Used for patients with exhaustion of all other upper limb accesses but patent superior vena cava, subclavian and brachiocephalic veins
Typical site of stenosis: Graft-vein anastomosis
Cephalic arch
Most central portion of cephalic vein
Arches through deltopectoral groove to join axillary vein
Most frequent site of stenosis in dysfunctional brachiocephalic fistulas (40-77%)
Rarely cause of dysfunction in RC fistulas
Etiologies of stenosis
Extrinsic compression by clavipectoral fascia
High concentration of valves in this venous segment
Turbulence caused by sharp turn of arch combined with high flow rate
Difficult to treat
High-pressure balloons often needed
Associated high rate of vessel rupture
Low primary patency rate at 1 year (~ 20%) with angioplasty alone
Hemodialysis Reliable Outflow (HeRO) graft: Merit Medical
Arterial graft component
6-mm inner diameter
Material: Expanded PTFE (ePTFE)
Venous outflow component
5-mm inner diameter
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, approximately 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 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 less than 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 sex
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
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
Niyyar VD et al: Clinical aspects of dialysis interventions: physical and sonographic findings. Semin Intervent Radiol. 39(1):9-13, 2022
Pourmoussa AJ et al: Stent graft outcomes in dialysis circuits: a review of clinical trials and literature. Semin Intervent Radiol. 39(1):75-81, 2022
Tabriz DM et al: Management of central venous stenosis and occlusion in dialysis patients. Semin Intervent Radiol. 39(1):51-5, 2022
Liu C et al: Drug-coated balloon versus plain balloon angioplasty for hemodialysis dysfunction: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 10(23):e022060, 2021
Yin Y et al: Efficacy and safety of paclitaxel-coated balloon angioplasty for dysfunctional arteriovenous fistulas: a multicenter randomized controlled trial. Am J Kidney Dis. 78(1):19-27.e1, 2021
Lok CE et al: KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis. 75(4 Suppl 2):S1-164, 2020
Lookstein RA et al: Drug-coated balloons for dysfunctional dialysis arteriovenous fistulas. N Engl J Med. 383(8):733-42, 2020
Dinh K et al: Mortality after paclitaxel-coated device use in dialysis access: a systematic review and meta-analysis. J Endovasc Ther. 26(5):600-12, 2019
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
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
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. 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
Certain solutes are removed
e.g., potassium, phosphorus, and urea
Dialysate solutes are added
e.g., bicarbonate
Plasma water often removed
End-stage renal disease
a.k.a. chronic kidney disease (CKD) stage 5
Glomerular filtration rate (GFR) < 15 mL/min/1.73 m²
Need HD, peritoneal dialysis, or kidney transplant for medium-term survival
Arteriovenous fistula (AVF)
Surgical anastomosis between artery and vein
Results in dilation and arterialization of vein draining fistula
Requires maturation period before use
Typically 8- to 12-weeks maturation
~ 50% never able to be used
Once mature, less infections and longer lifespan than arteriovenous grafts (AVGs)
Common types of AVF
Radiocephalic (RC) fistula (forearm)
Preferred dialysis access
Problem: Low rates of maturation
Typical site of stenosis: Juxtaanastomotic segment
Brachiocephalic fistula (upper arm)
2nd preferred dialysis access
Used when radial artery or forearm cephalic vein are unsuitable for RC creation
Problems: High rate of dialysis-associated steal syndrome (DASS), precludes subsequent ipsilateral forearm fistula creation
Typical site of stenosis: Cephalic arch
Brachiobasilic fistula (upper arm)
Used when upper arm cephalic vein unsuitable for AVF creation
Problems: Difficult and 2-stage surgery, high rate of steal syndrome
Typical site of stenosis: Proximal swing segment
Mature fistula
Mature fistula is able to be repeatedly punctured and provide adequate flow for dialysis
Satisfies "rule of 6s"
Flow > 600 mL/min
Diameter > 0.6 cm
No more than 0.6 cm deep
Should be mature by 6 weeks
Immature fistula
Occurs in > 50% of newly created AVFs
Inflow stenosis
Most common cause of nonmaturation
Does not allow for dilation and arterialization of fistula
Competing outflow veins
Accessory veins: Naturally occurring branches arising from venous outflow tract; treat with ligation, embolization
Collateral veins: Alternative drainage pathways; develop in setting of downstream stenosis; treat by addressing underlying stenosis
Fistula that has failed to mature at 6 weeks should trigger further evaluation
AVG
Surgically created connection between artery and vein, using prosthetic conduit to provide vascular access for HD treatment
Used if unsuitable vascular anatomy for AVF
Suitable: Artery > 2 mm in diameter, vein > 2.5 mm in diameter
AVG has shorter lifespan than AVF
6-10x greater infection risk and thrombosis
Polytetrafluoroethylene (PTFE) graft most frequently used AVG material
Used for patients with exhaustion of all other upper limb accesses but patent superior vena cava, subclavian and brachiocephalic veins
Typical site of stenosis: Graft-vein anastomosis
Cephalic arch
Most central portion of cephalic vein
Arches through deltopectoral groove to join axillary vein
Most frequent site of stenosis in dysfunctional brachiocephalic fistulas (40-77%)
Rarely cause of dysfunction in RC fistulas
Etiologies of stenosis
Extrinsic compression by clavipectoral fascia
High concentration of valves in this venous segment
Turbulence caused by sharp turn of arch combined with high flow rate
Difficult to treat
High-pressure balloons often needed
Associated high rate of vessel rupture
Low primary patency rate at 1 year (~ 20%) with angioplasty alone
Hemodialysis Reliable Outflow (HeRO) graft: Merit Medical
Arterial graft component
6-mm inner diameter
Material: Expanded PTFE (ePTFE)
Venous outflow component
5-mm inner diameter
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, approximately 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 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 less than 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 sex
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
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
Niyyar VD et al: Clinical aspects of dialysis interventions: physical and sonographic findings. Semin Intervent Radiol. 39(1):9-13, 2022
Pourmoussa AJ et al: Stent graft outcomes in dialysis circuits: a review of clinical trials and literature. Semin Intervent Radiol. 39(1):75-81, 2022
Tabriz DM et al: Management of central venous stenosis and occlusion in dialysis patients. Semin Intervent Radiol. 39(1):51-5, 2022
Liu C et al: Drug-coated balloon versus plain balloon angioplasty for hemodialysis dysfunction: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 10(23):e022060, 2021
Yin Y et al: Efficacy and safety of paclitaxel-coated balloon angioplasty for dysfunctional arteriovenous fistulas: a multicenter randomized controlled trial. Am J Kidney Dis. 78(1):19-27.e1, 2021
Lok CE et al: KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis. 75(4 Suppl 2):S1-164, 2020
Lookstein RA et al: Drug-coated balloons for dysfunctional dialysis arteriovenous fistulas. N Engl J Med. 383(8):733-42, 2020
Dinh K et al: Mortality after paclitaxel-coated device use in dialysis access: a systematic review and meta-analysis. J Endovasc Ther. 26(5):600-12, 2019
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
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
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. 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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