Radiopaque silicone, reinforced with braided nitinol
Titanium connector between arterial graft and venous outflow
Used for failing AVF/AVG secondary to central venous stenosis
Catheter dependent patients
Benefits
Lower infection compared to catheters
Improved HD adequacy compared to catheters
Higher patency rates compared to catheter
Qa: Access flow rate
Varies depending on access configuration, presence of stenosis, arterial inflow
Qb: Dialysis pump flow rate
Typically set at 350-400 mL/min
Kt/V: Number quantifying dialysis treatment adequacy
K: Dialyzer clearance of urea
T: Dialysis time
V: Volume of distribution of urea, ~ equal to patient's total body water
Monitoring: Periodic physical examination and review of routinely gathered data of dialysis patients performed to detect underdialysis and dysfunctional accesses prior to thrombosis
Weekly physical examination
Review of routinely gathered data collected during HD
Dialysis adequacy: Kt/V
Value < 1.2 or decrease by > 0.2 triggers referral for intervention
Dynamic pump pressures
Unreliable if taken in isolation
If abnormal trend or with other access abnormalities can be predictive of the side of stenosis
Needling problems
Prolonged bleeding suggests outflow stenosis
Difficulty with cannulation suggests inflow stenosis
Surveillance: Instrument-based, periodic evaluation performed to detect underdialysis and dysfunctional accesses prior to thrombosis
Access flows
Measured by ultrasound dilution/conductance, dilution/thermal, dilution/Doppler
AVG < 600 mL/min or < 1,000 mL/min if > 25% drop → referral
AVF < 400 mL/min or < 1,000 mL/min if > 25% drop → referral
Static venous pressure
Useful in AVGs
Insensitive to detect inflow problems, which are more common in AVFs
Intraaccess pressure to mean arterial pressure (MAP) ratio > 0.5 triggers referral
Detection of recirculation
Occurs when Qa < Qb
Could be due to inflow or outflow problem
Recirculation > 10% triggers referral
Not sensitive surveillance technique AVGs
AVGs can thrombose with Qa < 600 mL/min
Recirculation occurs when flow rates are < pump rates, typically set at 350-400 mL/min
Doppler ultrasound
Can measure flow rates, detect sites of stenosis
DASS
Arterial insufficiency ipsilateral to HD access
Risk factors
Diabetic patients with multiple prior shunts
Female gender
Brachial artery inflow
High-flow shunts/large anastomoses
Grafts (2.7-8.0%) more common than fistulas (< 2.0%)
Stages
Grade 1 (mild): Cool extremity but otherwise few symptoms
Distal flow augmentation with access occlusion
No treatment needed
Grade 2 (moderate): Intermittent ischemia
Pain during dialysis or with exercise
Treatment occasionally needed
Grade 3 (severe): Rest pain/tissue loss
Treatment mandatory, often with access ligation
National Kidney Foundation-Kidney Disease Outcomes Quality Initiative(NKF-KDOQI)
Provides multidisciplinary evidence-based clinical guidelines for CKD patients
Includes all stages of CKD and all aspects of care
Vascular Access Guidelines most relevant to interventional procedures
Published 2006, update forthcoming January 2018
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Equipment Preparation
Procedure Steps
Findings and Reporting
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
Things to Avoid
OUTCOMES
Complications
Expected Outcomes
Selected References
Vascular Access KDOQI Guidelines. Clinical practice guidelines for hemodialysis adequacy. http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/. Reviewed February 16, 2017. Accessed February 16, 2017
Haskal ZJ et al: Prospective, randomized, concurrently-controlled study of a stent graft versus balloon angioplasty for treatment of arteriovenous access graft stenosis: 2-year results of the RENOVA study. J Vasc Interv Radiol. 27(8):1105-1114.e3, 2016
Koirala N et al: Monitoring and surveillance of hemodialysis access. Semin Intervent Radiol. 33(1):25-30, 2016
Akoh JA et al: Review of transposed basilic vein access for hemodialysis. J Vasc Access. 16(5):356-63, 2015
Balaz P et al: True aneurysm in autologous hemodialysis fistulae: definitions, classification and indications for treatment. J Vasc Access. 16(6):446-53, 2015
Maytham GG et al: The use of the early cannulation prosthetic graft (Acuseal™) for angioaccess for haemodialysis. J Vasc Access. 16(6):467-71, 2015
Quencer KB et al: Arteriovenous fistulas and their characteristic sites of stenosis. AJR Am J Roentgenol. 205(4):726-34, 2015
Swinnen JJ et al: Paclitaxel drug-eluting balloons to recurrent in-stent stenoses in autogenous dialysis fistulas: a retrospective study. J Vasc Access. 16(5):388-93, 2015
Vasanthamohan L et al: The management of cephalic arch stenosis in arteriovenous fistulas for hemodialysis: a systematic review. Cardiovasc Intervent Radiol. 38(5):1179-85, 2015
Agarwal AK et al: How should symptomatic central vein stenosis be managed in hemodialysis patients? Semin Dial. 27(3):278-81, 2014
Hart D et al: Modification of the HeRO graft allowing earlier cannulation and reduction in catheter dependent days in patients with end stage renal disease: a single center retrospective review. ScientificWorldJournal. 2014:318629, 2014
Modabber M et al: Central venous disease in hemodialysis patients: an update. Cardiovasc Intervent Radiol. 36(4):898-903, 2013
Samett EJ et al: Augmented balloon-assisted maturation (aBAM) for nonmaturing dialysis arteriovenous fistula. J Vasc Access. 12(1):9-12, 2011
Bittl JA: Catheter interventions for hemodialysis fistulas and grafts. JACC Cardiovasc Interv. 3(1):1-11, 2010
Haskal ZJ et al: Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 362(6):494-503, 2010
Monroy-Cuadros M et al: Risk factors associated with patency loss of hemodialysis vascular access within 6 months. Clin J Am Soc Nephrol. 5(10):1787-92, 2010
Allon M et al: Hemodialysis vascular access monitoring: current concepts. Hemodial Int. 13(2):153-62, 2009
Casey ET et al: Surveillance of arteriovenous hemodialysis access: a systematic review and meta-analysis. J Vasc Surg. 48(5 Suppl):48S-54S, 2008
Gelbfish GA: Clinical surveillance and monitoring of arteriovenous access for hemodialysis. Tech Vasc Interv Radiol. 11(3):156-66, 2008
Mauro MA et al: Image-Guided Interventions. 1st ed. Philadelphia: Saunders, 2008
Nassar GM: Endovascular management of the "failing to mature" arteriovenous fistula. Tech Vasc Interv Radiol. 11(3):175-80, 2008
Rayner HC et al: Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study. Kidney Int. 63(1):323-30, 2003
Gallego Beuter JJ et al: Early detection and treatment of hemodialysis access dysfunction. Cardiovasc Intervent Radiol. 23(1):40-6, 2000
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Preprocedure
Procedure
TERMINOLOGY
Definitions
Hemodialysis (HD)
Patient's blood is modified by going through dialyzer
Radiopaque silicone, reinforced with braided nitinol
Titanium connector between arterial graft and venous outflow
Used for failing AVF/AVG secondary to central venous stenosis
Catheter dependent patients
Benefits
Lower infection compared to catheters
Improved HD adequacy compared to catheters
Higher patency rates compared to catheter
Qa: Access flow rate
Varies depending on access configuration, presence of stenosis, arterial inflow
Qb: Dialysis pump flow rate
Typically set at 350-400 mL/min
Kt/V: Number quantifying dialysis treatment adequacy
K: Dialyzer clearance of urea
T: Dialysis time
V: Volume of distribution of urea, ~ equal to patient's total body water
Monitoring: Periodic physical examination and review of routinely gathered data of dialysis patients performed to detect underdialysis and dysfunctional accesses prior to thrombosis
Weekly physical examination
Review of routinely gathered data collected during HD
Dialysis adequacy: Kt/V
Value < 1.2 or decrease by > 0.2 triggers referral for intervention
Dynamic pump pressures
Unreliable if taken in isolation
If abnormal trend or with other access abnormalities can be predictive of the side of stenosis
Needling problems
Prolonged bleeding suggests outflow stenosis
Difficulty with cannulation suggests inflow stenosis
Surveillance: Instrument-based, periodic evaluation performed to detect underdialysis and dysfunctional accesses prior to thrombosis
Access flows
Measured by ultrasound dilution/conductance, dilution/thermal, dilution/Doppler
AVG < 600 mL/min or < 1,000 mL/min if > 25% drop → referral
AVF < 400 mL/min or < 1,000 mL/min if > 25% drop → referral
Static venous pressure
Useful in AVGs
Insensitive to detect inflow problems, which are more common in AVFs
Intraaccess pressure to mean arterial pressure (MAP) ratio > 0.5 triggers referral
Detection of recirculation
Occurs when Qa < Qb
Could be due to inflow or outflow problem
Recirculation > 10% triggers referral
Not sensitive surveillance technique AVGs
AVGs can thrombose with Qa < 600 mL/min
Recirculation occurs when flow rates are < pump rates, typically set at 350-400 mL/min
Doppler ultrasound
Can measure flow rates, detect sites of stenosis
DASS
Arterial insufficiency ipsilateral to HD access
Risk factors
Diabetic patients with multiple prior shunts
Female gender
Brachial artery inflow
High-flow shunts/large anastomoses
Grafts (2.7-8.0%) more common than fistulas (< 2.0%)
Stages
Grade 1 (mild): Cool extremity but otherwise few symptoms
Distal flow augmentation with access occlusion
No treatment needed
Grade 2 (moderate): Intermittent ischemia
Pain during dialysis or with exercise
Treatment occasionally needed
Grade 3 (severe): Rest pain/tissue loss
Treatment mandatory, often with access ligation
National Kidney Foundation-Kidney Disease Outcomes Quality Initiative(NKF-KDOQI)
Provides multidisciplinary evidence-based clinical guidelines for CKD patients
Includes all stages of CKD and all aspects of care
Vascular Access Guidelines most relevant to interventional procedures
Published 2006, update forthcoming January 2018
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Equipment Preparation
Procedure Steps
Findings and Reporting
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
Things to Avoid
OUTCOMES
Complications
Expected Outcomes
Selected References
Vascular Access KDOQI Guidelines. Clinical practice guidelines for hemodialysis adequacy. http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/. Reviewed February 16, 2017. Accessed February 16, 2017
Haskal ZJ et al: Prospective, randomized, concurrently-controlled study of a stent graft versus balloon angioplasty for treatment of arteriovenous access graft stenosis: 2-year results of the RENOVA study. J Vasc Interv Radiol. 27(8):1105-1114.e3, 2016
Koirala N et al: Monitoring and surveillance of hemodialysis access. Semin Intervent Radiol. 33(1):25-30, 2016
Akoh JA et al: Review of transposed basilic vein access for hemodialysis. J Vasc Access. 16(5):356-63, 2015
Balaz P et al: True aneurysm in autologous hemodialysis fistulae: definitions, classification and indications for treatment. J Vasc Access. 16(6):446-53, 2015
Maytham GG et al: The use of the early cannulation prosthetic graft (Acuseal™) for angioaccess for haemodialysis. J Vasc Access. 16(6):467-71, 2015
Quencer KB et al: Arteriovenous fistulas and their characteristic sites of stenosis. AJR Am J Roentgenol. 205(4):726-34, 2015
Swinnen JJ et al: Paclitaxel drug-eluting balloons to recurrent in-stent stenoses in autogenous dialysis fistulas: a retrospective study. J Vasc Access. 16(5):388-93, 2015
Vasanthamohan L et al: The management of cephalic arch stenosis in arteriovenous fistulas for hemodialysis: a systematic review. Cardiovasc Intervent Radiol. 38(5):1179-85, 2015
Agarwal AK et al: How should symptomatic central vein stenosis be managed in hemodialysis patients? Semin Dial. 27(3):278-81, 2014
Hart D et al: Modification of the HeRO graft allowing earlier cannulation and reduction in catheter dependent days in patients with end stage renal disease: a single center retrospective review. ScientificWorldJournal. 2014:318629, 2014
Modabber M et al: Central venous disease in hemodialysis patients: an update. Cardiovasc Intervent Radiol. 36(4):898-903, 2013
Samett EJ et al: Augmented balloon-assisted maturation (aBAM) for nonmaturing dialysis arteriovenous fistula. J Vasc Access. 12(1):9-12, 2011
Bittl JA: Catheter interventions for hemodialysis fistulas and grafts. JACC Cardiovasc Interv. 3(1):1-11, 2010
Haskal ZJ et al: Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 362(6):494-503, 2010
Monroy-Cuadros M et al: Risk factors associated with patency loss of hemodialysis vascular access within 6 months. Clin J Am Soc Nephrol. 5(10):1787-92, 2010
Allon M et al: Hemodialysis vascular access monitoring: current concepts. Hemodial Int. 13(2):153-62, 2009
Casey ET et al: Surveillance of arteriovenous hemodialysis access: a systematic review and meta-analysis. J Vasc Surg. 48(5 Suppl):48S-54S, 2008
Gelbfish GA: Clinical surveillance and monitoring of arteriovenous access for hemodialysis. Tech Vasc Interv Radiol. 11(3):156-66, 2008
Mauro MA et al: Image-Guided Interventions. 1st ed. Philadelphia: Saunders, 2008
Nassar GM: Endovascular management of the "failing to mature" arteriovenous fistula. Tech Vasc Interv Radiol. 11(3):175-80, 2008
Rayner HC et al: Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study. Kidney Int. 63(1):323-30, 2003
Gallego Beuter JJ et al: Early detection and treatment of hemodialysis access dysfunction. Cardiovasc Intervent Radiol. 23(1):40-6, 2000
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