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2008/11/26 Arteriovenous Access for Hemodialysis R2

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2008/11/26 AV fistula

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2008/11/26 AV graft

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2008/11/26 Why AV fistulas are better than grafts Less hyperplesia of veinous intima less stenosis and eventual obstruction higher long term patent rate Fewer inectious rate Guidelines suggestion Early access evaluation and construction Preoperative imaging

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2008/11/26 Anticipating the need for AV access Progressive renal failure GFR < 30 ml/min/1.73 m 2 Peritoneal dialysis : back up AV fistula ? Kidney transplantation : < 6 months PICC : risk of central vein steosis

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2008/11/26 Preoperative evaluation Past history Physical examination Image studies Doppler ultrasonography Venography Arteriography Magnetic resonance Minimal vein and artery size Vein dilation test Arterial dilation test Brachial artery flow Mapping

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2008/11/26 AV fistula Location wrist radiocephalic or Brescia-Cimino fistula Construction side-of-artery-to-end-of-vein anastomosis Perioperative care and maturation Blood flow should be checked daily Never be used for venipuncture Hand exercises requires at least 1 month blood flow

2008/11/26 Complication Pseudoaneurysm AV fistula observation, avoiding puncture AV graft treated by resection and insertion of an interposition graft if they are (a)rapidly expanding (b)>12 mm in diameter (c)threatening viability of the overlying skin

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2008/11/26 Complication Infection AV fistula - staphylococci - 6 weeks of antibiotics AV graft - occurs eventually in 5% ~ 20% - Prophylactic antimicrobials - against G(-) and G(+) organisms as well as against Enterococcus - Septicemia may occur without local signs

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2008/11/26 Complication Congestive heart failure Wrist and forearm < Upper arm < Femoral Surgical narrowing or banding vasodilators (minoxidil or hydralazine ) without concomitant beta-blockade

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2008/11/26 Clinical outcome goals and monitoring Establishment of a vascular access team and continuous quality improvement (CQI) Maximizing AV fistula placement at least 60% of all patients new to H/D Goals for AV graft placement Failure rates, Cumulative patency rates Rate of graft thrombosis Goals for limiting use of venous catheters

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2008/11/26 Thanks for your attention