The ultimate objective for patients presenting for permanent hemodialysis access is to establish a safe, durable, and effective means of assuring adequate hemodialysis (Fig. 86-1). Unfortunately, there is no perfect hemodialysis access that satisfies all these requirements, and patients usually require several procedures and/or interventions over the course of their lifetime. Ideally, this requires a lifelong plan and a committed group of healthcare providers. The overwhelming majority of patients presenting for permanent access, including those designated as “complex” or “tertiary care” cases, are candidates for one of the more traditional upper-extremity access procedures. Indeed, most patients can have an autogenous configuration that potentially affords the advantage of improved patency and fewer infectious complications. Our approach, designed to optimize the use of autogenous upper-extremity accesses, is predicated upon the standard principles of vascular surgery, including adequate arterial inflow, adequate venous outflow, and a suitable conduit. Furthermore, it is based upon the use of tunneled catheters as a “bridge” or temporary access until the permanent access is suitable for cannulation and an aggressive approach to “failing” or “nonmatured” accesses. Our anecdotal impression has been that despite the multiple case reports describing “heroic” or “salvage” access options, these options are rarely necessary. Indeed, we have performed very few lower-extremity access procedures during the past few years among greater than 600 permanent hemodialysis access procedures.

The initial evaluation of patents presenting for permanent hemodialysis access includes a focused history/physical examination. Special attention should be directed at documenting the access history, including procedures, revisions, and associated complications. The latter should include any history of central vein cannulation, arm/facial edema, and hand ischemia. Physical examination should include a detailed pulse examination with an Allen test to determine the forearm vessel responsible for the dominant arterial supply to the hand and examination of the neck/chest to look for venous collaterals.

Noninvasive testing in the diagnostic vascular laboratory is the cornerstone of our algorithm. The examinations involve interrogation of both the arterial and venous circulation. The arterial studies include blood pressure measurements of the brachial, radial, ulnar, and digital arteries along with the corresponding velocity waveforms of all but the digital vessels. Additionally, the Allen test is repeated, and the diameters of both the radial and brachial arteries are measured. Venous imaging includes the interrogation of the cephalic and basilic veins from the wrist to the axilla complete with diameter measurements similar to the pre-operative vein survey obtained prior to infrainguinal arterial revascularization.
Additionally, the upper-extremity and central veins are examined for the presence of deep venous thrombosis (DVT), although the interrogation of the veins within the thoracic cavity is limited due to the associated bony structures.

A preliminary operative plan is then generated based upon the results of the history/physical and noninvasive imaging. Our objective has been to select the combination of artery and vein that would most likely result in a successful autogenous access, although a comparable approach for prosthetic accesses is appropriate. We have not felt constrained by the usual conventions of using the nondominant > dominant extremity and the forearm > arm, although we have followed these standard approaches when the choices are equivocal. The criteria for an adequate artery and vein include no hemodynamically significant arterial inflow stenoses, no venous outflow stenoses, and a peripheral vein segment of suitable length/diameter (Table 86-1). Our preferences in descending order include the radiocephalic, radiobasilic, brachiocephalic, and brachiobasilic autogenous accesses prior to use of any prosthetic material (Table 86-2). Admittedly, these preferences differ from the DOQI that advocate use of the radiocephalic autogenous access, the brachiocephalic autogenous access, and the forearm
prosthetic access, in descending order of preference. We have had particularly good outcomes with the brachiobasilic configuration. Indeed, the basilic vein is an excellent conduit for autogenous access, because it is usually relatively thick walled, large in diameter, and well preserved in terms of cannulation for venipunctures and intravenous catheters, due to its course deep to the subcutaneous fat.

Invasive imaging with both venography and arteriography is performed to confirm the preliminary access configuration selected. We have recently backed away from our practice of routinely obtaining arteriograms/venograms in all patients undergoing permanent hemodialysis access despite our published algorithm, but we still obtain these studies in patients with more complex problems. The venogram is performed first to confirm that there are no central vein stenoses or occlusions. Hemodynamically significant stenoses are suggested by the presence of collaterals, but they can be confirmed by measuring intraluminal pressures across the lesion. Unfortunately, the venogram has not been particularly helpful as a means to interrogate the more superficial basilic and cephalic veins. An ipsilateral arteriogram is performed if no central vein problems are identified. The arteriogram is performed using a retrograde femoral approach with complete visualization of the arterial tree from the aortic arch to the digits. If a significant central vein problem is identified, a venogram on the contralateral extremity is performed before proceeding with the arteriogram. Endovascular treatment with either angioplasty or angioplasty/stent may be performed at the same time of the invasive studies or at the time of the access procedure itself. However, the decision to proceed with intervention is contingent upon the clinical scenario and the other potential access options identified by the noninvasive testing. Carbon dioxide and gadolinium are used as contrast agents for the venogram and arteriogram, respectively, for patients with chronic renal insufficiency who have not yet begun dialyzing in an attempt to reduce or eliminate any contrastassociated nephrotoxicity.

The operative procedures are performed using standard techniques. Regional and/or local anesthesia is used for all forearm accesses and for the autogenous brachiocephalic accesses, while general anesthesia is used for the autogenous accesses and whenever it is anticipated that an additional vein segment will be harvested from another extremity. Patients with peripheral veins that are deemed too small (<3 mm) for autogenous accesses by the pre-operative noninvasive diameter criteria are re-imaged either immediately pre-operatively or intraoperatively after induction of anesthesia and the resultant vasodilation. We have been impressed with the variability in the vein diameter measurements during serial imaging performed on different days and have attributed it to the patients’ volume status and the changes associated with hemodialysis. Alternatively, the veins can be dissected and examined directly. The peripheral arm veins that are insufficient length but of suitable diameter can be augmented with a segment of saphenous vein. This occurs most commonly when constructing a brachiobasilic access and the length of the usable basilic vein is not sufficient to transpose subcutaneously over the lateral aspect of the biceps muscle. Admittedly, this sacrifices a segment of saphenous vein that may potentially be required later for arterial revascularization. It is frequently necessary to remove the thrombosed prosthetic grafts used for previous accesses to facilitate the arterial anastomosis and tunneling the new one. This is particularly relevant for patients with complex access problems who have had multiple previous procedures.

Patients are seen in the outpatient clinic within 2 weeks after their operative procedure and at monthly intervals thereafter until their accesses are usable for dialysis. The autogenous accesses must be both sufficiently dilated before the technologists can consistently cannulate the lumen and must be arterialized to sustain the repeated trauma of cannulation. We use 5 to 6 mm as the diameter criteria for initiating dialysis. Unfortunately, there are no means to assess the integrity of the access wall. Autogenous accesses that fail to dilate and those without a thrill are imaged with either a fistulogram or an arteriogram/fistulogram/ venogram. The choice is contingent upon the clinical suspicion, with the latter reserved for those patients in whom an arterial inflow problem is suspected, because the extent of the access including the arterial anastomosis and central venous runoff can usually be obtained by direct cannulation of its proximal aspect. Additional open surgical or endovascular procedures are performed as necessary to facilitate maturation of the access.

Temporary, tunneled catheters are used for hemodialysis until the new accesses are
suitable for cannulation. Indeed, the use of these temporary catheters affords the luxury of time to allow the autogenous accesses to mature. The complications associated with these catheters are well known, and every attempt is made to minimize their use. Ideally, all patients should have their accesses constructed far in advance of their anticipated dialysis start date, although this consideration is irrelevant in most patients with complex access needs, because they are usually actively dialyzing.