Vascular access for Dialysis a surgeon s perspective e. some observations
Age of New Haemodialysis Patients 2005 Australia Number (Total=1957) 0.7% 3% 5% 10% 15% 20% 26% 19% 2% 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >=85 No. Pats. 14 38 104 170 303 414 514 863 37
Method and Location of Dialysis 2000-2005 Number of Patients t 5000 SAT HD 3629 (43%) HOSP HD 2289 (27%) 5000 4500 CAPD 1027 (12%) 4500 4000 HOME HD 799 (9%) 4000 3500 APD 784 (9%) 3500 3000 2500 2000 1500 1000 500 0 2000 2001 2002 2003 2004 2005 3000 2500 2000 1500 1000 500 0
RPAH Waiting time for Kidney Transplant in 2006 (n=69) 25 22 20 Deceased Donor Living Donor 15 10 5 1 2 3 2 2 0 Pre- Emptive 1m-1yr 1-2yr 2-3yr 3-4yr 4-5yr >5yr
Stock and Flow of Haemodialysis Patients 2001-2005 Number of Patients 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 New Patients Transplants Perm. Transfer Deaths No. Dialysing 6717 Patients t 2001 2002 2003 2004 2005
Pr robability of surviv val 0.00 0.25 0.50 0 0.75 1.00 0 Patient Survival - HD at 90 days Censored for Transplant Australia 1993-1995 (1907) 1996-1998 (2462) 1999-2001 (3156) 2002-20042004 (3506) 0 1 2 3 4 5 Years
CRF in Australia 1. Number of kidney failure patients in Australia could triple 2. Dialysis patient number increasing by 7% per year 3. 47% of new patients are over 65 years old 4. Commonest treatment option is satellite haemodialysis 5. Transplantation is not a viable option for most patients 6. Haemodialysis is the commonest long term treatment 7. Death is commonest endpoint 50% at 5 years
Long term reliable vascular access 1. Demonstrate why AVF are better than AVG 2. Ask who are the decision makers for choice of vascular access? 3. The role of central venous catheters? 4. A plan for maximising AVF 5. Surveillance of AVF 6. Home versus satellite haemodialysis
K Polkinghorne/ANZDATA 2003
Association of Angioaccess and Mortality Haz zard Rat tio 3 2.5 2 1.5 1 0.5 0 Ref 1.24 0.097 2.54 17 1.7 <0.001 0.148 (2528) (402) (129) (28) AV Native AV Synthetic Tunnelled CV Catheter Type of Angioaccess Non-Tunnelled CV Catheter K Polkinghorne/ANZDATA 2003
Access Intervention in Previous Twelve Months - December 2005 n = Number of Patients Revision of Access Declotting of Access AVF AVG CVC AVF AVG CVC Australia n=6717 12% 35% 18% 5% 26% 14% Diabetics n=1660 12% 41% 17% 6% 29% 13% F emale n=2672 13% 35% 18% 6% 25% 15% AVG in 2005 were: 1. five times more likely to clot 2. three times more likely to require revision 3. less satisfactory than central venous catheters
Type of Access for Haemodialysis Australia December 2005 CVC AVG AVF 76% 74% 77% Only significant factors correlating with use of AVG are length of time 67% 82% on dialysis and the HD centre 12% 10% 13% 18% 9% All Pts Diabetic Non Diab Female Male (n=6717) (n=1660) (n=5057) (n=2672) (n=4045)
2003 Western Australia AVG 12% Catheters 18% 9% 3% Northern Territory AVG 6% Catheters 6% 8% Queensland AVG 16% Catheters 10% South Australia AVG 6% Catheters 4% New South NSW 20% Wales/ACT 10% AVG 30% Catheters 7% ACT 36% Victoria AVG 9% Catheters 8% 8% 8% Tasmania AVG 1% Catheters 20%
Mode of HAEMODIALYSIS NSW December 2004 100 80 60 40 20 0 NSW TEMP CVC Synthetic Native L'POO OOL WEST NSW STG TGH WGN GNG NEW EWC RPA/CO CON RNSH percent
First Haemodialysis Access Initial RRT By Referral - Australia Perce entage 60 80 100 40 16 19 19 29 4 31 33 4 3 34 55 43 42 46 49 Non-Tunnel CVC Tunnel CVC AVG AVF 0 20 52 46 46 Mar 04 Dec 05 Dec 04 Early 1 10 2 10 Late 1 8 Dec 04 Mar 04 Dec 05
Mode of INITIAL vascular access NSW in 2004 100 80 perce ent 60 TEMP 40 CVC Synthetic 20 Native 0 WEST L'POOL WGNG NSW NSW NEWC RNSH RPA/CON
h th d isi k s f h i who are the decision makers for choice of vascular access in your hospital?
Decision i makers 1. Nephrologist 2. Patient t 3. Patient s family 4. Dialysis nursing staff 5. Vascular surgeon time ease of surgery $$$
Central Venous Catheters temporary late presentation, BMI>35 and female necessary for bridging to native or synthetic AVF high complication rate thrombosis insertion? where and when? long term solution
Central Venous Catheters
Imaging of the IJV
Non-tunneled CVCs avoid use in neck
Positioning CVC junction of SVC and right atrium in sitting position risk of thrombosis right atrium
SVC obstruction - mechanical injury to SVC
Biofilm inevitable it and on outer side of catheter t - not tin the lumen. Bacteria adhere with source being at time of insertion or circulating organisms at any time thereafter. Usually S. aureus or S. epidermidis and therefore skin source. Patient to patient spread of staphylococcus demonstrated by?? Lab technique identification and therefore implication dialysis nursing staff and not patient source. Multiple options for catheter locking solutions. Need for perhaps p determined by Catheter Related Bacteraemia rate (events/1,000 catheter days). If CRB rate low, randomised trials have difficulty showing advantages over heparin alone. Centres should monitor CRB rates should be about 2/1,000 days. RCTs show Gentamicin to best at lowering CRB rate but antibiotic resistance rate unacceptable. Next best is. with 4% citrate. Not available in Australia ampoule worth about 12 Euro.
Long term reliable vascular access 1. Demonstrate why AVF are better than AVG 2. Ask who are the decision makers for choice of vascular access? 3. The role of central venous catheters? 4. A plan for maximising AVF 5. Surveillance of AVF 6. Home versus satellite haemodialysis
FISTULA FIRST National Vascular Access Improvement Initiative initiative to increase AVF prevalence started Northwest network in 2003 aim for 50% AVF
The team approach 1. Designate staff member in dialysis facility (RN if feasible) responsible for vascular access 2. Assemble multi-disciplinary vascular access team 3. Representatives of all key disciplines including access surgeons, ultrasonographers and interventionalists. 4. Investigate and track all non-avf access placements, and AVF failures 5. Benchmark against others
Referral 1. Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery referral. 2. Nephrologist refers for vessel mapping where feasible, prior to surgery referral. 3. Nephrologist refers patients to surgeons for AVF only evaluation. Surgery scheduled with sufficient lead-time for AVF maturation. 4. Nephrologist defines AVF expectations to surgeon
Vascular access surgeon Nephrologists refer to surgeons willing and able to meet the standards and expectations. Surgeons utilize current techniques for AVF placement including vein transposition. Surgeons ensure mapping is performed for any patient t not clearly suitable for AVF based only on physical exam. Surgeons are evaluated on frequency, quality and patency of access placements. Surgeons work with nephrologists to plan for and place secondary AVFs in suitable AV graft patients.
AV grafts to AVF evaluate and identify every AV graft patient for possible secondary AV fistula conversion, and document the plan in the patient s t record. examine outflow vein of all graft patients with sleeves up during dialysis treatments (minimum frequency, monthly). refer to surgeon for placement of secondary AVF before failure of AVG.
Cannulation Facility uses best cannulators and best teaching tools. Dialysis staff use specific protocols for initial dialysis treatments Assign the most skilled staff to patients with new AVFs Facility offers option of self-cannulation to patients who are interested and able.
Surveillance Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF. Nephrologists, interventional radiologists, and surgeons adopt standard criteria, and a plan for each patient Review data monthly or quarterly in facility staff meetings. Present and evaluate data trended over time
? experience of surgeon
Obese patients
AVF vs AVG Saphenous vein loops unpopular because of aneurysms and stenoses. Large numbers of brachiocephalic and brachiobasilic AVF (latter performed as two stage procedure). For example, 70% of native vein AVF were in upper arm in large and recent series from University it of Miami. i Same trend in Europe. Upper arm fistulae associated with high flows and cephalic arch stenoses interesting relationship between these two problems, particularly with respect to dilation and effect cardiac output. High venous return pressures can be a result of high flow. See later discussion on flow monitoring.
Brachiocephalic fistula
Surveillance of fistulae 1. Improve patient care reliability and predictability of access prolong and preserve access vessels 2. Reduce access related costs morbidity related home haemodialysis
sleeves up and arm up
Movie 1340
Movie 1347
Movie 1344
Venous hypertension
Whilst on dialysis Ease of cannulation Ability to rotate cannulation points Arterial inflow pressures Pump speed Venous return pressures Decannulation bleeding times
Distribution of Blood Flow Rates 4500 4000 Number of Patients 5000 Mar 2004 (5924) 3500 3000 2500 2000 1500 1000 500 0 Dec 2004 (6206) Dec 2005 (6717) Australia 200-249 250-299 300-349 350-399 >=400 mls/min
Ultrasound
dysfunction hypothesis Fistula stenosis causes graft dysfunction and dysfunction precedes and accurately predicts thrombosis Surveillance relies on:- 1. Reproducible measurements 2. Stenosis progressing slowly 3. Other factors such as hypercoagulability, low BP etc do not influence 4. Correlation with clinical examination
a must get!
Digital Ischaemia incidence 1 3% invariably diabetic patient radial = brachial incidence treat by banding or ligation DRIL procedure
Surveillance recommendations 1. High quality and continuous clinical assessment 2. Initial ultrasound assessment dialysis nurse driven 3. Early intervention
Mr T
5. Cannulation techniques Description three cannulation techniques: rope ladder or snail track for AVGs and good veins provided aneurysms do not develop in latter area technique which is prone to aneurysm formation, particularly in high flow fistulae button hole which I now have a very revised and more positive appreciation of. Should not be confused with area cannulation technique. button hole is a very precise technique and very operator dependent. Preparation and angle of entry very important, initially with sharp needles. Nursing recommendation that it be employed by limited number of staff for a given patient. No nurse should cannulate ate a given fistula without having witnessed another with knowledge of that given fistula.
educated smiling home HD patient