized saline. This
allows for evaluation of the caliber and extent of the vein and to identify any side branches.
• 2. With transposition accesses, the vein is completely dissected and mobilized, ligating all side branches,
to its origin.
• 3. After controlling the artery, an arteriotomy of 4 to 6 mm maximal length is made. The length of the
arteriotomy is limited to decrease the incidence of arterial steal.
• 4. The artery is flushed proximally and distally with heparinized saline to avoid thrombosis during the
anastomosis.
• 5. The AV anastomosis is performed between the side of the artery and the end of the vein; this
configuration decreases the subsequent risk of venous hypertension.
• 6. The AV anastomosis is performed using a 6-0 or 7-0 monofilament nonabsorbable continuous suture
to avoid subsequent anastomotic dilation.
• 7. With nontransposed access, after completion of the anastomosis, large venous branches can be
ligated through stab incisions. This encourages flow in the main venous segment, which may promote
earlier maturation.

One-Stage Versus Two-Stage Transposed Access (penjelasan di hlmn 2296)

Technique for Permanent Access (hlmn 2297)
Prosthetic Access
• 1. The length of the arteriotomy does not have to be limited to 4 to 6 mm.
The diameter of the graft will limit the incidence of arterial steal.
• 2. The artery is flushed proximally and distally with heparinized saline to avoid
thrombosis during the anastomosis.
• 3. A 6-mm polytetrafluoroethylene (PTFE) prosthetic graft is used for conduit
(see considerations further on).
• 4. The anastomoses are performed using a 6-0 or 7-0 monofilament
nonabsorbable suture in a continuous manner.
• 5. Careful attention to sterile technique is paramount to avoid graft infections.

Choice of Prosthetic Material (penjelasan di hlmn 2297)

FOLLOW-UP (penjelasan di hlmn 2297)
• POSTOPERATIVE FOLLOW-UP
• LONG-TERM FOLLOW-UP
Results (penjelasan di hlmn 2298)
• AV access is functional only if it can deliver a flow rate of 350 to 400 mL/min without
access recirculation to maintain a dialysis treatment time of less than 4 hours.
• Primary patency is the interval between the time of access placement and any
intervention designed to maintain or reestablish patency, access thrombosis, or the
time of measurement of patency.
• Assisted primary patency is the interval between the time of access placement and
access thrombosis or the time of measurement of patency, including any intervening
surgical or endovascular manipulation.
• Secondary patency is the interval between the time of access placement and access
thrombosis, access abandonment, or the time of measurement of patency, including
any intervening surgical or endovascular manipulations designed to reestablish
functionality after access thrombosis.