AV ACESS COMPLICATIONS. Ass. Prof. Dr. Habas

Transcription

1 AV ACESS COMPLICATIONS Ass. Prof. Dr. Habas

2 COMPLICATION AVF IS CONSIDERED A MINOR PROCEDURE INCIDENCE OF COMPLICATION % MANY A COMPLICATION LEADS TO FAILURE OF FISTULA LOSS OF SITE AND VEIN FOR FURTHER USE CAN BE AVOIDED BY PLANNING,TECHNIQUE AND PROPER USE OF FISTULA

3 COMPLICATION BLEEDING INFECTION THROMBOSIS NON MATURATION OF VEIN PSEUDOANEURYSM DISTAL ISCHEMIA VENOUS OEDEMA CARDIAC FAILURE -

4 BLEEDING PRIMARY SUTURE LINE BLEEDS HAEMATOMA OCCLUSION OF FISTULA REACTIONARY HYPERTENSION SECONDARY INFECTION NEEDS LIGATION OF FISTULA

5 THROMBOSIS EARLY WITH IN 48 HRS OCCLUSION OF FISTULA ( HYPERCOAGUBLE STATE, HYPOTENSION, HAEMATOMA, POOR VEIN CALIBRE, DISTAL THROMBOSIS) LATE SAME AS ABOVE, PUNCTURE SITE INTIMAL HYPERPLASIA, HAEMATOMA, SEPSIS, HYPOTENSION

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7 INFECTION INCIDENCE ISLOW USE OF PROPHYLACTIC ANTIBIOTICS DRESSING FISTULA CARE

8 NON MATURATION OF FISTULA INCIDENCE OF UPTO 27 % POOR VEIN CALIBRE PREVIOUS PHLEBITIS CALCIFIED ARTERIES COMMON INDIABETICS IMPROPER SURGERY REMEDY- NEW SITE / NEW FISTULA

9 PSEUDOANEURYSM SWELLING AT SITE OF FISTULA PAIN CONFIRM ONDOPPLER RISK OF RUPTURE HIGH LIGATION OF FISTULA AND ARTERY MAY REQUIRE A VENOUS GRAFT

10 CARDIAC FAILURE OVER FUNCTIONING OF FISTULA PROXIMAL FISTULA LARGE ANASTOMOSIS REMEDY CLOSURE OF FISTULA

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12 DISTAL ISCHEMIC SYMPTOMS ALLENS TEST IS MUST TO CHECK PATENCYOF PALMAR ARCH COMMON IN BRACHIAL FISTULAS INCIDENCE 4% EARLY DIAGNOSIS AND CORRECTION OF INFLOW- ARTERIAL THROMBOSIS STEAL SYNDROME NARROWING OF FISTULA OR LIGATION

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14 VENOUS OEDEMA COMMON IN SIDE TO SIDE FISTULA VENOUS OUTFLOW OBSTUCTION CORRECTION OF VENOUS OBSTRUCTION VENOGRAPHY-PLASTY SALVAGE FISTULA ASSESSMENT OF VENOUS ANATOMY BYDOPPLER USE THE SITE OPP TO CENTRAL VENOUS ACCESS

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16 COMPLICATION -SYNTHETIC GRAFT THROMBOSIS INFECTION PSEUDOANEURYMS REMOVAL OF GRAFT INFECTION ORANEURYSM

17 COMPICATION OF CV CATHETERS INFECTION FEVER, RIGORS DURING DIALYSIS OCCLUSION VENOUS THROMBOSIS DURING INSERTION TRAUMA TO ARTERY AND VEIN MIGRATION FRACTURE OF CATHETER

18 CONCLUSION MANY A COMPLICATION LEADS TO LOSS OF FISTULA PROPER VASCULAR ASSESSMENT BEFOREAVF FORMATION ISMUST EARLY DIAGNOSIS AND INTERVENTION CAN SALVAGE AVF

19 THANK YOU

20 COMPLICATIONS RELATED TO THE CATHETER

21 COMPLICATIONS RELATED TO THE CATHETER

22 COMPLICATIONS RELATED TO THE CATHETER

23 COMPLICATIONS RELATED TO THE CATHETER

24 KINK OF THE CATHETER Catheter can kink either subcutaneously or intravascularly

25 NKF-DOQI GUIDELINE Ultrasound-directed cannulation of veins minimizes insertion complications, and should be used when available. Because most NCCs are placed at the bedside, the need for a postinsertion chest radiograph after internal jugular or subclavian insertion is mandatory to confirm the position of the catheter tip in the SVC and exclude such complications as pneumothorax and hemothorax before a dialysis session NKF DOQI Guidelines 2006

26 LATE COMPLICATIONS: THROMBOSIS Responsible for 30-40% catheter loss During insertion, endothelial and vascular wall trauma at the catheter tip After insertion, turbulance in blood flow initiates the coagulation cascade to form a thrombi

27 THROMBOSIS Extrinsic (Mural and intra-atrial) Intrinsic (Intraluminal, catheter tip etc.)

28 FIBRIN SHEATH Catheter dysfunction incidence 13-57% The sheath starts to form at the vascular entrance of the catheter as soon as 24 hours Proteinaceous tissue begins to form in the catheter. Collagen, smooth muscle and inflammatory cells come into contact with the sheath and surrounds the entire catheter and the catheter tip. Savader SJ et al. J Vasc Interv Radiol 2001;12:

29 FIBRIN SHEATH Plug the holes on the surface of the catheter Can create a vacuum effect that may interfere with blood flow through the catheter The interaction between these tissue and the catheter is loose hence aspiration is more problematic than infusion If blood flow through catheter can not be fixed with thrombolytics or the same problem repeats itself then fibrin sheath formation should be considered Savader SJ et al. J Vasc Interv Radiol 2001;12:

30 FIBRIN SHEATH Diagnosis catheter can be drawn back and radiocontrast may be injected to demonstrate the sheath Savader SJ et al. J Vasc Interv Radiol 2001;12:

31 Fibrin sheath FIBRIN SHEATH

32 LATE DYSFUNCTION OF THE CATHETERS Both thrombosis and fibrin sheath; form a natural culture for colonization thus could lead to catheter related bacteriemia

33 LATE DYSFUNCTION OF THE CATHETERS Thrombosis Bolus isotonic NaCl administration Thrombolytic drugs Endovascular stripping Catheter replacement using a guidewire Savader SJ et al. J Vasc Interv Radiol 2001;12:

34 CATHETER DECLOTTING PROTOCOL Application procedure Catheter internal volume can be instilled with a declotting solution for a predetermined period Infusion of the declotting solution through the catheter Thrombolitic tpa (Alteplase) should be kept in the lumen at least 1 hour 1-2 mg/lumen tpaadministration accomplishes 73% success during the first and 83%success during the second attempt

35 TREATMENT OF FIBRIN SHEATH Endovascular stripping Risk of embolization Increased cost Not advantageous Risk of recurrence

36 TREATMENT FOR LATE CATHETER DYSFUNCTION No effect of systemic anticoagulation or aspirin use have been succesfull in prevention of thrombosis

37 CENTRAL VEIN STENOSIS Subclavian vein > internal jugular vein Left internal jugular vein catheterization Intravascular long catheter segment Catheter tip rotation more than once to reach the right atrium Small diameter of the left internal jugular vein External compression by brachiacephalic artery

38 CENTRAL VEIN STENOSIS Acute vascular injury during permanent catheter insertion, Turbulant flow thrombosis stenosis (11-50%) Same side edema and numbness in the arm Swelling and pain in the breast Collateral vein formation Venous pressure increase during HD

39 CENTRAL VEIN STENOSIS Due to subclavian vein catheterization

40 TREATMENT CENTRAL VEIN STENOSIS By pass surgery Invasive radiological interventions Balloon angioplasty Stent Atherectomy

41 SUBCLAVIAN STENOSIS

42 REGISTRY 2012

43 CONCLUSIONS Catheter-related complications are associated with significant morbidity, mortality and increased cost. ESRD patients should be informed about the risks and benefits of catheters and should be referred to early AVF operation. Central venous catheters should be reserved for those in need of acute hemodialysis and for those without permanent vascular access.