Stenosis in hemodialysis arteriovenous fistula: evaluation and treatment

Vascular access complications are one of the main causes associated with an increase in morbidity and mortality in stage 5 chronic kidney disease patients. The arteriovenous fistula is regarded as the vascular access of choice for hemodialysis (HD) because of its superior patency and lower complication rates. Stenosis is considered the major cause of dysfunction of arteriovenous fistula. Despite the relatively low thrombosis rates of arteriovenous fistula, surveillance programs are necessary for detection of stenosis. We report a case of a HD patient who had never achieved an adequate Kt/V since the start of maintenance HD. During the investigation, abnormal findings were found on physical examination of the fistula, in addition to an alteration in intra-access pressure (IAP) measurements. A venous stenosis was diagnosed by Doppler ultrasound and then promptly treated with percutaneous transluminal angioplasty. The purpose of the discussion is to highlight the peculiarities of arteriovenous fistulae, methods of surveillance, including physical examination, IAP, recirculation, and measurements of blood flow, and the importance of the correction procedures for the stenosis.     

Remove or not,that is the question: A case report on carotid artery cannulation during indwelling venous hemodialysis catheter

A 58‐year‐old woman visited the emergency department for acute occlusion of arteriovenous fistula. One session of hemodialysis was scheduled via temporary venous hemodialysis catheter before thrombectomy. Unfortunately, neck arterial cannulation was discovered after complete placement of catheter. The catheter was removed immediately but bleeding could not be stopped. Pseudoaneurysm over the right carotid artery was proved by angiography and repaired by graft stent. Arterial cannulation during venous hemodialysis catheter insertion is a rare but serious complication and there is no standard response recommended. Immediate removal of the misplaced hemodialysis catheter might not be the best choice. We suggest to leave the misplaced catheter in artery until further intervention in consideration of complications and repair access. Every hemodialysis center should standardize responses to arterial cannulation during venous hemodialysis catheter indwelling, especially carotid puncture happens, according to the medical facility.     

Our experience in using the brachial venae comitantes as a native vascular access for hemodialysis

A native arteriovenous fistula is the preferred vascular access for patients on long‐term hemodialysis. In the absence of suitable superficial veins, the deep venous system can be used. We intend to present our experience in using the brachial venae comitantes (VC) to create a native arteriovenous fistula. From January 2012 to December 2014, we utilized the brachial vena comitantes to create 12 arteriovenous fistulae. Data from these 12 subjects were analyzed retrospectively to produce this case series. The average age of our subjects was 55.6 years. Forty‐two percent of the subjects were women. Fifty percent of the subjects had diabetes mellitus and 58% had hypertension. We achieved a functional patency rate of 58% at 1 month's follow up after maturation. The brachio–brachial vena comitans fistula is a safe and plausible option in patients with no other suitable veins for a native fistula, more so in the hands of experienced surgeons. The longer time to cannulation has to be taken into consideration when creating a VC fistula. In suitable patients with end‐stage renal disease, it can delay the use of an arteriovenous graft or a tunneled central venous catheter.     

An unusual cause of subacute airway obstruction in a hemodialysis patient with brachio‐cephalic arteriovenous fistula: A rare presentation of central venous occlusion

A young lady with an arteriovenous (AV) fistula on hemodialysis was referred for surgical management following a failed endovascular approach to relieve central venous occlusion. She had an obstructed left brachiocephalic vein with a history of numerous central vein catheter placements. Alternative routes for new arteriovenous fistula creation had been exhausted due to previous contralateral upper limb fistula rupture and ligation. To the best of our knowledge, no similar cases of airway obstruction in central venous occlusion occurring in hemodialysis patients with AV fistula have been reported. The importance of identifying the possible emergency red flags in hemodialysis patients with central venous occlusion is important to prevent unwanted consequences.     

Carotid-jugular arteriovenous fistula: a case report of an iatrogenic complication following internal jugular vein catheterization for hemodialysis access

We report a case of diabetic end-stage renal disease patient who presented with a right common carotid artery jugular arteriovenous fistula as a complication of the insertion of a polyurethane double-lumen hemodialysis catheter into the right internal jugular vein .On physical examination of the neck, a pulsating mass with a palpable thrill and a bruit was noted in the right subclavicular region. The diagnosis was confirmed by color doppler ultrasonography of the neck and carotid angiography. The review of the literature suggests the occurrence of this complication as rather rare. The fistula was successfully repaired surgically. It is emphasized that while securing the access, a thorough physical examination with a special emphasis on seeking any neck swellings, thrill, and bruit along with routine use of vascular doppler for securing dialysis access is recommended.     

Effect of needle orientation during arteriovenous access puncture on needed compression time after hemodialysis: A randomized controlled trial

Background

There are two techniques for puncturing an arteriovenous fistula: one where the needle is inserted bevel up and then rotated to a bevel down position, and another where the needle is inserted bevel down. The aim of this study was to compare these two methods of needle insertion on minimum compression time required for hemostasis after needle removal.

Methods

This was a prospective, randomized, cross-over, blinded, single-center, routine care study. Each patient's average post-dialysis puncture site compression time was determined during a 2-week baseline period while using bevel-up access puncture. Subsequently, minimum post-dialysis puncture-site compression time was determined during each of two sequential follow-up periods, during which fistula puncture was done with needles inserted bevel up or down, respectively. The order of treatments (bevel up or bevel down insertion) was randomized. During each follow-up period, the minimum compression time necessary to avoid bleeding on needle removal was determined by progressively shortening the compression time. Puncture-associated pain was also assessed as prepump and venous pressures and ability to achieve desired blood flow rate during the dialysis session.

Results

Forty-two patients were recruited. The baseline compression time after needle removal averaged 9.99 ± 2.7 min During the intervention periods, the minimum compression time was on average 10.8 min (9.23–12.4) when the access needles had been inserted bevel down versus 11.1 min (9.61–12.5) when the access needles had been inserted bevel up (p = 0.72). There was no difference in puncture-associated pain between the two insertion techniques, and no difference in prepump or venous pressures or ability to achieve the desired blood flow rate during the dialysis session.

Conclusion

Bevel-up and bevel-down needle orientation during arteriovenous fistula puncture are equivalent techniques in terms of achieving hemostasis on needle removal, and puncture-associated pain.     

Hemodialysis access-related survival and morbidity in an elderly population in South West Thames, UK

Elderly patients form the most rapidly expanding group of hemodialysis (HD) patients in Europe and the United States. There are initiatives to promote an increase in arteriovenous fistula (AVF) formation. There are concerns that elderly patients may have lower rates of surgical vascular access compared with younger patients due to risks of higher co-morbidities, surgical complications, and higher AVF nonuse rates. The aim of this study was to compare access-related survival and morbidity for dialysis catheters and AVFs and to evaluate the AVF nonuse rate in an elderly population. We have performed a retrospective analysis of access survival and morbidity in patients > or = 70 years of age, either on maintenance HD or predialysis with preemptive formation of surgical access. One hundred and forty-six patients had permanent HD access created during the 18-month study period, from 1 January 2006 to June 2007. There were 89 male and 57 female patients in whom 78 AVFs and 137 tunneled venous catheters were inserted. There was a significantly greater loss of vascular access due to infection in the catheter group compared with the AVF group (P<0.016). Access survival was also significantly prolonged in the AVF group (446 days, 95% confidence interval 405-487) compared with the catheter group (276 days, 95% confidence interval 240-313), P=0.001. The rate of nonuse of AVFs was low (16%). We conclude that an AVF is the preferred form of vascular access in elderly HD patients.     

Use of the subcutaneous venous network of the forearm to create an arteriovenous fistula

The reconstruction of vascular access in patients with kidney allograft failure is a challenging problem. A case of a 62‐year‐old man with transplanted kidney insufficiency is described. The patient was initially dialyzed with a wrist radial‐cephalic arteriovenous fistula. In the post‐transplantation period, the enormously dilated venous part of the anastomosis was ligated and the part of the vein suspected of being the source of bacteremia was excised. The man was referred to our department due to kidney allograft failure for vascular access creation. During preoperative assessment, we unexpectedly found a soft thrill on the forearm. Doppler ultrasound confirmed fistula patency, although the blood supply was not sufficient to perform dialysis. Angiography showed the blood flow from the radial artery to the cephalic vein, through a complicated vessel system consisting of inter alia a dilated vein of the subcutaneous venous network. We successfully used this vein as the vascular access outflow for fistula recreation. In conclusion, making use of veins of the subcutaneous venous network of the forearm for creation of a native fistula should be considered in selected cases.     

Lethal cardiac arrhythmia during central venous catheterization in a uremic patient: A case report and review of the literature

Double‐lumen central venous catheter (CVC) is a rapid access technique for hemodialysis (HD) when an arteriovenous fistula or graft is not available. A variety of procedure‐related complications have been reported, such as infection and pneumothorax, but serious cardiac complications are relatively less mentioned. We report a uremic woman with preexisting left bundle branch block who required emergent HD and received jugular double‐lumen CVC insertion, which was complicated by short‐duration ventricular tachycardia followed by complete atrio‐ventricular block and bradycardia. Pharmacological management did not reverse heart rate and rhythm. External pacing was not applied because she remained hemodynamically stable in the course of HD. Heart rate returned to sinus rhythm with left bundle branch block 4 hours later and did not recur through the whole admission period. We speculate that the transient arrhythmia might have been induced by mechanical contact with the ventricular wall during the procedure with the guided metallic wire. In conclusion, physicians responsible for CVC catheterization should pay more attention to patients with preexisting cardiac arrhythmia to prevent such technical mistakes from transpiring.     

Urgent hemodialysis with the use of peripheral veins to avoid catheter insertion

Urgent hemodialysis (HD) in patients with uremia is usually performed using a central vein catheter unless an arteriovenous fistula (AVF) was created in the predialysis period. We present a unique approach, in a patient in whom the first two HD sessions were conducted without implantation of a catheter or AVF. The perfectly developed peripheral veins of a professional bodybuilder served as vascular access allowing catheter insertion to be avoided. The aim of this short case report is to recall a forgotten method for performing urgent HD in patients without a fistula, but with suitably enlarged superficial veins.     

An unusual cause of postdialysis dyspnea: Percutaneous endovascular management

Vascular access through femoral vein is commonly used for hemodialysis treatment in patients with end‐stage renal disease. Consequently, iatrogenic complications, such as femoral arteriovenous fistula, are increasingly being reported in these patients. Percutaneous endovascular management of such iatrogenic arteriovenous fistulas with stent graft placement is a minimally invasive technique with decreased morbidity and hospital stay compared with surgical repair. Here, we report a case with postcatheterization arteriovenous fistula between superficial femoral artery and femoral vein which was successfully managed with a placement of a self‐expanding stent graft.     

Comparing frozen saphenous vein with Gore-tex in vascular access for chronic hemodialysis

Performing chronic hemodialysis in patients suffering from end‐stage renal disease needs a suitable vascular access like arteriovenous fistula in the upper limbs and bridge fistula in the upper or lower limbs, and also use of permanent and temporary catheters. The purpose of this study is to compare frozen saphenous vein versus using synthetic Gore‐tex vascular graft for A–V fistula. In the prospective randomized study, 70 patients needing for dialysis access were randomly divided into two groups. We performed the frozen saphenous vein A–V fistula in the test group and the Gore‐tex fistula in the control group. An assessment included function criteria (fistula thrill and murmur) and complications (infection and thrombosis) in planned intervals. At the end of the follow‐up period, the flow rates of all fistulas were assessed by Doppler sonography. The data were compared. Comparing the function criteria (fistula murmur and thrill) and the flow rate of the test group (frozen saphenous A–V fistula) and the control group (Gore‐tex method) showed no significant difference and also no significant difference between two groups in thrombosis. Infection rate of the Gore‐tex method was significantly high (p < 0.05). Arteriovenous fistula was an acceptable alternative in chronic hemodialysis, and frozen saphenous vein arteriovenous fistula was superior to Gore‐tex arteriovenous graft in some aspects.     

Right atrial thrombus in an asymptomatic hemodialysis patient with malfunctioning catheter and patent foramen ovale

The creation of an accurate functioning arteriovenous fistula has been a long-lasting problem in the hemodialysis setting. In spite of recent guidelines and largely because of the old age of the current dialysis population and a high incidence of diabetes mellitus, atherosclerosis, and related vascular problems, it is not always possible to create an adequate fistula. In that case, long-term tunneled indwelling central vein catheters are a frequently used alternative. Of the many possible complications related to venous access in hemodialysis patients, catheter dysfunction is the most prevalent. We report a 23-year-old female hemodialysis patient in whom such malfunctioning was followed by echocardiography that revealed a large right atrial thrombus (RAT) in close contact to the tip of a long-term indwelling catheter in the presence of a patent foramen ovale. Although RAT is a rare complication in hemodialysis patients, it has very specific therapeutic implications. The present patient underwent a successful surgical atrial thrombectomy. Our experience underscores that in cases of malfunctioning catheter, echocardiographic screening is mandatory.     

Vascular access‐related infection in nocturnal home hemodialysis

Frequent hemodialysis is associated with increased vascular access adverse events. We hypothesized that bacteremia would be more frequent in patients with central venous catheter (CVC) than arteriovenous fistula or arteriovenous graft (AVF/AVG) in nocturnal home hemodialysis (NHHD). We reviewed blood culture reports and concurrent clinical data for a cohort of one hundred eighty‐seven NHHD patients between January 1, 2006 and June 30, 2012. The primary outcome was time to first bacteremia, technique failure, or death after commencing NHHD. Types of bacteremia and clinical consequences were analyzed. Analyses were adjusted for a priori defined confounders. One hundred eighty‐seven patients were included with a total follow up of six hundred five patient years. Initial vascular access was AVF in seventy‐eight (42%) patients, AVG in eleven (6%) patients, and CVC in ninety‐eight (52%) patients. A total of 79.3% of patients with a CVC reached the composite endpoint of bacteremia, technique failure, or death in the study period; 44.5% of patients with an AVF or AVG reached this composite endpoint. Adjusted time to first bacteremia, technique failure, or death was significantly shorter in patients with initial CVC access (hazard ratio 2.42, 95% confidence interval 1.50–3.90, p < 0.001). Risk factors for bacteremia were comorbid status quantified by the Charlson Comorbidity Index (p < 0.001) and diabetes (p < 0.001). Coagulase negative staphylococcus was the commonest organism cultured accounting for 51.4% bacteremias. The second commonest organism was staphylococcus aureus (20.3% bacteremias). Patients undergoing NHHD with a CVC have a shorter duration to first infection, technique failure, or death than those with permanent vascular access.     

Hemodialysis access at initiation in the United States, 2005 to 2007: Still "Catheter First"

Despite the broad consensus that native arteriovenous fistula is the access of choice for hemodialysis, national-level information about vascular access at dialysis initiation has been unavailable in the United States. For incident hemodialysis patients, June 2005 to October 2007 (n=220,157), vascular access type was determined from the new Centers for Medicare & Medicaid Services Medical Evidence Report (form CMS-2728). Proportions with each type at first dialysis, demographic and clinical associations of each type, and associations between initial access type and survival were assessed. The mean patient age was 63.6 years; 29.4% of patients were African American, and for 44.5%, end-stage renal disease was due to diabetes. Vascular access proportions were: fistula, 13.2% of patients; graft, 4.3%; catheter/maturing fistula, 16.0%; catheter/maturing graft, 3.3%; and catheter alone, 63.2%. Adjusted odds ratios (vs. fistula) of catheter use alone were ≥1.50 for lack of insurance (1.62 [95% confidence interval 1.62–1.68]), nephrologist care for 0 to 12 months (2.75 [2.69–2.81]), other (2.19 [2.09–2.29]), or unknown (1.53 [1.44–1.63]) cause of renal disease, institutional residence (1.51 [1.45–1.57]), and 7 of 18 end-stage renal disease networks. Over a mean follow-up of 1 year, 26.0% of the study population died. Compared with fistula, adjusted mortality hazards ratios were 1.39 (1.32–1.47) for grafts, 1.49 (1.44–1.55) for catheters/maturing fistulas, 1.74 (1.65–1.84) for catheters/maturing grafts, and 2.18 (2.11–2.26) for catheters alone. While geographic variability is pronounced, vascular access at dialysis inception is typically suboptimal; suboptimal access exhibits a graded association with mortality. Lack of timely access to specialty care appears to limit optimal access.     

Safety of arteriovenous fistulae and grafts for continuous renal replacement therapy: The Michigan experience

Introduction: Arteriovenous fistula or graft (AVF/AVG) use is widely considered contraindicated for continuous renal replacement therapy (CRRT), yet insertion of hemodialysis (HD) catheters can carry high complication risk in critically ill end‐stage renal disease (ESRD) patients. Methods: Single‐center analysis of 48 consecutive hospitalized ESRD patients on maintenance HD who underwent CRRT using AVF/AVG from 2012 to 2013. Primary outcome was access‐related complications. Findings: Mean age was 60 years, 48% were male, and 88% required vasopressor support. Median duration of AVF/AVG use for CRRT was 4 days (range 1–34). Ten (21%) patients had access complications (5 bleeding, 5 infiltration, 1 thrombosis); 5 (10.4%) required catheter placement. Overall 31 (65%) patients survived to hospital discharge and AVF/AVG access was functional at the time of discharge in 29 (94%) patients. Discussion: In our experience, use of AVF/AVG for CRRT can be performed with a low serious complication rate and low risk of access loss, potentially avoiding catheter‐related complications.     

Association between vascular access type and patient mortality among elderly patients on hemodialysis in Canada

Optimal vascular access in elderly patients requires consideration of the benefits and risks in a population with increased comorbidity and mortality. Our objective was to examine the association between vascular access type and patient mortality by age category among incident adult hemodialysis patients registered in the Canadian Organ Replacement Register between 2001 and 2010. We also describe the secular trend in incident and prevalent vascular access use. We used a Cox proportional hazards model to evaluate the overall mortality in patients aged less than 65, 65–74, 75–85, and greater than 85 years who initiated hemodialysis using a central venous catheter (catheter) or arteriovenous (AV)‐access (fistula or graft) using an intention‐to‐treat approach. The cohort of 39,721 patients consisted of 42%, 27%, 26%, and 5% of patients aged <65, 65–74, 75–85, and >85, respectively. Patients who initiated hemodialysis using an AV‐access constituted 21%, 22%, 20%, and 15% of each age category. AV access use was associated with lower adjusted mortality compared with catheter use in each age category (Hazard Ratios [HR], 0.67; 95% Confidence Interval [0.62–0.72]; HR, 0.76 [0.63–0.91]; HR, 0.77 [0.64–0.93], HR, 0.73 [0.56–0.96], respectively). In Canada, use of an AV‐access is associated with lower mortality across all age categories, even in the very elderly. Further studies are required to understand the patient preference, complications, and resource use when selecting access type in the elderly.     

Brachial‐cephalic fistula recovered with drainage for the basilic vein: Case report

Vascular access is essential for the implementation of hemodialysis (HD). The arteriovenous fistula (AVF) can be constructed in various locations using various veins. However, the quality of the veins will influence the construction site, as well as the functioning of the AVF. Careful analysis of the vascular network allows options for the development of new fistulas presentations. We present and discuss the case of a woman aged 69 years in HD in which a brachial‐cephalic fistula with drainage to basilic vein was created, through rotation of the cephalic vein on the forearm level. This kind of access serves to prolong the time spent dialyzing through native fistulae, with their reduced complications and greater cost‐effectiveness.     

Cephalic arch stenosis in patients with fistula access for hemodialysis: relationship to diabetes and thrombosis

Numerous studies have identified the fistula as the best access for hemodialysis with fewest complications. The radiocephalic fistula (RCF) is the first access of choice, but often results in poor maturation. Therefore, an increased number of brachiocephalic fistulas (BCF) have been placed. Cephalic arch stenosis (CAS) can occur in patients with fistula access. The current study was done to determine the incidence and associated comorbidities in patients with BCF or RCF who have CAS. A retrospective review of 450 hemodialysis patients in 3 outpatient hemodialysis units between July 1, 2000 and July 1, 2005 (60 months) was preformed. We reviewed demographics, medications, and indications for venograms. Interventional Radiologists reviewed the venograms for evidence of CAS. Radiology reports were screened to determine incidence of thrombosis, treatment with either angioplasty or stent placement and if a complication such as venous rupture occurred. One hundred and twenty-seven patients had fistula access with at least 1 venogram. Of these, 30 were RCF and 97 were BCF. Cephalic arch stenosis occurred in 77% of patients with BCF and in 20% of patients with RCF. Those with diabetes had a lower rate of occurrence than those without (p<0.01). Cephalic arch stenosis led to a high rate of thrombosis (p<0.01). The probability of having multiple radiology procedures was higher with CAS than without (p<0.01). Cephalic arch stenosis is an important problem in hemodialysis patients who have fistula access, and contributes to thrombosis. Diabetes was found to have a negative association with CAS for undefined reasons. Attempts to understand this relationship are important.     

Physical examination of arteriovenous fistula: The influence of professional experience in the detection of complications

Vascular access is one of the leading causes of mobilization of financial resources in health systems for people with chronic kidney disease on hemodialysis. Physical examination of the arteriovenous fistula (AVF) has demonstrated its effectiveness in identifying complications. We decided to evaluate the influence of nurses' professional experience in the detection of complications of the AVF (venous stenosis and steal syndrome). The study took place in eight hemodialysis centers between May and September of 2011 in the north of Portugal. Sample was constituted by registered nurses. The nurses involved in the experiment were divided in two groups: those who had more than 5 years of experience and those who had less than 5 years of experience. Ninety‐two nurses participated in the study: 34 nurses had less than 5 years of professional experience and 58 had more than 5 years of professional experience. In the practices considered by nurses in the detection of venous stenosis, there were no differences observed between the groups (P > 0.05). In steal syndrome, there were no differences observed between the groups in the practices of the nurses in the detection of this complication of the AVF (P > 0.05). We concluded that professional experience does not influence the detection of venous stenosis and steal syndrome.