arterio-venous shunt (a-v shunt) -...
TRANSCRIPT
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Arterio-Venous Shunt (A-V Shunt)
Dr. Arief Rakhman Hakim, Sp.BTKVDepartment of Thoracic, Cardiac, and Vascular Surgery
Airlangga University -Dr. Soetomo General Hospital Surabaya, Indonesia
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Dr. Arief Rakhman Hakim, SpBTKV
Airlangga University (MD)
Airlangga University (Thoracic cardiovascular surgeon
Seoul National University Hospital (Fellowship)
Lecturer at Department of Cardiothoracic and VascularSurgery, Airlangga University
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TABLE OFCONTENTS
Anatomy of Dialysis Vascular Access ..................................................... 1
Tunneled Catheters ............................................................................. 13
Arteriovenous Fistulas ........................................................................ 28
Arteriovenous Grafts .......................................................................... 53
Glossary ................................................................................................ 67
Bibliography ..................................................................................... 68
iii
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End Stage Renal DiseaWorldwide
se (ESRD) -
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15353
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35000
paien baru pasien baru pasien baru pasien baru
2011 2012 2014 2015
Axi
s Ti
tle
Axis Title
pasien baru pasien aktif
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Treatment Options for Renal Replacement Therapy
ESRD Comfort Care
Hemodialysis Peritoneal Dialysis
Kidney Transplant
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Hemodialisa97%
capd3%
Data IRR 2015
Hemodialisa capd
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Principle of Hemodialysis
Vein
Artery
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Hemodialysis Vascular Access
Polytetrafluoroethylene
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Which Vascular Access andWhen Should It Be Placed?
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Patients who started using an AV access by timing offirst referral to a nephrologist
When??
Sooner, Better!N=356 hemodialysis patients
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Dialysis Access - PrinciplesProvides location for easy access to patient’s blood for dialysis
Bane of dialysis physician’s existence
Higher flows and cannulation can lead to stenosis or thrombosis
Maintenance of dialysis access patency is critical, at times life-saving◦ Patency is assessed while patient is on HD by multiple parameters
Early detection of stenosis can lead to intervention before thrombosis occurs
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Dialysis Access
Catheter (most common)
AV Fistula (most common)
Graft (rarely in Indonesia)
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1. AV Fistula (AV Shunt)
◦
◦
◦
Vein cross-cut, attached end-to-side to artery
High-pressure flow dilates and thickens
Best alternative:◦ Lowest infectious risk
◦ Longest lasting with least thromboses
Drawbacks◦ Takes 2-4 months to mature
◦ Only about 50% ever mature
Goal for all dialysis patients
vein
◦
◦
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REVIEWAnatomy of Upper Extremity Vessels
Subclavian v.
Internal jugular v.
Cephalic arch segment
Carotid a.
DELTOID
Axillary v.
Brachial v.
Upper arm cephalic v.
BICEPSBasilic v.
Brachial a.
Forearm cephalic v.
Radial a.
Ulnar a.
Palmar arch
2
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Radiocephalic Arteriovenous Fistula (Brescia-Cimino)
3
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Snuff-box Arteriovenous Fistula
End-to-side anastamosis
Forearm cephalic vein
Radial a.
4
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Proximal Forearm Arteriovenous Fistula
Anastomosis betweenperforating branchand proximal radial artery
Cephalic v.
Brachial a.
Proximal
perforating
branchRadial a.
5
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Proximal Forearm Arteriovenous Fistula
Anastomosis betweenproximal radial arteryand median antecubital vein
Basilic v.
Cephalic v.
Brachial a.
Median
antecubital v.
Radial a.
6
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Anatomoses between perforating branchand proximal radial artery
Anatomoses bet perforating bra and proximal ra
Brachiocephalic Arteriovenous Fistula
ween nchdial artery
7
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BICEPS
Transposed Basilic Vein Arteriovenous Fistula
Cephalic v.
Basilic v.
BICEPS
End-to-side anastamosis
Brachial a.
8
Inset: “swing point”
depicting the basilic
vein mobilization from
the deeper location to
the superficial tunnel
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rate
2. AV Graft
◦ Tube made of biocompatible material (gortex) attached end-to-side to artery and vein
◦ Often required in patients with vascular disease,veins
Advantages◦ Ready to use when swelling resolves (~2 weeks)
◦ Able to use in most patients
Disadvantages◦ High stenosis/thrombosis
◦ Moderate infectious risk
occluded distal
◦
◦
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Forearm Loop Arteriovenous Graft
9
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Upper Arm Arteriovenous Graft
Cephalic v.
Axillary v.
End-to-side anastamosis
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Thigh Arteriovenous Graft
External
iliac a.
Femoral a.
Femoral v.
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3. Catheter (most common)
◦ Tunnelled under skin to reducewith blood
Advantages◦ Ready for use immediately
Disadvantages
communication from skin flora
◦
◦◦
◦
◦
High infectious risk
High thrombosis risk
A/W increased mortality
◦ Can be a sign of poor pre-dialysis care or extensive vascular disease
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The catheter is placed in
the right internal jugular
vein with a smooth curve in
the subcutaneous tunnel.
The tip of the catheter is
placed in the right atrium
to achieve adequate blood
flow during hemodialysis.
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Right-sided Catheter
Actual right internal
jugular vein tunneled
catheter removed from
a patient showing a
single smooth
curve.
A: Schematic
representation of the
smooth curve
B: Cross-sectional
schematic repre-
sentation of the smooth
curve
A B
Computer generated figures designed by Vipul Vachharajani
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COMPLICATION
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CATHETER
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Kinked Catheter
The catheter in the
subcutaneous tunnel is
acutely kinked causing
mechanical obstruction
to the blood flow.
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Malpositioned Tip of Catheter
Left internal jugular catheter
with kink in the subcutane-
ous tunnel (arrow). The tip is
placed in the left innominate
(brachiocephalic) vein.
The catheter is unlikely to
provide adequate blodd flows
for dialysis
Catheter tip
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Malpositioned Tip of Catheter
Tesio catheter with malpositioned
tips. Catheter tips are in the proxi-
mal superior vena cava.
Catheter tip
Catheter tip
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Catheter Tip Retraction
7th rib7th rib
The catheter tip often retracts from a supine to an erect position,
especially if it is anchored on
breast or pectoral fat. Thus, the tip of the catheter should be placed
in the right atrium.19
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Catheter Tip in Azygos Vein
A B
Catheter tip
A: The tip of the left internal jugular cath-
eter is placed in the azygos vein. An
acute angle curve is noted with twist-
ing of the catheter at the junction of the
superior vena cava and azygos vein.
B: The catheter tip has been repositioned in
the right atrium.
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Fibrin Sheath Formation
A B
Fibrin sheath develops around the catheter. The sheath acts like a one-way valve and preventsadequate and free pulling of blood through the catheter. The fibrin sheath can be disruptedeither with an angioplasty or can be stripped using a snare device. The pre-angioplasty imageabove (A) shows poor filling of the right atrium and the contour of the catheter is maintainedbeyond the catheter tip. Post-angioplasty image above (B) shows the contrast flowing freelyin to right atrium. The fibrin sheath can extend from the cuff to beyond the catheter tip.
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Fibrin sheath
A
B
22
An intact fibrin sheath pulled
out along with the catheter.
A fibrin sheath is a flimsy
fibroepithelial tissue that
extend from the cuff (A) to the
tip of the catheter (B)
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Intraluminal Thrombus
Fibrin sheath extending beyond the
tip of the catheter and occluding it
completely.
A
An organized Thrombus
occluding the tip of catheter.
B
The organized clot been extruded
from the catheter.
C
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Split Tip catheter
A split tip tunneled cath-
eter placed in the left in-
ternal jugular vein. The
arterial tip is curled up
(arrowheads) and kinked
leading to high dialysis
arterial pressure and poor
delivery of blood flow
during dialysis
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Exposed Cuff
A: The cuff of the catheter is exposed at the exit site.The exit site should be evaluated prior to each dialysis session. A catheter with an exposed cuff can be easily pulled out and can lead to loss of a vital vascular access site. The exposed catheter cuffwould also suggest that the tip is no longer at the proper location and delivery of blood through this catheter may not be adequate. The replacement of the catheter over a guide wire canbe easily performed with proper anchoring and thepatient can return for dialysis therapy on the sameday.
A
B
B : Disrupted subcutaneous tunnel
(arrowheads) with exposed cath-
eter cuff at the exit site.
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Exit Site Infection
Exit site erythema with crusting
suggestive of infection or allergic
reaction to topical ointment or
tape. The exit site should be
evaluated prior to every dialysis
therapy for early signs of infection.
The exit site infection can spread
through the subcutaneous tunnel
causing bacteremia, sepsis and
worsening morbidity and mortality.
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Tunnel Infection
A: Purulent fluid collection
under the dressing suggestive
of infection.
A
BB : Purulent secretion, Erythema over the
tunnel and skin changes secondary to
infection in the subcutaneous tunnel.
The catheter must be removed promptly for
effective antibiotic therapy and morbidity
reduction.
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AV FISTULA /
SHUNT
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Well-preserved Forearm Veins
Well-preserved veins in the forearm and upper arm for creating a functional arte-
riovenous fistula. Vessel preservation is essential in chronic kidney disease patients.
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Well-preserved Upper Arm Cephalic Vein
Avoiding venepuncture in the forearm and ellow and refraining from
placing peripherally introduced central catheters (PICC) are two methods
to preserve veins.
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Snuff-box AVF
The anastomosis is generally distal to the wrist joint in the snuff-box.
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Radiocephalic AVF
A normal radiocephalic fistula with the anastomosis proximal to
the wrist joint.
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Transposed Forearm Basilic Vein AVF
The forearm basilic vein is
transposed to create radio-
basilic vein AVF.
The forearm basilic vein (marked
by arrows) is transposed to the
volar surface of the forearm and
anastomosed to the radial artery
at the wrist.
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Transposed Forearm Cephalic Vein AVF
The forearm cephalic vein (marked by arrows) is transposed to
create a loop configuration and anastomosed to the brachial artery
at the elbow.
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Proximal Forearm AVF
A fistulogram highlighting proximal forearm AV fistula.
Gracz et al in 1977 described the proximal forearm
arteriovenous fistula involving an end-to-side
anastomosis between a perforating branch of the
cephalic or median antecubital vein and the proximal
radial artery. Subsequently several modifications have
been described by Bender et al and Kroner et al creating
a native fistula utilizing the deep venous system in
the forearm and either the proximal radial or
brachial artery. The proximal
forearm fistula is a valuable additional site for native
vascular access for hemodialysis before considering an
upper arm access.
Ulna bone
Radius bone
Ulnar a.
Radial a.
Cephalic v.
Proximal forearm anastomosis
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Upper Arm AVF
Transposed Basilic
Vein AVF
A normal transposed basilic vein
arteriovenous fistula showing
the scar extending from the
axilla to the elbow on the medial
aspect of the upper arm.
Brachiocephalic AVF
A normal brachiocephalic fistula
with a horizontal scar at the elbow.
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Massive Infiltration
Eighty-year-old patient who had a functioning
right brachioce- phalic fistula placed well before
the need for dialysis. Unfortunately during his
first treatment
the fistula infiltrated due to improper
cannulation technique resulting in a large
hematoma almost encircling his upper arm.
Fortunately for the patient the fistula was still
functional and after 4 weeks of rest to the
arm the hematoma resolved completely and
the access could be used for dialysis.
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Complication of PICC Line
A fistulogram performed on a non-
maturing brachiocephalic fistula. The
entire cephalic vein segment in the
upper arm was small and sclerosed
secondary to a previous placement
of a peripherally introduced central
catheter (PICC). The devastating
results of a PICC line can be clearly
appreciated in this case.
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“Swing site” Stenosis
A B C
Radial artery
Stenosed forearm basilic vein
Wrist
The fistulogram showing a long inflow segment stenosis which was successfully balloon angioplastied. A: Pre-angioplasty. B: Waist
on the balloon. C: Post-angioplasty image. Thirty-five-year-old patient with a forearm basilic vein to radial artery fistula. The
forearm basilic vein was mobilized surgically leading to significant stenosis in the “swing site.” The patient presented with
inability to achieve prescribed blood flows during dialysis and
with high dialysis arterial pressures. On physical examination the inflow augmentation was poor with a very weak pulse and
bruit.
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A B C D
A: Transposed basilic vein AVF with a tight stenosis at the “swing site” (arrowhead). B: Waist on the balloon shown during
percutaneous angioplasty. C: Complete resolution of the stenosis. D: Recurrence of the stenosis 4 months later. A “swing site”
stenosis typically presents as a highly pulsatile fistula with a high pitched bruit on physical examination. The dialysis venous
pressures are recorded to be high and often the patient continues to bleed for a prolonged period of time once the needle is
withdrawn post dialysis therapy.
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Aneurysm
Brachiocephalic fistula with an
aneurysm at the arterial a has tomotic
site. The aneurysm has a tight, shiny
skin. The patient needs to be referred for
an urgent surgical evaluation before a
catastrophic event occurs.
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A B C
Mushroom-shaped Aneurysm
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Steal syndrome
A
B
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B C
Hematoma
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Hematoma
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C
Central Vein Stenosis
A
percuta-
B
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Skin Rash
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C
Stable Aneurysm
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Arm Elevation Test
A B
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C
Red Hand Syndrome
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Tourniquet Use
BA
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Forearm Loop Arteriovenous Graft
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Upper Arm AVG
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Thigh AVG
BA
Femur
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Pseudoaneurysm
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A B
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Multiple Arteriovenous Grafts
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“Sleeves Up” Examination
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Central Vein Stenosis
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Central Venogram
A B C
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Venous Outflow Stenosis
A B
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Pseudoaneurysm
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Pseudoaneurysm
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Glossary
AVF – Arteriovenous fistula
AVG – Arteriovenous graft
CVC – Central venous catheter
TCC – Tunneled cuffed catheter (same as CVC)
Fistulogram – A radiological test performed using
an iodinated radiocontrast material to evaluate
the access
PTA – Percutaneous transluminal angioplasty or
balloon angioplasty
PTFE – Polytetrafluoroethylene graft , the synthetic
material used for AVG
tPA – Tissue plasminogen activator a thrombolytic
agent used for clot lysis
Terminologies used for dialysis access examination:
Inflow or upstream – indicates the arterial side of
the access
Outflow or downstream – indicates the venous side
of the access all the way to the right atrium
Arterial anastomosis – Point where the native vein is
surgically connected to the feeding artery or
where the PTFE is connected to the artery
Venous anastomosis – Native fistulae do not have a
venous anastomosis. The AVG connection to
the outflow vein is called venous anastomosis
Proximal – Anything towards the heart from a
reference point
Distal – Anything away from the heart from a
reference point
Bifurcation – Forking of a vein or an artery
Collateral veins – Accessory veins that are prominent
and may prevent maturation of the fistula
Terminologies used for a central vein catheter:
Venotomy site - The site where the catheter enters
the vein
Exit site – Site where the catheter exits from the skin
Tunnel – The subcutaneous section of the catheter
between the venotomy and exit sites
Butterfly – The wing beyond the exit site on the cath-
eter used for anchoring the catheter to the skin
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Reference
• Badero OJ, Salifu MO, Wasse H, Work J. Frequency of swing-segment stenosis in referred dialysis patients
with angiographically documented lesions. Am J Kidney Dis. 2008;51:93-8.
Balaz P, Rokosny S, Klein D, Adamec M. Aneurysmorrhaphy is an easy technique for arteriovenous fistula salvage. J Vase
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