Vascular access for DialysisVascular access for Dialysis a s rgeon’s perspecti e– a surgeon’s perspective

…. some observations

Age of New Haemodialysis Patients 2005Age of New Haemodialysis Patients 2005

Australia

Number (Total=1957)

20%26%

19%

3% 5%10%

15%20% 19%

2%0.7%0.7%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >=85NNo. Pats. 14 38 104 170 303 414 514 863 37

Method and Location of Dialysis 2000 20052000 - 2005

N b f P ti t

5000 5000 SAT HD 3629 (43%)HOSP HD 2289 (27%)

Number of Patients

350040004500

350040004500

HOSP HD 2289 (27%) CAPD 1027 (12%) HOME HD 799 (9%) APD 784 (9%)

200025003000

200025003000

500100015002000

500100015002000

0500

2000 2001 2002 2003 2004 20050500

W iti ti f Kid T l t i 2006RPAH

25

Waiting time for Kidney Transplant in 2006 (n=69)RPAH

22

20

25

Deceased Donor

15

Living Donor

10

12

32 2

5

0Pre-

Emptive1m-1yr 1-2yr 2-3yr 3-4yr 4-5yr >5yr

Stock and Flow of Haemodialysis Patients2001 - 2005

Number of Patients

80009000

6717 P ti t

New PatientsTransplantsPerm. Transfer

60007000

PatientsPerm. TransferDeathsNo. Dialysing

40005000

20003000

01000

2001 2002 2003 2004 2005

Patient Survival - HD at 90 days

0

Censored for TransplantAustralia

51.

00

val

00.

75

y of

sur

viv

50.

50

roba

bilit

y

0.25P

r

1993-1995 (1907)1996-1998 (2462)1999-2001 (3156)2002 2004 (3506)

0.00

0 1 2 3 4 5

Years

2002-2004 (3506)

Years

CRF in AustraliaCRF in Australia

1. Number of kidney failure patients in Australia could triple

2. Dialysis patient number increasing by 7% per yeary p g y p y

3. 47% of new patients are over 65 years old

C4. Commonest treatment option is satellite haemodialysis

5. Transplantation is not a viable option for most patients

6. Haemodialysis is the commonest long term treatment

7 Death is commonest endpoint 50% at 5 years7. Death is commonest endpoint – 50% at 5 years

Long term reliable vascular access

1. Demonstrate why AVF are better than AVGy

2. Ask “who are the decision makers for choice of vascular access?”

3 The role of central venous catheters?3. The role of central venous catheters?

4. A plan for maximising AVF

5 Surveillance of AVF5. Surveillance of AVF

6. Home versus satellite haemodialysis

K Polkinghorne/ANZDATA 2003

Association of Angioaccess and Mortality

3

2

2.5

3tio

2.54

1 7

1.5

2

zard

Rat

1.24Ref

1.7

0.5

1

Haz

(2528) (402) (129) (28)

Access Intervention in Previous Twelve Months December 2005 Access Intervention in Previous Twelve Months - December 2005 n = Number of Patients

Revision of Access Declotting of Access

AVF AVG CVC AVF AVG CVC

Australia n=6717 12% 35% 18% 5% 26% 14%

Diabetics n=1660 12% 41% 17% 6% 29% 13%

Female n=2672 13% 35% 18% 6% 25% 15%

AVG in 2005 were:1. five times more likely to clot2. three times more likely to require revision3. less satisfactory than central venous catheters3. less satisfactory than central venous catheters

Type of Access for HaemodialysisAustralia December 2005

CVC AVG AVF

67%

Only significant factors correlating with use of AVG are length of time76% 74% 77% 67% 82%with use of AVG are length of time on dialysis and the HD centre

12% 13%18%10%

9%

All Pts(n=6717)

Diabetic(n=1660)

Non Diab(n=5057)

Female(n=2672)

Male(n=4045)(n=6717) (n=1660) (n=5057) (n=2672) (n=4045)

2003

Northern3%

8%Northern TerritoryAVG 6%

Catheters 6%QueenslandAVG 16%

8%

South Australia

Western AustraliaAVG 12%

C h 18%

Catheters 10%

AVG 6%Catheters 4%

Catheters 18%

New South Wales/ACT9%

NSW 20%

AVG 30%Catheters 7%

10% ACT 36%

VictoriaAVG 9%

8%AVG 9%Catheters

8%

TasmaniaAVG 1%

Catheters 20%8%

Mode of HAEMODIALYSIS NSW – December 2004

100

80

100

40

60

erce

nt

TEMP

CVC

20

40pe SyntheticNative

NSW0

OOL

WEST

NSW

TGH

GNG

EWC

CON

RNSH

NSW

L'POO WE N

S

STG

WGN

NEW

RPA/C

O

RN

First Haemodialysis Access – Initial RRTBy Referral AustraliaBy Referral - Australia

16 19 1934

43 4280

100

4

2931 33

43 42

608

enta

ge Non-Tunnel CVCTunnel CVC

52

44 3

5546 49

40Per

ce AVGAVF

52 46 46

101

102

81

020

0

Early Late

Mar 04Dec 04

Dec 05Mar 04

Dec 04Dec 05

y

Mode of INITIAL vascular access – NSW in 2004Mode of INITIAL vascular access NSW in 2004

100

60

80

ent TEMP

40perc

e

CVC

Synthetic

0

20 NativeNSW

WEST

L'POO

L

WGNG

NSW

NEWC

RNSH

RPA/

CON

“ h th d isi k s f h i “who are the decision makers for choice of vascular access in your hospital?”

D i i kDecision makers

1. Nephrologist

2 P ti t2. Patient

3. Patient’s family

4. Dialysis nursing staff

5 Vascular surgeon5. Vascular surgeon• time• ease of surgery• ease of surgery• $$$

Central Venous CathetersCentral Venous Catheters

• temporary• late presentation, BMI>35 and female

• necessary for bridging to native or synthetic AVF

• high complication rate• thrombosisthrombosis

• insertion … ? where and when

• ? long term solution

Central Venous Catheters

Imaging of the IJV

Non-tunneled CVCs

• avoid use in neck

Positioning CVC

• junction of SVC and right atrium in sittingright atrium in sitting position

• risk of thrombosis right atrium

SVC obstruction - mechanical injury to SVC

Bi fil i it bl d t id f th t t i th l• Biofilm inevitable and on outer side of catheter - not in the lumen.

• Bacteria adhere with source being at time of insertion or circulating organisms at any time thereafter. Usually S. aureus or S.organisms at any time thereafter. Usually S. aureus or S. epidermidis and therefore skin source.

• Patient to patient spread of staphylococcus demonstrated by ?? Lab technique identification and therefore implication dialysis nursingtechnique identification and therefore implication dialysis nursing staff and not patient source.

• Multiple options for catheter locking solutions. Need for perhaps p p g p pdetermined by Catheter Related Bacteraemia rate (events/1,000 catheter days). If CRB rate low, randomised trials have difficulty showing advantages over heparin alone.

• Centres should monitor CRB rates – should be about 2/1,000 days.

• RCTs show Gentamicin to best at lowering CRB rate but antibiotic resistance rate unacceptable. Next best is ………. with 4% citrate. Not available in Australia – ampoule worth about 12 Euro.

Long term reliable vascular access

1. Demonstrate why AVF are better than AVGy

2. Ask “who are the decision makers for choice of vascular access?”

3 The role of central venous catheters?3. The role of central venous catheters?

4. A plan for maximising AVF

5 Surveillance of AVF5. Surveillance of AVF

6. Home versus satellite haemodialysis

FISTULA FIRSTFISTULA FIRSTNational Vascular Access Improvement Initiative

• initiative to increase AVF prevalence• started Northwest network in 2003• started Northwest network in 2003• aim for 50% AVF

The team approachpp

1 Designate staff member in dialysis facility (RN if1. Designate staff member in dialysis facility (RN if feasible) responsible for vascular access

2. Assemble multi-disciplinary vascular access team

3. Representatives of all key disciplines including access surgeons, ultrasonographers and interventionalists.

4. Investigate and track all non-AVF access placements, g p ,and AVF failures

5 Benchmark against others5. Benchmark against others

ReferralReferral

1. Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery referral.

2. Nephrologist refers for vessel mapping where feasible, prior to surgery referral.

3. Nephrologist refers patients to surgeons for “AVF only” evaluation Surgery scheduled with sufficient lead-timeevaluation. Surgery scheduled with sufficient lead time for AVF maturation.

4 Nephrologist defines AVF expectations to surgeon4. Nephrologist defines AVF expectations to surgeon

Vascular access surgeong

• Nephrologists refer to surgeons willing and able to meet• Nephrologists refer to surgeons willing and able to meet the standards and expectations.

• Surgeons utilize current techniques for AVF placement• Surgeons utilize current techniques for AVF placement including vein transposition.

S i i f d f ti t• Surgeons ensure mapping is performed for any patient not clearly suitable for AVF based only on physical examexam.

• Surgeons are evaluated on frequency, quality and t f l tpatency of access placements.

• Surgeons work with nephrologists to plan for and place secondary AVFs in suitable AV graft patients.

AV grafts to AVFAV grafts to AVF

• evaluate and identify every AV graft patient for possible secondary AV fistula conversion, and document the plan i th ti t’ din the patient’s record.

• examine outflow vein of all graft patients with “sleeves up” during dialysis treatments (minimum frequency, monthly).

• refer to surgeon for placement of secondary AVF before failure of AVG.

CannulationCannulation

• Facility uses best cannulators and best teaching tools.

• Dialysis staff use specific protocols for initial dialysis treatments

• Assign the most skilled staff to patients with new AVFsg p

• Facility offers option of self-cannulation to patients who are interested and ableare interested and able.

SurveillanceSurveillance

• Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF.

• Nephrologists, interventional radiologists, and surgeons adopt standard criteria, and a plan for each patient

• Review data monthly or quarterly in facility staff meetings. Present and evaluate data trended over time

? experience of surgeonp g

Obese patients

AVF vs AVGAVF vs AVG

S h i l l b f d• Saphenous vein loops unpopular because of aneurysms and stenoses.

• Large numbers of brachiocephalic and brachiobasilic AVF (latter• Large numbers of brachiocephalic and brachiobasilic AVF (latter performed as two stage procedure). For example, 70% of native vein AVF were in upper arm in large and recent series from U i it f Mi i S t d i EUniversity of Miami. Same trend in Europe.

• Upper arm fistulae associated with high flows and cephalic arch stenoses – interesting relationship between these two problemsstenoses interesting relationship between these two problems, particularly with respect to dilation and effect cardiac output. High venous return pressures can be a result of high flow. See later discussion on flow monitoringdiscussion on flow monitoring.

Brachiocephalic fistula

Surveillance of fistulae

1. Improve patient care• reliability and predictability of access• prolong and preserve access vessels

2. Reduce access related costs• morbidity related• home haemodialysis

“sleeves up and arm up”sleeves up and arm up

Movie 1340

Movie 1347

Movie 1344

Venous hypertension

Whilst on dialysisWhilst on dialysis

• Ease of cannulation

• Ability to rotate cannulation points• Ability to rotate cannulation points

• Arterial inflow pressuresp

• Pump speed

• Venous return pressures

D l ti bl di ti• Decannulation bleeding times

Distribution of Blood Flow RatesNumber of Patients

Australia

400045005000 Mar 2004 (5924)

Dec 2004 (6206)Dec 2005 (6717)

Australia

250030003500

Dec 2005 (6717)

150020002500

0500

1000

0

200-249 250-299 300-349 350-399 >=400

mls/minmls/min

UltrasoundUltrasound

“dysfunction hypothesis”

• Fistula stenosis causes graft dysfunctionand dysfunction precedes and accurately predictsand dysfunction precedes and accurately predicts thrombosis

• Surveillance relies on:-

1. Reproducible measurements2. Stenosis progressing slowly3. Other factors such as hypercoagulability, low BP etc

do not influence4. Correlation with clinical examination

t t!… a must get!

Digital Ischaemia

incidence 1 3%• incidence 1 – 3%

• invariably diabetic patient

• radial = brachial incidence

• treat by “banding” or ligation

•DRIL procedurep

Surveillance recommendations

1 High quality and continuous clinical assessment1. High quality and continuous clinical assessment

2. Initial ultrasound assessment – dialysis nurse driven

3 Early intervention3. Early intervention

Mr T

5. Cannulation techniques

• Description three cannulation techniques:– ‘rope ladder’ or ‘snail track’ for AVGs and good veins provided

aneurysms do not develop in latter– ‘area’ technique which is prone to aneurysm formation, particularly inarea technique which is prone to aneurysm formation, particularly in

high flow fistulae– ‘button hole’ which I now have a very revised and more positive

appreciation of. Should not be confused with ‘area’ cannulation technique.

• ‘button hole’ is a very precise technique and very operator dependent Preparation and angle of entry very important initiallydependent. Preparation and angle of entry very important, initially with sharp needles. Nursing recommendation that it be employed by limited number of staff for a given patient. No nurse should cannulate a given fistula without having witnessed another with ca u ate a g e stu a t out a g t essed a ot e tknowledge of that given fistula.

educated smilinghome HD patientp