Acute hemodialysis vascular access:

Acute dialysis catheters

Cuffed,tunneled dialysis catheters

Chronic hemodialysis vascular access:

native arteriovenous (AV) fistulas
synthetic grafts
 Acute Hemodialysis Catheters
Double-lumen, non-cuffed, non-tunneled hemodialysis catheters
have become the preferred method for obtaining acute hemodialysis
vascular access

An acute triple-lumen dialysis catheter has been developed. The

third lumen is available for blood drawing and the intravenous
administration of drugs and fluid.

The maximum blood flow is usually blood pump speeds of 300

mL/min, with an actual blood flow of 250 mL/min or less.
Acute Hemodialysis Catheters
Site of catheter Insertion
can be inserted into the jugular, subclavian,
and femoral veins
Routine use-life of catheters
The limits on use-life are caused by infection
internal jugular catheters are suitable for 2 to
3 weeks of use
femoral catheters are usually used for a
single treatment (ambulatory patients) or for 3
to 7 days in bed bound patients
Double lumen cuffed tunneled catheters

Are principally constructed of silastic/silicone and other

soft flexible polymers, which are less thrombogenic
than polymers used in acute catheters.

Require fluoroscopy for insertion due to their larger

size and to the confirmation of tip location.

Many allow right atrial tip location based on their soft

polymer construction
Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters, Usually

blood pump speeds of 400 mL/min
Actual blood flow rates are almost always lower than
those reported by the blood pump(20%-30%)

Compare to fistulas or arteriovenous grafts, most

patients require an increase in treatment time of
approximately 20 percent to achieve equivalent
urea removal.

Cuffed tunneled catheter survival

is highly variable, 74 percent 1-year and a 43
percent 2-year catheter survival
Acute Double Lumen Catheter Complications

Complications associated with insertion:

Transient atrial or even ventricular arrhythmias due to

overinsertion of guidewires
Hemothorax
Pneumothorax
Catheter-induced subclavian stenosis

The location of the catheter in subclavian and internal jugular insertion

should always be confirmed by x-ray prior to the initiation of
hemodialysis or the administration of anticoagulants
Catheter Malfunction
Definition:
Failure to achieve blood flow rate at least
300ml/min on 2 consecutive occasions or less
than 200ml/min on a single occasion
Early:Inproper positioning of catheter tip
subcutaneous kinking of catheter
Late: intraluminal thrombi and less commonly
extrluminal thrombi( fibrin tails)
Double Lumen Catheter Complications
Catheter thrombosis
Prevention
Heparin of either 1 mL = 1000 Units, 1 mL= 5,000 Units, or 1
mL = 10,000 Units can be used
alteplase (recombinant tissue-type plasminogen activator,
rtPA)
administration of alteplase (2 mg injected into each lumen)
was associated with significantly higher blood flow rates and
better arterial and venous pressures compared with heparin
Treatment Lytic agents such as urokinase and alteplase are
effective
Non-cuffed catheters should be exchanged if flow is
inadequate
Double Lumen Catheter Complications
Central vein thrombosis and stenosis

occur more often with subclavian (40 to 50

percent of cases in some studies) than with
internal jugular insertions (up to 10 percent)

The K/DOQI guidelines therefore recommend

avoiding placement in the subclavian vein,
unless no other options are available
Double Lumen Catheter Complications

Infection

local exit site infection

systemic bacteremia

Bacteremia generally results from either contamination

of the catheter lumen or migration of bacteria from the
skin through the entry site, down the hemodialysis
catheter into the blood stream
Double Lumen Catheter Complications

Prevention of infection:

strict adherence to proper placement technique

optimal exit site care
management of the catheter within the hemodialysis
facility
antiseptic or antibiotic-bonded hemodialysis
catheters, minocycline-rifampin coated
catheter,citrate4%
Double Lumen Catheter Complications
MICROBIOLOGY
Staphylococcal infection, both coagulase-negative and S. aureus,
accounts for 40 to 81 percent of cases,and enterococci and Gram
negative rods

DIAGNOSIS:
Blood cultures
colony count four-fold higher in blood drawn from the catheter
compared to the peripheral specimen had a sensitivity of 94 percent,
a specificity of 100 percent,
A single bacterial count of >100 cfu/mL from catheter cultures with
an identical organism growing from the peripheral blood specimen
it is common to occur in the absence of evidence of an exit-site
infection
Double Lumen Catheter Complications

Treatment of infection:

initially treating with broad spectrum agents ( vancomycin

and an aminoglycoside).

Obtaining of blood cultures two to four days after initiation of

antibiotic therapy.
Double Lumen Catheter Complications

Catheter removal
All non-cuffed catheters should be removed in the presence of bacteremia
if follow-up blood cultures remain positive for more than five days despite
appropriate antimicrobial therapy
signs of accompanying exit-site or tunnel infection (erythema or pus at exit-
site)
infection with Candida or an infected clot.
An infected clot should be suspected if infusing or drawing blood through the
line is difficult or associated with rigors.
the patient becomes hemodynamically unstable or if the fever persists or
cultures remain positive after two to four days.
Patients who remain febrile or have positive cultures after the catheter is
removed should undergo a thorough examination for metastatic
complications (such as endocarditis and vertebral osteomyelitis)
Double Lumen Catheter Complications
Recommendations:

All personnel should be adequately trained in aseptic

techniques and about the importance of routine hand hygiene
before and after patient contact.

topical use of povodone-iodine on the catheter hubs

nurses or technicians routinely wear nonsterile gloves and a

mask when dialysis catheters are accessed

monitor rates of dialysis-associated infections to detect and

understand local trends in types of pathogens, incidence and
antimicrobial resistance
Chronic hemodialysis vascular access

Native arteriovenous (AV) fistulas

Synthetic grafts
Double-lumen tunneled cuffed catheters
Native arteriovenous (AV) fistulas
constructed with an end-to-side vein-to-artery
anastomosis between an artery and vein
Radial artery and cephalic vein (radiocephalic or wrist
fistula)
Brachial artery and cephalic vein (brachiocephalic or
upper arm fistula).
Native arteriovenous (AV)
fistulas
Synthetic grafts
are constructed by anastomosing a synthetic
conduit, usually polytetrafluoroethylene (PTFE,
also known as Gortex), between an artery and
vein.
The 2006 K/DOQI work group recommends a graft
either of synthetic or biologic material
Comparison of Fistulas and Grafts
Primary failure
defined as an access that never provided reliable
hemodialysis.
In radiocephalic fistulas 24 to 35 percent
brachiocephalic fistula 9 to 12 and
brachiobasilic fistulas 29 to 36 percent
forearm grafts 0 to 13 percent
upper arm grafts 0 to 3
Comparison of Fistulas and Grafts
Time to use
Grafts
Grafts can be cannulated for hemodialysis earlier than fistulas.
Grafts can usually be cannulated within weeks.
Some times within days of surgery
Fistulas
Cannulation before two weeks of age should be avoided.
Cannulation between two to four weeks may be attempted but only if
the fistula is considered mature.
Cannulation after four weeks of maturation may be safe, if the fistula
is mature.
Independent of the age of the fistula, clinical examination prior to
cannulation is very important, given that some fistulas require up to
six months to mature.
Comparison of Fistulas and Grafts

Patency/secondary failure
In native fistulas the risk of secondary failure is
low.
The 5-year and 10year cumulative patencies for
radiocephalic fistulas are reported to be 53 and
45 percent, respectively
cumulative patency for PTFE grafts at one, two,
and four years is approximately 67, 50 and 43
percent, respectively
Comparison of Fistulas and Grafts
Complications: grafts vs. AVF
Thrombosis: 3.8 times
Infection: 10%,2%
Steal syndrome: 5% in both
Aneurysms: 5%, 3%
venous hypertension: 3% in both
seromas
heart failure: less than 1% in AVF
local bleeding
Thrombosis, infection, and seromas occur more frequently
with grafts than with fistulas
Steal syndrome
Symptoms and signs:
Mild:
Coldness, numbness, paresthesias,pain during dialysis, with
retained pulses
Severe(Indication for ischemia correction):
Constant pain, severe numbness,a nonhealing ischemic
fissure,digital cyanosis or gangrene,finger contracture
Mild symptoms and signs usually improve over a period of weeks with
the development of collateral blood flow.
Careful, frequent observations and an alert nursing staff are required
in this setting
Aneurysm and Pseudoaneurysm

Usually result from repeated cannulation in the same

area of the fistula

Can be avoided by rotation of needle insertion sites

Aneurysm and Pseudoaneurysm
Indications for revision/repair of AV fistula aneurysm:
The skin overlying the fistula is (ischemic)compromised
There is a risk of fistula rupture
Available puncture sites are limited
indications for revision/repair of pseudoaneurysm formation :
symptomatic or threatens the viability of the overlying skin
Evidence of infection
Pseudoaneurysm that is enlarging in size or that exceeds twice the
diameter of the graft
Limited number of cannulation sites
Cannulation through a pseudoaneurysm must be avoided
Venous Hypertension
Sign and symptoms:
severe upper limb edema
skin discoloration
access dysfunction
peripheral ischaemia with resultant fingertip ulceration.
In most cases, the underlying venous pathology follows
ipsilateral central venous catheter placement with
consequent venous stenosis.
Infection
The second most commonn cause of AV access
failure(0-3% in AVF and 6%-25%in AV grafts)
Treatment:
AVFs:Local drainage and antibiotic therapy for 6
weeks
AV grafts:antibiotic therapy and surgical
treatment( in most cases complete excision of
prosthetic graft)
 Buttonhole Technique
for
Cannulating AV Fistulae
Buttonhole Structure
Needles sharp and blunt
Buttonhole Technique

Reuse same sites

each treatment with
blunt needles

Must follow the

track/tunnel of the
original cannulator
Doppler Ultrasound Tunnel
Benefits for the patient
Less painful elimination of anesthetic
Fewer infections
Fewer missed needle sticks
Fewer infiltrations/hematomas
Cannulation of access takes less time
Why offer the Buttonhole Technique?

Prolong AV fistula life

Decrease hospitalizations related to
access infections and complications
Promote patient self-cannulation
Decrease pain associated with needle
Cannulation