CHAPTER 3 ARTERIOVENOUS ACCESS: INFECTION, NEUROPATHY AND OTHER COMPLICATIONS

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1 CHAPTER 3 ARTERIOVENOUS ACCESS: INFECTION, NEUROPATHY AND OTHER COMPLICATIONS AUTHORS: Jennifer MacRae MSc MD, Christine Dipchand MD MSc, Matthew Oliver MD MSc, Louise Moist MD MSc, Serdar Yilmaz MD Phd, Charmaine Lok MD MSc, Kelvin Leung MD, Edward Clark MD MSc, Swapnil Hiremath MD MPH, Joanne Kappel MD, Mercedeh Kiaii MD, Rick Luscombe RN, Lisa Miller MD On Behalf Of The Canadian Society Of Nephrology Vascular Access Work Group

2 CONTENTS Introduction AV Access Infection Neuropathy Ischemic Monomelic Neuropathy Steal Aneurysm Access Flow and Heart Failure Last Access Options Unconventional fistula Unconventional arteriovenous grafts Atypical tunneled catheter placement Hybrid graft catheter device Summary of Recommendations 2

3 INTRODUCTION Complications of vascular access lead to morbidity and may reduce quality of life. In this chapter we highlight some potentially novel approaches in support of the challenging patients who have developed many complications and are now nearing their last vascular access. 3

4 AV ACCESS INFECTION Definitions: Systemic infection: involves presence of bacteremia in association with evidence of infected AV access Localized infection: refers to cellulitis (absent bacteremia), post op incision infection or an abscess/ infected exudate associated with the AV access Incidence of AV Access Infection Grafts typically 10 X higher infection rate vs fistula Risk Factors for fistula infection include: poor patient hygiene, diabetes, skin excoriations and buttonhole cannulation (See AV Access complications Chapter 1, section 7 on Cannulation) Common bacteria for fistula infection: s. aureus and s. epidermidis Risk factors for graft infection include: poor patient hygiene, diabetes, older age, femoral site of placement and history of bacteremia Common bacterial organisms for graft include: s. aureus, s. epidermidis, Streptococcus viridans and Pseudomonas aerugenosa 4

5 AV ACCESS INFECTION Diagnosis: Symptoms - fevers, chills, rigors, malaise Signs - Patients may present with a localized cellulitis or erythema at the access site If skin integrity looks compromised (necrotic patch or shiny, thin skin) at a buttonhole site then a surgical consult is required Signs of graft tenderness or exudate, even in absence of fever, could indicate underlying access infection Most common presentation of infected graft draining sinus tract, purulent drainage, which if present, requires surgical consult 5

6 AV ACCESS INFECTION Treatment: Antibiotics The recommended treatment for an infected fistula without fever or bacteremia is 2 weeks Treatment for an infected fistula with bacteremia is a minimum of 4 weeks with an extension to 6 weeks in the case of s. aureus Blood cultures should always guide antibiotic choice Recommended treatment for graft infection is for a full 4-6 weeks of antibiotics after the whole or portion of the graft has been removed Surgery The surgical revision or excision of a fistula may be required if the access fails to respond to medical management. However, a surgical consult is mandatory when dealing with graft infections An infection involving the anastomosis is an indication for the complete excision of the graft 6

7 AV ACCESS INFECTION Prevention: Patients to wash access arm upon entry to HD unit Clean gloves and antiseptic solution such as chlorhexidine with 70% alcohol to disinfect skin prior to needling For buttonhole patients, face masks and topical antibiotics should be used 7

8 NEUROPATHY Temporary digital and hand numbness and tingling can occur following AV-access surgery due to soft tissue swelling or hematoma compressing nerves Typically resolves within 4 weeks If not, the following neuropathies should be considered: Type of Neuropathy Diagnosis Treatment Carpal Tunnel Caused by median nerve compression at the wrist Ischemic Monomelic Neuropathy (IMN) Caused by infarction of the vasa nervosa and generally occurs very quickly after access creation Symptoms: Pain, numbness of hand, pain in forearm or shoulder or weakness of thumb. Signs: rarely positive Tinel s or Phalen s present. Possible muscle wasting in hand/forearm Symptoms: Pain, weakness and sensory changes in an otherwise warm hand Deep, burning discomfort in the hand which is continuous and persistent Signs: Motor impairment; wrist drop, difficult finger extension, use of thumb, claw-hand deformity Mild form -Eliminate causative activity and wrist splint for night or during HD (worsening symptoms) Mod/Severe surgical decompression Once IMN is suspected AV access should be sacrificed immediately 8

9 NEUROPATHY Type of Neuropathy Diagnosis Treatment Steal Symptoms: Pain, Stage 1 - associated with a duskiness of hand, cold, pale or blue hand coolness, paresthesias, paralysis of hand. Stage 2 -pain with exercise or on hemodialysis Stage 3 -complicated by rest pain and/or ulcers, necrosis or gangrene of the fingertips or hand Signs: Pallor, abnormal sensory or motor function, cool to touch, decreased or absent radial pulse. Ischemic steal syndrome diagnosispredominantly clinical, based on history and physical exam Stage 1- steal can often be managed with conservative measures including keeping the hand warm. Stage underlying arterial inflow lesion should be ruled out. Surgery should be considered for patients with stage 3 steal Surgical options include: Distal Revascularizations- Interval Ligation (DRIL) Revision Using Distal Inflow (RUDI) Proximalization of Arterial Inflow Flow Limiting Procedures Ligation 9

10 ANEURYSM Type of Neuropathy Diagnosis Treatment Aneurysm *Monitoring at every Incidence range from 0 session required 10%. Thinning of the skin Often occurs due to (skin takes on a shiny repeated needling in translucent appearance same area (see Figure 2) Necrotic skin patch True aneurysm involves all (see Figure 3) layers of the venous wall History of rapid enlargement False (pseudo-) aneurysm involves fibrous tissue and thrombus (see Figure 1) Complications can include; skin erosion, infection, thrombosis, inability to dialyze and rupture or exsanguination Endovascular Endovascular stent graft repair for pseudoaneurysm management for minimal invasiveness and immediate use post-intervention Surgery: Pseudo aneurysm resection Partial aneurysmectomy Ligation results in loss of access 10

11 ANEURYSM Figure 1: Pseudoaneurysm from miscannulation Photo by JMacRae, with permission from patient. 11

12 ANEURYSM Figure 2: Shiny Skin aneurysm Which one do you want to use? see Figure 3: Necrortic Patch aneurysm 12

13 ACCESS FLOW AND HEART FAILURE High Flow Access The flow rate of a fistula and graft varies according to their location with typical flows of m/min in the lower arm and ml/min in the upper arm Risk Factors for high flow access ( 2 L/min) : young age, male sex, upper arm access and previous access surgery Access Flow to Cardiac Output Ratio (Qa:CO) Typically AV access requires 20% of cardiac output Normal range of Qa:CO is 17-23% with increased risk for heart failure beyond this standard range High Output Cardiac Failure Defined by presence of heart failure symptoms (shortness of breath, reduced exercise tolerance, peripheral or pulmonary edema) in presence of an elevated cardiac index ( 3L/min 2 ) and low systemic vascular resistance 13

14 ACCESS FLOW AND HEART FAILURE Diagnosis Symptoms: Heart failure symptoms of shortness of breath, decreased exercise tolerance and edema Signs: Elevated heart rate, widened pulse pressure, increased jugular venous pressure, abnormal hepatojugular reflex, S3, edema and an enlarged often aneurysmal fistula, usually in the upper arm Special Tests: Serial echocardiograms show decreasing LV function and progressive increase in LV dilatation. Access flow/ cardiac output ratio > 25% may indicate risk of high output cardiac failure Treatment All revolve around reducing the flow through the AV Access RUDI Flow limiting procedures AV access Ligation (see slide 9- Treatment of Steal) 14

15 LAST ACCESS OPTIONS: ATYPICAL LOCATIONS OF FISTULAS, GRAFTS AND CENTRAL VENOUS CATHETERS AVF Upper Extremity Ulnar artery-basilic vein Radial artery-basilic vein Brachial artery-median cubital vein Brachial artery-brachial vein Brachial artery-basilic vein Axillary artery-axillary vein Lower Extremity Tibial artery-saphenous vein Femoral artery saphenous vein Popliteal artery-femoral vein Popliteal artery-saphenous vein Dorsalis pedis-saphenous vein AVG Upper Extremity Axillary artery-axillary vein ( Necklace ) Subclavian artery-subclavian vein Brachial artery-internal jugular vein Axillary artery-femoral vein Axillary artery-popliteal vein Lower Extremity Catheter Upper Extremity External jugular vein Translumbar Transhepatic Lower Extremity Femoral artery-femoral vein External iliac artery-external iliac vein superficial femoral artery-femoral vein ( Adductor loop ) Femoral artery-contralateral femoral vein ( Bikini ) Iliac artery-inferior vena cava Femoral Saphenous 15

16 UNCONVENTIONAL FISTULA Upper Extremity Forearm Option Options include radial or basilic forearm Use of radial /ulnar basilic fistula has limited uptake due to low patency rates, long maturation times, and potential discomfort due to patient position during HD Upper Extremity Upper Arm Option The brachial-artery-basilic vein transposed fistula Associated with better maturation and patency outcomes compared to forearm options Associated with complications of arm swelling No difference in outcomes for 1 stage vs 2 stage creation Maturation rates tend to be high with a primary 1 yr patency rate ~68% and secondary 1 yr patency rates of 70 80% 16

17 UNCONVENTIONAL FISTULA Lower Extremity Thigh Options Femoral vein anastomosed with femoral artery or saphenous vein for fistula creation Femoral artery-femoral vein fistula: 1 yr primary patency rates ~ 90% and secondary patency rates 80%, associated with high ischemic complications Femoral artery-saphenous vein fistula, created from transposing the saphenous vein across the anterior thigh: 1 yr primary and secondary patency of 70% and 80%, with no reported ischemic complications 17

18 UNCONVENTIONAL AV GRAFT Upper Extremity Upper arm grafts options include axillary artery ipsilateral axillary vein graft or axillary artery contralateral axillary vein (necklace) graft Infection, thrombosis, and outflow stenosis are common complications, described in 41% in one small series of 27 patients Lower Extremity Lower extremity AVG are placed after only once other locations have been exhausted Most common leg graft is femoral artery- femoral vein 1 yr assisted primary patency rate of 38%; secondary patency rate of 62% 1 yr infection free graft survival ay 79%; 5 yr at 61% 18

19 ATYPICAL TUNNELED CATHETER PLACEMENT Preferred sites for tunneled cuffed catheter placement are; right internal jugular (IJ), followed by left IJ, then external jugular veins, then femoral veins Catheter placement shown to be most significant independent risk factor for catheter failure Upper Extremity External jugular (EJ) catheter have shown 3 month outcomes similar to internal jugular catheters Translumbar catheters are truly the last access option Limited reported outcomes, based on small studies Inserted via translumbar route into inferior vena cava- technically challenging with higher infection rate than conventional placements Transhepatic CVC Higher infection and thrombosis rate than conventional placements 19

20 ATYPICAL TUNNELED CATHETER PLACEMENT Lower Extremity Femoral vein and saphenous vein are options for lower extremity CVC Important considerations are catheter length and infection prophylaxis Complications include; bacteremia, deep vein thrombosis, iliac vein occlusion, and catheter dysfunction Femoral catheters have higher risk of infection and reduced catheter survival as compared to conventional IJ catheters 20

HERO DEVICE The Hemodialysis Reliable Outflow (HeRO) vascular access device approved for use as a graft for HD patients who have exhausted traditional AVF/AVG options The HeRO graft is comprised of 2

21 HERO DEVICE The Hemodialysis Reliable Outflow (HeRO) vascular access device approved for use as a graft for HD patients who have exhausted traditional AVF/AVG options The HeRO graft is comprised of 2 parts: i. Standard expanded polytetrafluoroethylene graft component ii.connected to a nitinol-reinforced silicone outflow component Patency rates and infection rates with HeRO device are similar to upper arm or lower limb grafts Average # of 2 interventions/yr is required to maintain the HeRO device Graft component is tunneled in the upper arm over biceps muscle; distal end of graft anastomosed to brachial artery typically Silicone outflow component is inserted similar to traditional CVC, with the proximal component in right atrium Titanium connector joins graft and silicone components to provide an AV access that bypasses any central venous stenosis and avoids a graft-to-vein anastomosis See video link 21

22 SUMMARY OF RECOMMENDATIONS In patients in whom high output cardiac failure is considered, a detailed cardiac history and symptoms should be obtained along with a baseline echo or cardiac MRI to evaluate cardiac anatomy (See Chapter 1 Hemodynamics of fistula creation) An access flow of > 2L/min is considered to be high flow In cases of suspected high output cardiac failure a baseline Qa/ CO ratio should be done. Qa/CO > 25% is considered high Refer for flow reduction surgery if any concerns of heart failure or if Qa/CO ratio is increasing Prospectively follow patients with high-flow fistulas with annual serial echocardiograms to track for any progression in left ventricle dilation, worsening left ventricle hypertrophy, decreasing left ventricle function, or the development of pulmonary hypertension 22

23 SUMMARY OF RECOMMENDATIONS There are a limited number of potential vascular access sites; clinician must be aware of all options, including non-conventional ones Non-conventional forearm options include radial or ulnar basilic forearm fistula Transposed brachio-basilic fistula are increasingly common with maturation rates of 80% and 1 yr primary patency rates of 70% Transposed brachial fistula provide an alternate upper arm fistula option but are associated with complications of arm swelling Femoral artery femoral vein fistula have a high ischemic complication rate while femoral artery saphenous vein fistula have no reported ischemic complications and a 70% primary patency rate Upper arm graft options include axillary artery ipsilateral axillary vein graft or axillary artery contralateral axillary vein (necklace) graft, but frequently complicated by infection, thrombosis, or venous stenosis 23

24 SUMMARY OF RECOMMENDATIONS The most common lower leg graft is the femoral artery- femoral vein graft which has a 1 yr secondary patency rate of 60%; 1 yr infection free survival for these grafts is 80% Atypical catheter locations include transhepatic and translumbar which have higher infection rates than conventional catheters Tunneled femoral catheters have shorter survival and higher risk of deep venous thrombosis compared to conventional catheters HeRO device offers an alternate access for patients with central vein occlusion and no suitable veins for upper arm fistula or graft The order of preferred vascular access in the HD patient with reasonable life expectancy remains AVF followed by AVG in the upper extremity If there are no upper extremity AVG options available, the choice for a catheter or a HeRO graft should be individualized for each patient 24

Distal Hypoperfusion Ischemic Syndrome (DHIS)

Pathophysiology Traditional View ( Steal Syndrome ) Distal Hypoperfusion Ischemic Syndrome (DHIS) Steven Wu, MD Director of Interventional Nephrology Massachusetts General Hospital Harvard Medical School