© Springer Science+Business Media New York 2014
Samir K. Shah and Daniel G. Clair (eds.)Cleveland Clinic Manual of Vascular Surgery10.1007/978-1-4939-1631-3_99. Hemodialysis Access
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Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Mail Code H32, Cleveland, OH 44195, USA
Chronic Kidney Disease
One in ten American adults, more than ten million people, has chronic kidney disease (CKD) [1]. CKD is defined as a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 for more than 3 months or when a patient’s urine albumin to creatinine ratio is greater than 30 mg of albumin for each gram of creatinine (30 mg/g).
Epidemiology and Costs
The incidence of patients age 65 and older with CKD more than doubled between 2000 and 2008. End Stage Renal Failure (ESRD) is defined as total and permanent kidney failure. ESRD rates are three times higher for African-Americans compared to non-Hispanic whites. Treating ESRD cost the US more than $40 billion in public and private funds in 2010 [2, 3].
Hemodialysis Routes
Routes for hemodialysis vascular access include (1) tunneled dialysis catheter (TDC), (2) prosthetic bridge graft (PBG), and (3) arteriovenous fistula (AVF).
In 1997, the National Kidney Foundation Disease Outcomes Quality Initiative (NKF DOQI) [4] set forth a goal of increasing prevalent rates of AVF to 40 % nationally. In 2006, The Fistula First Breakthrough Initiative (FFBI), based upon early progress, modified the prevalent AVF goal to 66 %. Additionally, FFBI set forth a goal of reducing national rates of long-term TDC (i.e., not as a bridge) to less than 10 %. Currently the program’s name is modified to Fistula First/Catheter Last [5]. In the first year following the initiation of HD, all-cause mortality in ESRD is 20 %. Cardiovascular complications account for 10 % and infectious causes 1–2 %. Extended use of central venous TDC is associated with up to 30 % incidence of significant central vein stenosis. To this extent, early referral with prompt creation of AVF preferably or PBG next can avoid infectious and central vein complications associated with TDC use.
National Trends
Despite broad systemic efforts to identify and refer patients earlier for permanent dialysis access creation, nationally 80 % of patients newly diagnosed with ESRD are initiated on hemodialysis (HD) via a TDC [3]. At 6 months after initiating HD, 55 % of patients continue to be dialyzed with a TDC. Current national rates of AVF are 55 %, PBG 27 %, and TDC 18 %.
Evaluation
History
Obtain information on hand dominance (preferable to use nondominant extremity although vein caliber takes precedence), previous vascular access (central venous catheter, peripherally inserted central catheter, pacemaker, and defibrillator), upper and lower extremity venous thrombosis, hand ischemia, and pulmonary hypertension (potentially exacerbated by arteriovenous fistula).
Physical Exam
Examine with upper arm tourniquet (note frequently neglected basilic vein).
Prominent cutaneous chest wall veins.
Brachial pressure comparison from arm to arm may reveal occult subclavian stenosis. Twenty percent prevalence on left.
Presence and quality of radial and ulnar pulse. Eighteen to twenty percent overall prevalence of brachial artery variant anatomy. Note also lower extremity pulses.
Arm circumference. Large circumference may represent a challenge to transposed reconstructions in upper arm and necessitate transposition in the forearm.
Imaging
Noninvasive Vascular Exam
Duplex venous ultrasound (US) evaluation of the arms and legs, preferably performed by the surgeon. This provides insight into aberrant branching patterns that dictate incision placement. Vein diameter of 2.5–3.0 mm is preferred; however the absence of phlebitic or calcific changes is equally important and a 2.5 mm nondiseased vessel is useable.
Arterial mapping with duplex US evaluation is used to quantify vessel diameter and the absence of calcification. Note the presence of high brachial bifurcations, which is associated with fistula nonmaturation, graft occlusion. The role of corresponding arterial dilation necessary to cause vein maturation is underappreciated and likely explains the lower rate of maturation in diabetics with fibrocalcific vascular changes.
Pulse volume recordings (PVR) of the arms or legs in the face of absent pulses, which may be due to noncompressible diabetic calcinosis.
Invasive Testing
I suggest selective use of venograms for primary vascular access creation in patients with history of central catheters or stigmata of central venous stenosis given that the rate of stenosis in unmanipulated central veins is low. Whether to intervene prospectively or only if symptoms develop after access creation remains controversial. In patients with preserved renal function CKD IV/V, carbon dioxide with or without a small amount of contrast can allow the central veins to be cleared.
For secondary access creation in surgical fields that have previously been operated, I routinely perform venography to compliment duplex vein mapping as duplex is less reliable as a standalone modality to evaluate vessel continuity.
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