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The retrograde pressure and flow is expected to make progressive dilatation of venous tributaries. If these small veins do not mature adequately, endovascular balloon angioplasty may be used [32].

Arteriovenous graft AVG for hemodialysis The ideal vascular graft for patients on HD should be easy to handle, closely mimicking the native vessels, nonthrombogenic, immunologically inert, resistant to infection and puncture trauma, able to retain tensile strength, and manufactured at a reasonable cost [33].

Denatured homologous vein allograft. Cryopreserved saphenous vein d. Human umbilical vein. Sheep collagen grafts [36, ].

The current Omniflow II vascular graft has a more resistant mesh but requires delicate manipulation, avoiding cross clamping the graft with metal instruments and traction during the passage through the tunnel [42].

Biohybrid and bioresorbable prostheses, graft pretreatment with endothelial cell culture, methods of affixing antibiotics, anticoagulants and growth factor to graft surfaces are under investigation to enhance the results of prosthetic vascular materials, as biologic materials facilitate cell repopulation and tissue remodeling [33].

However, this was not seen in practice and PTFE, a fluorocarbon polymer became the prosthetic graft of choice [43]. Available data supports PTFE over other biologic and synthetic materials except bovine mesenteric vein based on a lower risk of disintegration with infection, low thrombogenicity, low tissue reactivity, prolonged patency and improved surgical handling but this concept may change in the future with introduction of tissue engineered AVG or more recent biological grafts [44].

Other new graft materials include polyurethane grafts with their self-sealing properties and reported low complication rates. The polyetherurethaneurea Vectra graft is suitable for early needling [45, 46].

Straight AVG between the radial artery at the wrist and an antecubital vein should be avoided due to the risk of early thrombosis. Forearm loop AVG b.

The forearm loop between the brachial artery and one of the available veins in the antecubital fossa is far more better option figure 4.

One of the venae comitantes of the brachial artery should be used as outflow for both types rather than the superficial veins as outflow for a straight or looped forearm AVG graft, because if the basilic or cephalic veins are still available they should be used instead to construct an autogenous AVF with the brachial artery [47].

Straight AVG in the upper arm between the brachial artery and the axillary vein or the proximal brachial or basilic vein is ideal and common figure 5.

The forearm loop between the brachial artery and one of the available veins in the antecubital fossa and the straight AVG in the upper arm between the brachial artery and the axillary vein or the proximal brachial or basilic vein are the most popular graft configurations [48].

Lower extremity options AVGs in the lower limb have generally given less encouraging results than for the upper limb, because of increased rates of infection, ischaemia, and lower patency rates.

However, groin access is a useful option when upper extremities are unavailable and peritoneal dialysis has failed [28].

When implanted in the thigh, the graft can be either a straight, looped or curved configuration figure 6 between femoral artery and either stump of GSV or femoral vein.

Anastomosing AV Hemodialysis Figure 5. Straight brachial-axillary AVG. This has led to implantation of the AV graft more distal to the mid-superficial femoral vessels.

This approach preserves the proximal vessels for future graft revision [49]. Moreover, when large vessels, such as the axillary artery and femoral veins, are employed severe venous or arterial problems may follow AVG thrombosis [52].

Guidelines for selection and placement of hemodialysis access according to KDOQI [11] A structured approach to the type and location of long-term HD accesses should optimize access survival and minimize complications.

The access should be placed distally and in the upper extremities whenever possible. Options for fistula placement should be considered first, followed by prosthetic grafts.

Catheters should be avoided for HD and used only when other options listed are not available. Autogenous AVF. A wrist radiocephalic primary fistula.

An elbow brachiocephalic primary fistula. A transposed brachial basilic vein fistula b. There is no convincing evidence to support tapered versus uniform tubes, externally supported versus unsupported grafts, thick versus thin-walled configurations, or elastic versus nonelastic material.

While the majority of past experience with prosthetic grafts has been with the use of PTFE, other prosthetics eg, polyurethane [PU] and biological conduits bovine have been used recently with similar outcomes.

Physical examination monitoring : to detect dysfunction in fistulae and grafts at least monthly by a qualified individual looking for: persistent swelling of the arm, presence of collateral veins, prolonged bleeding after needle withdrawal, or altered characteristics of pulse or thrill in a graft.

Monthly in 1st 1. Directly measured or derived static venous dialysis pressure. A venous segment static pressure mean pressures ratio greater than 0.

An arterial segment static pressure ratio greater than 0. Indicators of risk for graft rupture. All patients should be taught how to: 1.

Compress a bleeding access 2. Seal the site of a central venous catheter CVC with ointment to keep air embolus from entering 3.

Wash skin over access with soap and water daily and before dialysis 4. Recognize signs and symptoms of infection 5.

Select proper methods for exercising AV fistula arm with some resistance to venous flow 6. Listen for bruit with ear opposite access if cannot palpate for any reason All patients should know to: 1.

Avoid carrying heavy items draped over the access arm or wearing occlusive clothing 2. Avoid sleeping on the access arm 3.

Insist that staff rotate cannulation sites daily 4. Insure that staff are using proper techniques in preparing skin prior to cannulation 5.

Complications of vascular access 6. First, the AVF should have adequate blood flow to support dialysis; second, it should have enough size to allow for successful repetitive cannulation.

Although flow and size may appear as two separate parameters, they are intricately related [57]. Interventions to salvage with early AVF failure Studies demonstrated that the two most common problems observed in early AVF failure are the presence of stenosis and accessory veins.

These studies have emphasized that a great majority of these failed fistulae can be salvaged using percutaneous techniques.

The single major complication consisted of a vein rupture with an expanding hematoma. It resulted in loss of the access.

The minor complications all were hematomas that required no treatment and had no sequelae [58].

Reports have highlighted a newer technique sequential dilation to salvage an AVF that fails to develop because of diffuse stenosis [59, 60].

In addition to endovascular techniques, surgical intervention has been used for AVF salvage [61]. There is a lack of prospective studies that have examined the role of surgical approach in the salvage of AVF with early failure only.

Inability to navigate the wire across a stenotic lesion during percutaneous approach and deep location of an AVF are some of the indications for surgical intervention [62].

Dialysis access infection Dialysis-access-related infections are common, and often result in great cost and morbidity, may be mortality.

It is the most important cause of loss of vascular catheter access and an important cause of failure of native and prosthetic arteriovenous grafts and fistula [63, 64, 65].

Diabetes seems to increase the risk of S. Useful criteria for diagnosis of AV fistula infection includes, the presence of bacteremia associated with local tenderness or redness of the fistula site and no other obvious source of bacteremia, evidence of local infection at the fistula site with recovery of a pathogen by culture of draining pus or direct aspiration [67].

Prevention: The pillar of prevention is practicing meticulous aseptic technique and avoiding bleeding or hematoma when cannulating the graft.

This is not only responsibility of the dialysis nurses and stuff but also the patient. Avoidance of repeated needle insertion at one particular site on the graft is also critical to eliminate complications.

The presence of foreign material makes synthetic conduit especially susceptible to infection [68]. Fistula surgical excision should be performed in cases of septic emboli.

Thrombosis This is the commonest cause of failure in the long term and is most often due to underlying stenosis, overdialysis leading to dehydration and hypotension, poor needling technique leading to haematoma and undue post-cannulation compression to control bleeding.

The type of access and the site of thrombosis are important determinants of outcome. Thrombosis may affect the anastomotic or post- anastomotic segments as a result of neointimal hyperplasia or may begin at a needling site.

When radiocephalic or brachiocephalic AVFs thrombose at or close to anastomosis, the clot usually remains localized and run off remains patent as it has a number of natural tributaries which maintain some venous flow.

This situation can be treated by a local refashioning of the AVF, anastomosing the arterialized vein to the artery at a more proximal site [69].

In contrast, thrombosis of AVFs involving transposed veins usually leads to thrombus propagation so that the entire AVF clots. This is a result of the fact that all the tributaries of the venous outflow had been ligated during the creation of this type of AVF.

Successful salvage of such a clotted AVF must be attempted as soon as possible before the clot organizes.

There are two choices for the treatment of the thrombosed graft: surgical and endovascular. The choice should be based on local expertise.

Treatment must be timely, not delayed, and central venous catheters should be avoided. Venous stenosis must be corrected and all abnormal haemodynamic parameters present prior to thrombosis should return to normal [70].

Surgical correction: The thrombectomy is usually performed with a small transverse incision at the nadir of a loop PTFE graft or at the venous anastomosis of straight PTFE grafts.

The thrombectomy is then performed with a fogarty balloon catheter to extract the clot. Assessment of the presence of stenosis is made by the surgeon based on the resistance to passage of the fogarty balloon catheter or a similar dilators.

More recently, intraoperative angiographic evaluation of the graft may be performed to better assess for the presence of stenoses [71].

Surgical correction of intimal hyperplasia at venous anastmosis is best managed by one of three methods depending on the extent of disease and adjacent venous anatomy: 1.

Widening of the lumen with patch angioplasty. Interposing a short segment of new graft material and construcing a more proximal venous anastmosis jump graft.

Transferring the venous end of the graft to an adjacent vein, such as from an antecubital to the cephalic vein [72].

Enzyme-mediated thrombolysis can be subdivided into two categories:- pharmacological and pharmacomechanical. Pharmacological thrombolysis: refers to thrombus dissolution using only the effects of a fibrinolytic enzyme.

Complication rates have ranged from none to This complications included: bleeding at needle puncture sites, embolus to the peripheral artery [75] and systemic fibrinogen depletion has been routinely seen because of the large doses of enzyme used.

Urokinase offers the advantages over streptokinase of having shorter effective half-life and no antigenicity it can be readministered in cases of recurrent thrombosis [76].

The first is pharmacological, consisting of enzymatic lysis. This is immediately followed by the second phase, mechanical maceration and removal of residual thrombus.

Vascular steal syndrome Clinically significant distal extremity ischemia occurs in 1. Risk factors include female sex, age greater than 60 years, diabetes, arteriosclerosis, multiple operations on the same limb, the construction of an autogenous fistula, and most commonly the use of the brachial artery as the donor vessel [83].

Theoretically, the presence of a large arteriovenous fistula always results in reduced perfusion to more peripheral tissues.

This is evidenced by the fact that the perfusion pressure is always lower distal to an arteriovenous fistula [84]. Symptoms associated with the ischemic steal syndrome present over a broad spectrum, ranging from vague neurosensory deficits to ischaemic rest pain or tissue loss [85].

Recently, this classification was proposed [86]: 1. Stage III, pain at rest. Steal can be limited by reducing the anastomotic length to 75 percent or less of the proximal arterial diameter, which in most patients translates length of 5 mm.

Steal syndromes following a radiocephalic fistula are relatively unusual. The cause is thought to be diversion of the ulnar arterial flow through the palmer arches to create retrograde distal radial artery flow into the fistula with a steal of blood flow away from the digital arteries.

A DRIL procedure involves two parts: a bypass and interval ligation of the native artery. The bypass graft is connected to the artery proximal to the access anastomosis and its outflow directed to the native artery distal to the access anastomosis.

The reversal of blood flow is eliminated by ligation of the artery distal to the AV access, providing the distal vascular bed with normal perfusion pressure and flow [88].

Recognizing that brachial arterial origin was a common feature of symptomatic steal, others have reported success with extending the arterial end of the access distally to smaller arteries with revision using distal inflow RUDI figure 7c and proximally to larger arteries with proximalization of arterial inflow PAI.

Each of these management solutions is based on small case series involving an uncommon but clinically significant complication of AV access.

More experience is needed before an appropriate solution can be recommended [89, 90]. Haemorrhage This occurs in the first 24 postoperative hours and may be from a specific bleeding point such as the anastomosis or from a slipped ligature.

These are due to technical errors and should be avoidable. Generalized 'oozing' resulting in haematoma formation is probably more common and is a result of the functional platelet disorders and bleeding diathesis associated with uremia.

This complication can be minimized by careful preoperative preparation including correction of anaemia with recombinant erytheropoietin and adequate dialysis.

Aneurysm formation False aneurysms may occur at the anastomosis when there has been an error in surgical technique or more commonly at a needling site which has been over used.

These can be treated by resection with either direct end-to-end anastomosis or by the placement of a short PTFE bridge graft.

The number of cannulation sites are limited by the presence of a large or multiple pseudoaneurysm s. The pseudoaneurysm threatens the viability of the overlying skin.

The pseudoaneurysm is symptomatic pain, throbbing. There is evidence of infection. True aneurysmal dilatation of autogenous arterialized veins are common.

Often no action is required but corrective surgery is indicated if the overlying skin becomes very thin or there is evidence of progressive expansion.

In some patients the whole length of arterialized vein becomes very dilated and the AVF may have to be sacrificed by ligating it [69].

Stenosis This may-occur directly at the anastomosis, in the first few centimeters of the venous outflow from an AVF or at needling sites.

Anastomotic stenosis results from either errors in surgical technique or from the development of neointimal hyperplasia. Radiocephalic AVFs can often be refashioned by creating a more proximal anastomotic site but this may not be possible for brachiocephalic or brachiobasilic AVFs.

In that case a "jump graft'' can be created using a short segment of PTFE to bypass the stenosis. Post-anastomotic or needling site stenoses may be amenable to treatment by percutaneous transluminal angioplasty.

The disadvantage is that recurrent stenosis is common and this may require surgical revision using a prosthetic interposition graft [69].

Central vein stenosis [11] Patients with extremity edema that persists beyond 2 weeks after graft placement should undergo an imaging study including dilute iodinated contrast to evaluate patency of the central veins.

The preferred treatment for central vein stenosis is PTA. Lymphocele This occurs when the lymphatic channels have been divided or diathermed.

It is particularly associated with brachio-basilic fistula formation and operation in the groin.

Treatment by intermittent closed drainage under-sterile condition and antibiotics cover is usually successful.

Recurrent and persistent lymphocele may require re exploration and open drainage [69]. Venous hypertension A venous hypertension syndrome may develop in which the hand distal to the fistula becomes swollen and uncomfortable with thickening of the skin and hyperpigmentation [93, 94].

Hypertension may be avoided by forming an end-to-side or end-to-end anastomosis. Ligation of the enlarged venous tributaries causing the hypertension of the distal digits may relieve symptoms while preserving the fistula.

The increasing use of subclavian lines for dialysis has lead to an increased incidence of subclavian vein thrombosis or stenosis.

The subsequent placement of a fistula may lead to massive arm edema caused by venous hypertension and, in women, breast enlargement [95].

Subclavian vein thrombolysis and angioplasty with stenting may allow continued use of the-fistula. This complication may also be lessened by using the internal jugular vein for central line placement [96].

Neuropathy Ischemic neuropathy is unusual with the radiocephalic fistula and is seen mainly in diabetic patients with preexisting atherosclerotic disease and in patients with proximal site fistulas.

It is characterized by the onset of severe, acute, painful weakness of the distal extremity, with wrist drop and minimal wrist flexion.

This development is probably due peripheral nerve ischemia and if recognized early, fistula interception may preserve neurologic function [97].

Indeed definite thickening of the flexor synovium within the carpal tunnel is occasionally observed either in patients with a functioning shunt.

The most prominent symptom of carpal tunnel syndrome in dialysis patients is painful nocturnal acroparesthession of the affected limb. The pain and numbness are in the distribution of the median nerve.

In differentiating the carpal tunnel syndrome from painful uremic neuropathy, one should consider that the symptoms of uremic neuropathy are symmetric, often beginning as a burning sensation in the soles of the feet, with progressive involvement in the legs.

The upper extremities are involved only after the presence of severe lower extremity disease. On examination of the median conduction velocity across the wrist it will be found to be delayed.

Relief is achieved by median nerve decompression by division of the transverse carpal ligament. Some patients may achieve relief from symptoms by conservative measures such as simply moving the hand during dialysis.

Using digital compression of the puncture site, rather than using a compression bandage avoids increased venous pressure [98].

Treatment usually involves ligation of the fistula, although banding may be attempted []. Factors affecting access patency Patient related factors: 1.

Age: Increasing age has no effect on fistula patency []. Gender: The patency of distal forearm, wrist or snuffbox AVFs is poorer in women than in men.

Since, this seems to apply also to more proximal AVFs it may be unrelated to the larger vessels of men and may have a hormonal basis [, ].

Diabetes: There is conflicting evidence as to whether diabetes is an adverse factor for fistula patency with some authors suggesting that flow rates and patency are poorer [], whereas others have found no effect [, ].

Obesity: It is more difficult to create a suitable AV fistula in obese patients because the deeper veins are more difficult to cannulate but this does not affect patency [].

Smoking: Smokers may have poorer fistula survival []. Thrombotic tendencies and vasculitis: Increased fibrinogen predisposes to access thrombosis and vasculitis is a strong predictor of access failure [].

Access related factors: 1. Vessel size: Small vessels have higher initial failure rates, more frequent failure to mature and poorer long-term patency [7].

Access position: More proximal AV fistulae have improved blood flow and patency but leave fewer options for access in the event of failure [, ].

However, their patency can be improved by using a wider diameter graft or adding a vein cuff to the venous anastomosis [, , ]. Fistula flow rates: The flow rate AV fistulae the day after surgery correlates inversely with the risk of thrombosis although intraoperative flow rates are less reliable [7].

Anastomotic method: Anastomosis using non-penetrating vascular clips, which give an interrupted anastomosis with excellent endothelial apposition and less bleeding, are quicker and may have improved patencies [, ].

Surgeon related factors: Surgical experience: There can be little doubt that experienced surgeons with adequate training have good outcomes [], but well supervised trainees can produce equivalent results [].

Access surveillance: The use of postoperative surveillance and pre-emptive repair of detected defects has been shown to improve access survival in a randomized controlled trial [].

Early cannulation: This is not a risk factor for fistula failure []. Drugs: Antiplatelet agents such as aspirin and dipyridamole prolong fistula survival and are used routinely [ , 11 8] although a combination of aspirin and clopidogrel increased haemorrhagic complications without influencing patency in prosthetic AV grafts [11 9] Anticoagulation with warfarin reduces AVF thrombosis in patients with hypercoagulable states [], but routine use is best avoided because of the risk of haemorrhage [].

Central venous catheter for hemodialysis Another way to get access to the circulation to perform hemodialysis is the usage of the central venous catheters.

Indications and patient selection Central venous catheter is the preferred method for short term hemodialysis and it is also used for emergent dialysis as temporary access while a permanent access is maturing.

Central venous catheter is used as a permanent access in patients who have exhausted all other options for autogenous AVF or AVG. It is the method of choice in patients who are not candidate for AVF or AVG, like patients with limited cardiac reserve, children weighting less than 30 kg, and patients with extensive peripheral vascular disease.

Catheter types There are many commercially available percutaneous hemodialysis catheters, all are grouped into two main types; the non-tunneled and the tunneled catheters figure 8 , both are usually provided with dual lumen; one for withdrawal and the other for return of blood, but in some cases they were of three lumens, with the third one for I.

The tunneled catheters have Dacron or Teflon cuff on their shaft near the distal end which promotes tissue ingrowth in order to fix the catheter to the subcutaneous tissue, some catheters have another antimicrobial cuff distal to the fixation cuff in order to limit microbial invasion through the subcutaneous tunnel, the antimicrobial cuff is formed of porous collagen incorporating an antimicrobial agent.

The non-tunneled catheters are used in patients who are planned for short term catheter dependent hemodialysis less than one month , while tunneled catheters are used in patients who are planned for long term catheter dependent hemodialysis.

Most of hemodialysis catheters made of silicone or polyurethane. The cuffed catheter is tunneled subcutaneously from the desired exit site to the site of vein entry.

The non-cuffed double lumen catheters are placed by conventional Seldinger technique, while the cuffed one are flexible and required the use of rigid introducer or peel-apart sheath that is latter removed, leaving the catheter in place.

The catheter is placed into one of the large central veins so the tip lies in the junction of superior vena cava with the right atrium.

They also are acceptable for access of shorter duration. In addition, some patients who have exhausted all other access options require permanent access via tunneled cuffed catheters.

For patients who have a primary AV fistula maturing but need immediate hemodialysis, tunneled cuffed catheters are the access of choice.

Catheters capable of rapid flow rates are preferred. The preferred insertion site for tunneled cuffed venous dialysis catheters is the right internal jugular vein.

Other options include: the right external jugular vein, the left internal and external jugular veins, subclavian veins, femoral veins, or translumbar access to the inferior vena cava.

Subclavian access should be used only when jugular options are not available. Tunneled cuffed catheters should not be placed on the same side as a maturing AV access, if possible.

Fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The catheter tip should be adjusted to the level of the caval atrial junction or into the right atrium to ensure optimal blood flow.

Atrial positioning is only recommended for catheters composed of soft compliant material, such as silicone. Real-time ultrasound-guided insertion is recommended to reduce insertion-related complications.

There is currently no proven advantage of one cuffed catheter design over another. Catheters capable of a rapid blood flow rate are preferred.

Catheter choice should be based on local experience, goals for use, and cost. The subclavian vein is approached by inserting the needle under the clavicle at the junction of its lateral third with the medial two thirds directing the needle toward the sternoclavicular joint with the patient in supine position.

The femoral vein is approached by inserting the needle at the inguino-crural crease just medial to the femoral pulsation directing the needle toward the umbilicus with the patient in supine position.

Complications Many complications may occur during catheter placement, but they could be prevented by adopting careful maneuver, using ultrasound and fluoroscopic guidance.

Complication list include hemothorax, pneumothorax, arterial puncture, hematoma and air embolism. Catheter related problems 8.

If this occurs in a previously functioning catheter, catheter thrombosis should be suspected. The thrombus may be intraluminal, at the tip of the catheter or rarely the catheter induces thrombosis in the vein in which it is placed.

Other cause of catheter malfunction is the fibrin flap, in this condition fibrin extends from the fibrin sheath to come in front of the catheter tip acting as a valve preventing withdrawal but allowing infusion of blood.

In spite of the proper adjustment of the catheter lock solution to just fill the catheter lumen, some amount usually leak to the circulation [], in case of citrate this causes no problem [], but in case of heparin this may cause bleeding complications in susceptible patients [].

Recently trials are going on to evaluate the use of small dose of tissue plasminogen activator as catheter lock solution aiming to obtain better results than those obtained with heparin and citrate [ , 13 3].

The use of oral anticoagulant in the form of warfarin in therapeutic dose with the INR 1. Treatment of catheter dysfunction In case of low catheter flow, simple measures may succeed in restoring adequate blood flow such as repeated aspiration and flushing with saline, passage of guide wire through the lumen of the catheter, changing the position of the patient, and reversal of the lines withdrawal from the venous line and return the blood through the arterial line.

The thrombolytic agent is injected inside the catheter lumen and left for min before its withdrawal. Higher doses of urokinase were tried using infusion through the catheter rather than locking the catheter with higher success rate and less recurrence [], provided that there were no contraindications to lytic therapy.

If these methods failed to restoreadequate blood flow, then catheter exchange over guide wire will be the appropriate option.

Catheter infection Infection is the most common complication of hemodialysis catheter and it is one of the leading causes of morbidity and catheter removal in hemodialysis patients.

The catheter infection rate is variable and is related to the duration of use. Catheter infection may be exit-site infection, tunnel infection or catheter-related bacteremia.

Catheter-related bacteremia is thought to be commonly originated from bacteria in the catheter biofilm. The biofilm is formed on the catheter lumen in the first 24 hours after catheter insertion.

The bacteria in the biofilm are resistant to antibiotic at therapeutic plasma concentration, but are usually susceptible to higher concentrations [].

The catheter exit site should be examined at each hemodialysis treatment for signs of infection. Catheter exit site dressings should be changed at each hemodialysis treatment.

Use of dry gauze dressing combined with skin disinfection, using either chlorhexidine or povidone iodine solution, followed by povidone iodine ointment or mupirocin ointment at the catheter exit site are recommended after catheter placement and at the end of each dialysis session.

During catheter connect and disconnect procedures, nurses and patients should wear a surgical mask or face shield.

Nurses should wear gloves during all connect and disconnect procedures. Treatment of Infection of Tunneled Cuffed Catheters Tunneled cuffed catheter infection is a serious problem.

Appropriate treatment is dependent upon the nature of the infection: 1. Apply topical antibiotics, ensuring proper local exit site care; do not remove the catheter.

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