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 Vascular Access

Mitchell H. Goldman, M.D., Enrico Ascer , M.D., Gary Peterson, M.D.

Includes:

  • Vascular Access for Hemodialysis
  • Ischemic Hand After Vascular Access
  • Peripheral Dialysis Access

I. Anatomy and Pathophysiology

1. To know that arterial and venous anatomy involved in the commonly palced grafts and sited for hemodialysis in the upper and lower extremities; know the options for unusual grafts sites when extremities are not available.

2. To know the local and systemic, anatomic effects of creating an arteriovenous fistula for the purpose of hemodialysis .

3. To know the anatomic landmarks for the various routes of access to the circulation for the use of chemotherapy, chronic infusion, obtaining blood samples, and physiologic monitoring.

4. To know the hemodynamic and physiologic effects of creating an arteriovenous fistula; understand the effects of large and small fistulae on the adjacent arteries and veins and on the body as a whole.

5. To know the anatomic and physiologic etiologies for arterial steal, decreased extremity flow and venous hypertension in AV fistulas created for hemodyalysis .

II. Diagnostic Evaluation

1. To know the physical exam and diagnostic tests used in selecting a site for a vascular access including Allen's test, use of duplex screening of veins, and steriogrpahy .

2. To know the diagnostic tests used in evaluating an arteriovenous access with high resistance, poor pressure , thrombosis, and infection.

3. To know the complciatiosn of obtaining access to the central curclation and the diagnostic examinations and tests used to diagnose pneumothorax , misplaced line, pseudoaneurysm , venous thrombosis, and hemorrhage.

4. To know the use of duplex scanning in the evalution of AV accesses.

III. Treatment

1. To know the uses and benefits of using autologous or synthetic grafts for the purpose of hemodialysis including the locations, timing of placement, maturation of and longevity of the various access routes and grafts.

2. To know the treatment of complications of arteriovenous fistulas for hemodialysis including infection, steal syndrome, aneurysms, venous hypertension, thrombosis, stenosis , and the failing graft.

3. To know the use of revision, patching, extending, banding, angioplasty and stenting as methods of prolonging AV access.

4. To know the advanteages , techniques and commensurate applications of each route of access to the circulation for the use of administering chemotherapy, chronic infusions, obtaining blood samples and hemodynamic monitoring.

5. To know the complications of the above routes and their treatment.

6. To know the catheter types, their advantages, available for gaining access to the circulation.

7. To know the long term outcome and patencies of the various access types.

References

1. Tordoir JH, DeBruin HG et al. Duplex ultrasound scanning int he assessment of arteriovenous fistulas created for hemodialysis access: comparison with digital subtraction angiography. J Vasc Surg 1989; 10 (2): 122-128.

2. Pagno D, Green MA et al. Surveillance policy for early detection of failing arteriovenous fistulae for hemodialysis . Nephrol Dial Transplant 1994; 9: 277-279.

3. Rivers SP, Scher LA, Veith FJ. Correction of steal syndrome secondary to hemodialysis access fistulas: a simplified quantitative technique. Surg 1992; 112: 593-597.

4. Ballard JL, Bunt TJ, Malone JM. Major cpmplications of angioaccess surgery. Am J Surg 1992; 164: 229- 232.

5. Chazan JA, London MR, Pono LM. Long-term survival of vascular access in a large chronic hemodialysis population. Nephron 1995; 69: 228-233.

6. Feldman HI, Held PJ et al. Hemodialysis vascular access morbidity int he United States . Kidney International 1993; 43: 1091-1096.

7. Mansfield PF, Holn DC , Fornage BD et al. Complications and failures of subclavian vein catheterization. NEJM 1994; 331: 1735-1738.

8. Ramee SR. The role of percutaneous intervention in treating hemodialysis insufficiency. In Henry ML, Ferguson RM, editors. Vascular Access for Hemodialysis -IV. W. L. Gore & Asscoaites , Inc., Precept Press 1995; 83- .

9. Vorwerk D, Gunther RW et al. Follow-up results after stent plcement in failing arteriovenous shunts: a three-year experience. Cardiovasc Intervent Radiol 1991; 14: 285-289.

10. Turmel-Rodrigues L, Pengloan J et al. Insufficient dialysis shunts: improved long-term patency rates with close hemodynamic montioring , repeated percutaneous balloon angioplasty, and stent placement. Radiol 1993; 187: 273-278.

11. McDowell DE, Moss AH et al. Percutaneously placed dual-lumen silicone catheters for long-term demodialysis . Am Surg 1993; 59: 569- 573.

12. Anderson CB, Allen BT, Sicard GA. Physiology and Hemodynamics of Vascular Access. In Sommer BG, Henry ML, editors. Vascullar Access for Hemodialysis . W.L. Gore & Assocaites , Inc. Pluribus Press, Inc. 1989; 17-31.

Posted June 2010