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 Arteriovenous Hemodialysis Access

Anatomy

  • Snuff-box fistula.
  • Brescia-Cimino fistula.
  • Radial artery to antecubital vein (straight graft).
  • Radial artery to basilic vein-above elbow (straight graft).
  • Brachial artery-below elbow to antecubital vein (loop graft).
  • Brachial artery-below elbow to basilic vein-above elbow (loop graft).
  • Brachial artery-above elbow to axillary vein (C-shaped graft).
  • Basilic transposition.

Physiology

  • Resistance.
  • Velocity and volume.
  • Flow patterns.
  • Energy changes.

Pathophysiology

  • Local hemodynamics/pathophysiology (hemodynamic and structural changes in the proximal artery, the distal artery, the proximal vein and the distal vein).
  • Systemic hemodynamics/pathophysiology (determinants and consequences of the drop in total peripheral resistance).

Pathogenesis of complications

  • Thrombosis.
  • Infection.
  • Steal syndrome.
  • Pseudoaneurysm formation.
  • Venous hypertension.

References

Roy-Chaudhury P, Kelly BS, Narayana A, Desai P, Melhem M, Munda R, Duncan H, Heffelfinger SC. Hemodialysis vascular access dysfunction from basic biology to clinical intervention. Adv Ren Replace Ther 2002;9:74-84.

Venous stenosis and thrombosis as a result of venous neointimal hyperplasia are the major causes of hemodialysis vascular access dysfunction. This review describes the lesion of venous neointimal hyperplasia in human samples and in a pig model and suggests possible future directions for the development of effective local therapies for this condition.

Dikow R, Schwenger V, Zeier M, Ritz E. Do AV fistulas contribute to cardiac mortality in hemodialysis patients? Semin Dial 2002;15:14-17.

Potential fistula-related problems which may impact on patient survival include high fistula flow with hyperkinetic circulation and cardiac failure, low fistula flow with the risks of underdialysis and fistula thrombosis, vascular access infection with local or systemic manifestations, and possibly induction and maintenance of a microinflammatory state. All of these problems are briefly reviewed in this article.

Lavigne JE, Messina LM, Golding MR, Kerr JC, Hobson RW 2nd, Swan KG. Fistula size and hemodynamic events within and about canine femoral arteriovenous fistulas. J Thorac Cardiovasc Surg 1977;74:551-556.

The effects of diameters of canine femoral arteriovenous fistulas upon regional and central hemodynamics were determined to correlate fistula size with fistula flow, as well as changes in cardiac output, reversal of distal arterial flow, and distal venous hypertension. The study shows that there is a direct correlation between fistula size and cardiac output, a direct correlation between fistula size and venous hypertension and an inverse relation between fistula size and distal femoral artery flow and pressure.

Joseph S, Adler S. Vascular access problems in dialysis patients: pathogenesis and strategies for management. Heart Dis 2001;3:242-247.

This article describes the means of accessing the circulation for hemodialysis, the pathogenesis of access failure through progressive stenosis followed by thrombosis, methods of detecting access dysfunction before thrombosis, and therapeutic options. Although angiographic or surgical intervention remain the mainstays of management, medical treatments to decrease stenosis and delay thrombosis are currently under investigation.

Anderson CB, Allen BT, Sicard GA. Physiology and hemodynamics of vascular access. In Sommer BG, Henry ML, editors. Vascular access for hemodialysis. W.L. Gore & Associates, Inc. Pluribus Press, Inc. 1989;17-31.

Physiologic and hemodynamic issues related to the construction of a vascular access for hemodialysis are reviewed in this section. These issues provide the basis for the understanding, prevention and treatment of vascular access complications.

Posted June 2010