Vascular access

Vascular access

1. Dr. tarek fayez Dr. mohamed kamal Dr ahmed alnakeeb Dr. emad anter Dr. mohamed abdsattar Vascular access

2. Basilic vein arises from the ulnar side of the superficial venous network of the dorsum of the hand Drain medial side of upper limb Cephalic vein origin: radial aspect of the superficial venous network of the dorsum of the hand Drain laateral side of upper limb

3. Types of vascular access 1- Arteriovenous fistula 2- Areteriovenous Graft 3- Catheter : * Temporary double lumen catheter * Permenant catheter

4. Native arteriovenous fistula *it has the longest patency rates among the access options * it has low rates of local or systemic infection *it has low rates of thrombosis *the delivered dialysis dose is superior to tunneled cuffed dual lumen catheters and comparable with grafts

5. FISTULA MATURATION Rule of 6’s In general, a mature fistula should: Be a minimum of 6 mm in diameter when a tourniquet is in place Be less than 6 mm deep Have a blood flow greater than 600 mL/min Be evaluated for non maturation 4-6 weeks after surgical creation

6. These fistulae are typically fashioned to connect -the radial artery to the cephalic vein - the brachial artery to the cephalic vein - the brachial artery to a basilic vein.

7. Native arteriovenous fistula

8. Grafts Upper-arm loop graft (brachial artery to basilic vein). *grafts have lower initial nonfunction rates than autogenous fistulae *grafts can be used earlier postoperatively compared with native fistulae, 2 to 3 weeks after the surgery

9. Forearm Loop Arteriovenous Graft

10. Upper Arm Arteriovenous Graft

11. Thigh Arteriovenous Graft

12. Examination of AVF * LOOK * FEEL * LISTEN

13. LOOK - Vascular access scar site - Hematoma or signs of infection (redness, warmth,pain,pus ) - Ischemic signs : blue or cold hands up to gangrene , pain at rest. (steal phenomena >> backflow of I blood from the hand to I fstula ) - Aneurysm Arm elevation test > normally collapse if not > outflow stenosis in venous side - collaterals

14. FEEL - AVF pulse character (normal > soft compressible) Abn > hyperpulsatile > outflow stenosis Abn > hypopulsatile > inflow stenosis - AVF thrill ( normal > continous thrill) Abn > discontinuous and strong > outflow stenosis Abn > discontinuous and weak > inflow stenosis

15. FEEL - Augmentation test : ( normally > pulse augmentation and absence of thrill) Abn > no pulse augmentation and no thrill> inflow stenosis Abn > no pulse augmentation and still thrill > accesory vein - Sequential occlusion test : to detect level of accesory vein

16. Listen Bruit ( normal continous thrill ) Abn > discontinuous thrill > loud > outflow stenosis Abn > discontinuous thrill > soft > inflow stenosis

17. venous catheter Temporary non Cuffed Catheters Cuffed Tunneled Catheters

18. Temporary non Cuffed Catheters  More ridged.  Easy and fast insertion.  Immediate use.  Higher infection rate.  Preferred IJ or femoral.  Avoid subclavian .  < 3wks for IJ.  <5 days for femoral.

19. Cuffed Tunneled Catheters  Dacron cuff.  Softer.  Sheath for insertion.  Different holes, length and material.  Requires sedation.  Lower neck insertion site.  More bleeding.

20. Catheters Disadvantages  Associated with higher mortality risk than fistula  Thrombosis.  Infection.  Central venous thrombosis.  Discomfort.  Cosmetic.  Shorter expected using time .

21. We had done vascular access assesment on 137 pt (94 males , 42 females ) in our nephrology department on regular hemodialysis Assesment include: * History (Name -Age - Type of access – date of creation – n. of previous AVF and past catheter – reasons of access failure – date of starting HD – aet . of renal failure – max. blood flow and any problems on sessions ) * Inspection – palpation - auscultation

22. Conclusion Arteriovenous fistula (AVF), due to the possible long-term use and low-level complications, is known to be the best method to perform the process of chronic hemodialysis.

23. AVF remains the first choice for chronic HD. It is the best access for longevity and has the lowest association with morbidity and mortality, and for this reason AVF use is strongly recommended by guidelines from different countries.

24. According to the guidelines of the National Kidney Foundation (NKF-K/DOQI),6 the site order for the surgical intervention of AVF for HD is the following: *Forearm (radio–cephalic or distal AVF ) *Elbow ( brachio –cephalic or proximal AVF ) *Arm (brachial– basilic AVF with transposition or proximal AVF).

25. prosthetic fistulae become the second option of maintenance HD access alternatives . CVCs have become an important adjunct in maintaining patients on HD. The preferable locations for insertion are the internal jugular and femoral veins.

26. The tunneled cath is preferable than non tunneled as preventing infection because the tunneling makes the insertion site away from were it goes into the vein. The other is just a straight stick into skin . Vascular surgeon with nephrologist should assess together the best method and site for fistula and catheter insertion for the most benefit to the patient.

27. Thank you