Dr. Edwin Stephen Professor and Head Department of Vascular and Endovascular Surgery Christian Medical College Vellore Tamilnadu India
[email protected] 0416-2282085
Seven Gothic Tales Lancet;Vol 382 August 2013
“The human being is a minutely set, ingenious machine for turning with infinite artfulness, the red wine of Shiraz into urine?” Isak Dinesen
Chronic kidney disease: global dimension and perspectives Lancet 2013;382:260-72, Incidence Vivekanand Jha et all •
Lancet 2013; 382: 260–72 , Incidence
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Vivekanand Jha, Guillermo Garcia-Garci et al
Renal access complications
Kidney Disease Outcomes Quality Initiative guidelines • ESRD MDT - nephrologists, vascular / transplant surgeons / interventional radiologists • reducing morbidity related to vascular access • increasing long-term access function
• guide forthcoming research agendas • National Kidney Foundation – 1997,2000,2006,2012
Renal access • Non- tunnelled • Tunnelled • AV fistula • AV graft
Renal access complications tunnelled / non-tunnelled • Access / insertion • Catheter dysfunction / thrombosis / infection • Central vein thrombosis • Fibrin sheath • Catheter locking solution
Renal access complications Permanent • Infection • Bleeding • Aneurysmal changes • Steal • Stenosis / Thrombosis
Journal of vascular surgery 2011 Sep;54(3):760-5 Kimball TA,Barz K et al
• Denver, Portland
• Objective - determine the incidence of HD, - the functional patency,
- associated morbidity of AVFs
Journal of vascular surgery 2011 Sep;54(3):760-5 Kimball TA,Barz K et al
Methods • Consecutive patients, late-stage CKD • AVF creation using KDOQI guidelines for anatomy • January 2003 and December 2007 , 2 tertiary academic centers retrospectively evaluated • Patients stratified into one of four groups , A-D • 2 end points: patency of their AVF whether HD began
Journal of vascular surgery 2011 Sep;54(3):760-5 Kimball TA,Barz K et al
Complications • Maturation failure for cannulation (15%) • Focal stenosis requiring intervention (13%) • Inadequate flows on HD (9%) • Steal syndrome (9%) • Thrombosis (8%)
Journal of vascular surgery 2011 Sep;54(3):760-5 Kimball TA,Barz K et al
Complications • Cumulative functional patency for all AVFs -19% and 27% at 6 and 12 months • Mean of two interventions per AVF (range, 1-10) • Mortality during the study was 23%.
Case scenario • 67 year old lady, thrice weekly dialysis • Diabetic, Hypertensive on treatment- 22 years • Started dialysis Left BC AVF, 2 weeks ago • C/O pain left hand during dialysis • Technician adjusts flow and continues
Diagnosis ?
Procedures for fistula salvage
DRILDistal revascularization interval ligation
Case scenario • 54 year old male, Status failed renal
transplant • Right radio-basilic fistula used 1 year • Difficulty cannulation – transposed
• Post repair- bleeding from wrist , clots
Diagnosis ?
Case scenario • 72 year old lady, Left BC AVF
• Used for dialysis - 3 years, bi - weekly • Increasing swelling • No pain, good thrill proximal
• Pulsatile at proximal arm
Diagnosis ?
Case scenario • 45 year old male • Diabetic – 20 years
• Status left AV graft – axillobrachial • Swelling / bleeding puncture site
Diagnosis ?
Case scenario • 72 year old lady , DM ,HTN
• AF on warfarin • Bi-weekly dialysis • Pulsatile swelling 2 days post dialysis
• INR-
Diagnosis ?
Precautions • Cleanliness important - patient should keep an eye for infection, pain, tenderness, swelling, redness around access area
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Unrestricted flow - no tight clothing - no application of BP cuff on same arm - no blood drawn
Precautions - Not to sleep on it - Check for thrill daily, if missing or reduced contact your doctor - If bleeding after dialysis access or accidental apply pressure and go to ER • Newly created fistula must be evaluated, 4 - 6 weeks after creation for maturation
Rule of 6…. • Vein diameter on expansion 6mm • Vein 6mm from skin surface • 6 weeks to mature • 6 inch long [ 15cm ] cannulation length • Cannulate 6cm from arterial anastomosis • Flow 600 cm/sec
THANK YOU FOR YOUR ATTENTION
Sunset –sea of Oman
