Chapter 61 Arteriovenous Hemodialysis Access
INTRODUCTION
Currently, over 325,000 patients are on dialysis in the United States, and more than 100,000 new patients begin dialysis each year.1 Medicare spends over $18 billion dollars annually in the care of these patients; a large portion of the expenses is dedicated to dialysis access and its complications.2 With these numbers, it is no surprise that vascular access is a prevalent part of many surgeons’ practices. With the ever-increasing numbers and cost of care of these patients, it is imperative that surgeons provide the most reliable dialysis access with the lowest possible risk of complications.
Autogenous arteriovenous accesses have consistently been shown to have excellent patency rates and low risk of complications when compared with prosthetic arteriovenous accesses. Two-year primary patency rates of autogenous access range between 34% to 69%, which is clearly superior to the 2-year primary patency rates of prosthetic access, which averages 25%.3–6 Complications of infection, pseudoaneursyms, and seromas are rarely seen in autogenous access. With these benefits, the disadvantages of autogenous access, including a long maturation time, failure to mature, and acute thrombosis, are acceptable. In consideration of these data, the current Dialysis Outcomes Quality Initiative (DOQI) recommendation is to place autogenous access in at least 50% of all patients requiring long-term access.7
In order to place long-term autogenous access with the lowest risk of complications, preoperative evaluation is essential. A thorough patient history is taken, documenting the patient’s dominant extremity, recent history of peripheral intravenous lines, site of indwelling or previous central lines, all previous access procedures, any history of trauma or previous surgery to the extremity, and all comorbid conditions. On physical examination, the patient’s arm is evaluated for edema and varicosities. With an upper arm tourniquet in place, the arm is inspected for visible cephalic and basilic veins. Indications for preoperative venography are listed in Box 61-1; venography may be substituted with a venous duplex scan as long as the surgeon recognizes the limitations of evaluating the central venous system. To assess for adequate arterial inflow, a thorough pulse examination including Allen’s test is done. Abnormal pulses in the planned operative extremity are further evaluated with arteriogram.7,8
Box 61-1 Indications for Venous Imaging before Access Insertion
Adapted from NKF-K/DOQI Clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis 2001;37(suppl):S137–S181.
Box 61-2 lists the multiple access configurations possible in the upper and lower extremities as well as the body wall.9 An autogenous access is always attempted before prosthetic access, including use of basilic vein transpositions. One-year primary patency rates of basilic vein transpositions range between 35% and 84% with an acceptably low complication rate and are, therefore, an excellent alternative to cephalic vein access.6,10–13 Preference is given to the nondominant arm over the dominant arm, followed by distal location over proximal location. Controversy still exists whether a prosthetic forearm access should be placed before an upper arm autogenous access. The autogenous access will likely offer longer patency but eliminates the placement of subsequent forearm prosthetic access. Therefore, this decision remains surgeon and patient dependent. Lower extremity and body wall access are used only once both upper extremity uses have been exhausted.7
OPERATIVE STEPS
OPERATIVE PROCEDURE
Venous Exposure
Early Autogenous Arteriovenous Access Thrombosis
• Consequence
• Repair
![image](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/B9781416029519500773_gr4.jpg?w=960)
Figure 61-4 Central venous stenosis. A, Upper extremity varicosities associated with central venous stenosis. B, Upper extremity edema associated with central venous stenosis. C, Venogram of the patient in Figure 61-4A demonstrates subclavian vein stenosis.
(A and C, Reproduced with permission from Adams ED, Sidawy AN. Nonthrombotic complications of arteriovenous access for hemodialysis. In Rutherford RB (ed): Vascular Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1700.)
• Prevention
Late Arteriovenous Access Thrombosis
• Consequence
• Repair
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