Chapter 33. Vascular Access for Dialysis

• End-stage renal disease; recommendations from the Kidney Dialysis Outcomes Quality Initiative:
  • Creatinine clearance < 25 mL/min.
  • Serum creatinine > 4.0 mg/dL.
  • Dialysis anticipated within 1 year.
• Long-term plasmapheresis.

• Ipsilateral proximal venous and arterial occlusion or stenosis.
• Systemic or local infection.
• Multiple comorbidities precluding safe intervention.

Expected Benefits

• Provides access for dialysis.

Potential Risks

• Clotting, narrowing, or scarring of the graft requiring surgical or radiologic revision.
• Infection of the graft requiring surgical excision and replacement.
• Wound infection.
• Injury to the neurovascular structures of the arm.
• Bleeding.
• Failure of the fistula to mature for adequate dialysis access.
• Pain or numbness.
• Development of arterial "steal," resulting in decreased blood flow to the hand.

• No. 10 or 15 blade scalpel for skin incision.
• Electrocautery unit.
• Heparinized saline solution.
• Prosthetic expanded polytetrafluoroethylene (ePTFE) graft (frequently tapered 4–7 mm) for forearm loop grafts or brachial artery to axillary vein arteriovenous grafts if arteriovenous fistula is not possible.
• Tunneling device if needed.
• Small vascular clamps or vessel loops.
• No. 11 blade scalpel and Micro-Potts scissors.
• Double-armed polypropylene suture.
• Doppler ultrasound unit.

Preoperative History

• Specific focus on history of indwelling catheters, pacemaker, internal automatic cardiac defibrillator, or extremity trauma.
• Dominant extremity should be documented.
• Patients with severe congestive heart failure may not tolerate the additional cardiac output required to circulate blood through the fistula.

Physical Examination

• All pulses should be palpated.
• The Allen test should be performed to evaluate perfusion to the hand.
• Blood pressure should be obtained in both arms to evaluate proximal arterial disease.
• Veins of the wrist, forearm, elbow, and upper arm should be evaluated with or without a tourniquet.
  • Repetitive hand squeeze may make veins more prominent.
  • Visible veins can be considered for access.

Ultrasonography

• Doppler: to assess arterial flow.
• B-mode: to image and size potential veins.
  • Vein segments < 2.5 mm may be technically difficult to use for anastomosis and are associated with higher rates of failure.

Indications for Venography

• Edema in the extremity in which access is planned.
• Collateral vein development in the planned access site.
• Differential extremity size of the considered limb.
• Current or previous central access or transvenous catheter in the ipsilateral limb.
• Previous arm, neck, or chest trauma on the same side as the planned access site.
• Prior failed attempts to establish access in the ipsilateral extremity.

• The patient should be supine with the operative arm extended on an arm board and supinated.
• The arm should be prepared circumferentially from the fingers to the axilla, and the hand covered with a sterile towel.

• Figure 33–1: Vascular anatomy of the upper extremity.
  • The basilic vein courses medially down the arm and is found in the deeper subcutaneous ...