Vascular Access

How I Do It

Gareth Griffiths

Department of Vascular Surgery, Ninewells Hospital, Dundee, UK

Chairman of the Specialty Advisory Committee in General Surgery

Team Working

• Nephrologist• Vascular technician• Dialysis nurses• Radiologist• Anaesthetist• Surgeon

Pre Operative Assessment• Clinical• Ultrasound– Vein

• Size• Intravenous webs / thrombus• Beware of spasm• Examine full length• Central deep veins

– Artery• Wall calcification• Waveform pattern• Examine full length

Pre Operative Assessment

• Suspicion of central vein stenosis– Venography• MR• CT • Catheter

Pre Operative Assessment

• Upper limb before lower limb• Non-dominant before dominant• Distal before proximal• Autogenous before prosthetic

• Priority depends on the patient– Already on haemodialysis– Age

Sequence of Operations

1. Radio-cephalic2. Brachio-cephalic3. Brachio-basilic4. Brachio-axillary PTFE 5. Long saphenous thigh straight / loop6. PTFE thigh straight / loop 7. Superficial femoral vein straight / loop

Rarely Needed Options

• Iliac artery – vein PTFE loop• Necklace axillary artery – vein PTFE• Arterio-arterial PTFE

Operative Technique

• Local or regional anaesthesia

• Gentle handling of tissues

• Meticulous technique

• Microvascular instruments

• Magnification and light

Operative Technique

• Radiocephalic / brachiocephalic– Single incision when possible– Mobilise vein– Avoid twisting– Isolate artery– Microvascular clamps– Careful siting of arteriotomy– Relieve spasm – hydrostatic pressure, balloon– Check, check, check

Operative Technique• Brachiobasilic– One stage procedure

– Mobilise maximum length of vein– 3-4 short incisions ?endoscopic– Fashion tunnel to match vein length– Straight tunnel preferable– Arched tunnel if vein short

Operative Technique

• Prosthetic fistula– 6mm PTFE– Miller cuff at each end • Protects native vessels from PTFE thrombosis• Facilitates removal of infected PTFE

Follow Up• Life long surveillance– Clinical

• Bleeding• Cannulation difficulties

– Ultrasound • Duplex identified stenosis

– Dialysis parameters• Venous pressure < 180mm Hg• Arterial pressure > -180 mmHg• Urea reduction ratio >70%• Access flow >600ml/min

<25% fall

Multidisciplinary Meeting

• Surgeon• Vascular technologist• Nephrologist• Radiologist• Dialysis specialist nurse

• Discuss all patients with duplex or dialysis identified issues

• Review all post intervention outcomes

Multidisciplinary Meeting

• Selective intervention– Dialysis parameter abnormality + identified stenosis– Angioplasty first

• Cutting balloon if necessary• Stenting if necessary

– Surgical re-fashioning • Failed endovascular intervention

Multidisciplinary Meeting

• Surveillance and repeated intervention– Longest assisted primary patency possible

• Pre-emptive new fistula creation– When fistula failure is predicted– Before loosing fistula access

Fistula Thrombosis

• Attempt salvage unless– Fistula had been identified as failing– Active infection– Aneurysmal with organised thrombus

• Radiological salvage– Combined mechanical and lytic– Concomitant angioplasty / stenting when needed

• Surgical thrombectomy– Early post op thrombosis

Aneurysmal Fistulae• No issue if uncomplicated

• Cosmetic– Ask patient to accept

• Thin skin– Lateral cannulation

• Bleeding– Repair with vein buttress occasionally possible– Ligation often needed

Steal• Exclude central arterial stenosis• Often mild– Conservative management

• Significant– Pain, tissue loss– High flow

• Good distal vessels• High fistula flow

– Low flow • Diseased distal vessels• Critical flow distally

Steal• High flow– Assess direction of flow in distal artery– If retrograde

• Radial fistula – ligate distal radial artery– Maximises ulnar flow into hand

• Brachial fistula - Distal Revascularisation and Interval Ligation (DRIL)– Restores antegrade flow towards hand

– If antegrade• Band fistula

– Reduces fistula flow, improves distal perfusion

Steal

• Low flow– Diseased distal vessels– Poor outlook– Increasingly common

• Banding– Rarely possible – fistula flow already low

• Ligate fistula

Swollen Arm

• Assess promptly• Generally indicates central vein stenosis• Urgent catheter venography • Angioplasty or stenting when possible• May need fistula ligation

• Try to avoid with careful pre-op assessment

Vascular AccessHow I Do It

• Multi-disciplinary team

• Attention to detail

• Logical sequence for fistula creation

• Perseverance

• Fistula surveillance and repeated interventions