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Vascular Access:

Pre-operative Evaluation

Jeffrey H. Lawson, M.D., Ph.D.

Departments of Surgery and Pathology

Duke University Medical Center

Durham, North Carolina

DisclosuresConsulting, Clinical Trials and Opinion

Hemosphere/Cryolife

Baxter Research

Lemaitre American Heart

Johnson & Johnson/Ethicon ACS

Endologix NIH

Zymogenetics ADA

Gore Medical HHMI

Atrium Medical DOD

NovoNordisk

Pervasis Therapeutics

HumacyteNanovasc

US Standards of Access - 2012

Estimated that nearly 600,000 Americans

suffer from ESRD

Rate of ESRD increasing at more that 10%

each year

Leading Causes of ESRD in the US Diabetes 37%

Hypertension 24%

Glomerulonephritis 16%

Cystic Kidney Disease 5%

Urologic Diseases 3%


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US Vital Statistics of ESRD

Total Cost: >$40 billion dollars (US)

1/3 to total expenditures related to access care Access care estimated to cost nearly $15 billion

dollars (US)

Mode of Dialysis Care:

Hemodialysis: 92%

Peritoneal Dialysis: 8%

Fistulas, Grafts and Access (USA)

Current Estimates of Access in the US

45% AV fistulas

30% Catheters

25% Grafts

Increasing pressure to place fistulas in all

patients

Pay for performance goals by US Medicare

Vascular Access at Initiation of Dialysis

Hakim, Kidney International (2009) 76, 10401048

In the USA, more that

60% of patients initiate

dialysis with a dialysis

catheter.


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Incident Patients Starting Dialysis

Keep Dialysis Simple

How do you get blood out of a patient to a

machine and back three times a week?

Life sustaining therapy

Flow rates > 600 ml/min

A part of the body that is accessible

Rule of 6s

6 mm in diameter

6 cm long

6 mm from the skin

Primary/AVFistula Secondary/Graft Venous/TemporaryCatheter

(Autogenous)

http://www.aakp.org/library/attachments/understandingyourhemodialysisaccessoptionseng.pdf

Typesofaccessforhemodialysis

9


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HemodialysisvascularaccessCompleteCircuit

Accessflowcanbeadverselyaffectedbyproblemsthatoccuranywherewithinthiscompletecircuit

10Kidney International(2005)67,19861992;doi:10.1111/j.15231755.2005.00299.x

Heart

ArterialSystem

ArterialAnastomosis

Fistula/Graft

VenousSystem

Pre OP Evaluation

General medical condition (patient)

Obesity, diabetes, lupus, age

Heart failure, pacemakers, pic lines

Hypercoagulable, stroke, hyper/hypotensive

New patient or already had a number of

permcaths and failed access (problem)

Geography of the arms and legs (anatomy)

Pre dialysis or needs to get off the catheter

(timing)

Evaluate the Access History

M.T. 48 yo BM with Hepatic Catheter Access

More than six (6)

different tunneled

dialysis catheter

scars

More than five (5)

different dialysis

access grafts scars

Currently using a

trans-hepatic

tunneled dialysis

catheter


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Physical Exam look and feel

the arms and legs

Geography

Fat vs. Thin

Physiology

Young vs. Old


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Iatrogenic Vascular Trauma

Multiple IVs and blood draws?

Pics, Ports and Pacers?

A-lines and ABGs?

Blood and Biology

Sticky blood?

Veins grow closed?

No way to know

Sticky Blood Syndromes??

Canadian studyThrombophilia and theRisk for Hemodialysis

Vascular Access

Thrombosis

Association of any

thrombophilia and access

thrombosis OR 2.42

(adjusted for risk factors)

J Am Soc Nephrol, 2005


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Ultrasound

Should I make a fistula??

Size - usually greater than 2 mm Depth usually not deeper than 6 mm from

the skin (transpose/superficialize)

Evidence of stenosis or old thrombus

Quality of the artery

Venogram Outside chance for a fistula.looking for

the best place to put a graft

Evaluate axillary and central veins

MRI/MRA/MRV Limited number of cases

Long history of dialysis or other

medical/surgical interventions

Mixed picture of both arterial and venous

pathology


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New Patient Not on Dialysis

CKD stage 4 with expected dialysis in 3 to6 months

Life expectancy more than 1 year

Place an arm fistula

Non dominate arm. (stroke or pacer)

Palpable pulse

Use a vein > 2 mm (pre-op/intra-op ultrasound)

Let it grow and follow-up with an ultrasound in

3 months

New Patient On Dialysis

CKD stage 5 with life expectancy > 1 year

Where and how long has the permcath(s) been

in?

Any clinical sign of central venous occlusion?

Pulses and any other arm pathology.

Preop ultrasoundif there is a good target

vein (> 2 mm with no sign of stenosis or

scarring), use it an make a fistula.

If the peripheral veins are badplace a graft

and get out the catheter.

New Patient Needs a graft

Geography of the arm

Fat or thin, prior access (fistula sites)

Pulses, pacers and permcaths

Start distal and work proximal

Radial to anticubitial Forearm loop - brachial (a) to

anticubitial/brachial/basilic (v)

Upper arm brachial (a) to axillary/brachial/basilic

(v)

Upper arm axillary (a) to axillary (v) tear drop

loop


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All Rights Reserved, DukeMedicine 2007

The Problem: Central venous occlus ion

Recurrent central venous

instrumentation

Central venous catheters

Balloon Angioplasty

Central venous stents

Shear stresses

HD associated Inflammation

Aggressive venous intimal

hyperplasia

Young patient

OR not on

HD

Upper Extremity

HeROTM

DA Upper Arm AVG

NDA Upper Arm AVG

DA Forearm Loop

AVG

DAWrist or elbow AVF

NDA AX AX teardrop

OR chest wall AVG

DA Elbow AVF

NDAForearm Loop

AVG

NDA Brachiobasilic AVF

OR Dominant arm (DA)

wrist AVF

NDA Elbow AVF

NonDominant Arm

(NDA) Wrist AVF

History,Physical Exam, and

Duplex Ultrasound

Patient New to

Hemodialysis

NDAForearm Loop

AVG

NDA AX AX teardrop OR

chest wall AVG

NDA UpperArm AVG

DA AX AX teardrop OR

chest wall AVG

Femoral AVG

Yes No

Young

or not

on HD

Old

or

on HD

Thank You

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