COMPLICATIONS OF DIALYSIS - PART 1 pps

Nutritional Complications in Chronic Hemodialysis and Peritoneal Dialysis Patients 405 T.. re-Table 1 Uses of the Tunneled-Cuffed CatheterAs a temporary vascular access more than a few d

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To my parents Raj and Rajindra L Mehta; my mentor Prof K S Chugh; my wife, Gita; my children, Isha and

Sachin, and to my patients, from whom I continue to learn

—R Mehta

The worldwide incidence of end-stage renal disease

(ESRD) is increasing, with the current total number of

cases estimated at 3 million cases Over the last three

decades, advances in the management of this chronic

disease have focused primarily on renal replacement

therapy with dialysis on renal transplantation Of the

600,000 people worldwide who will be treated with

renal replacement therapy, fewer than 40,000 patients

will receive a renal transplant The large numbers of

patients supported with dialysis has spurred several

ad-vances in dialysis technology that have allowed

ne-phrologists to offer patients a choice of therapeutic

mo-dalities However, as new applications of dialysis have

emerged, new complications have also been identified

that are often not well reported The availability of

sev-eral books covering dialytic techniques and their

ap-plications raises the question: Whey another book on

dialysis? We believe the answer lies in the focus of this

book on recognition and management of complications

of dialysis

This book is a comprehensive multidisciplinary

re-source for the nephrologist and caregiver providing

di-alysis, covering all aspects of dialysis therapies We

have developed the book on the premise that

compli-cations result from the interaction of the patient, the

technique, and the environment in which dialysis is

provided As a consequence, the complications have

been discussed from three angles: patient-related,

tech-nique-related, and those contributed to by the

organi-zation of care reflecting the changing relationship

be-tween providers and beneficiaries of dialysis We haveintegrated the knowledge gained from experience witheach technique with clinical outcomes, and have ex-plored the emerging role of the economics of thesetherapies in contributing to adverse outcomes New andoriginal material has been added rather than known ma-terial duplicated The result is a book that not only iscomprehensive and resourceful but also offers details

on management of each major complication and tical advice to the dialysis team on several topics thatare only covered as exceptions in other books.Another unique feature of this book is that it is trulyinternational It was our ambition to cover the problemsglobally and not to limit coverage to North Americaand Western Europe Both our contributors and the top-ics reflect this theme We believe that in the immediatefuture the strategic context of ESRD therapy will make

prac-it necessary to maximize clinical and economic comes in a rapidly changing healthcare environment.Therefore, attention has also been given to the eco-nomic, public health, and environmental problems in-volved in dialysis We hope therefore that this bookwill be useful beyond the need for continuing post-graduate education of the nephrologists and that it willalso be of interest to health care providers ranging fromgovernment to hospital administrators, health careeconomists, and all who are directly and indirectly in-volved in the care of patients with ESRD

out-Some degree of overlap among chapters in a authored book, whose writers hail from several coun-

multi-tries cannot be avoided As it should be in a book at

the postgraduate academic level, some differences of

opinion among authors have not been discarded We

are extremely grateful to all contributors for their time

and their efforts in making this book a reality We are

indebted to several people at Marcel Dekker, Inc., for

their patience and support as this book has developed

We sincerely appreciate the enormous work by oursecretaries Mrs I Verslycken and Ms I Van Dorpe inGent for Dr Lameire and Ms Rachel Manaster in SanDiego for Dr Mehta

Norbert Lameire Ravindra L Mehta

Preface v

Contributors xi

1 Complications of Vascular Access 1

Gerald A Beathard

2 Complications Related to Water Treatment, Substitution Fluids, and Dialysate Composition 29

Ju¨rgen Floege and Gerhard Lonnemann

3 Complications of Biocompatibility of Hemodialysis Membranes 41

Brian J G Pereira and Alfred K Cheung

4 Acute Dialysis Complications 69

K M L Leunissen, J P Kooman, and F M van der Sande

5 Complications Related to Inadequate Delivered Dose: Recognition and Management in Acute andChronic Dialysis 89

Jane Y Yeun and Thomas A Depner

6 Problems Related to Anticoagulation and Their Management on Intermittent Hemodialysis/Hemodiafiltration 117

Konrad Andrassy

7 Complications of Hemoperfusion 127

James F Winchester

8 Complications of Peritoneal Access in Acute and Chronic Peritoneal Dialysis 133

Madhukar Misra, Zbylut J Twardowski, and Ramesh Khanna

9 Problems of Peritoneal Membrane Failure 151

Simon J Davies, Gerald Anthony Coles, and Nicholas Topley

10 Complications Related to Inadequate Delivered Dose of Peritoneal Dialysis 179

Antonios H Tzamaloukas and Thomas A Golper

11 Infectious Complications and Peritonitis and Their Management 195

Ram Gokal

12 Problems with Anticoagulation for Continuous Renal Replacement Therapies 215

Andrew Davenport

13 Complications of Fluid Management in Continuous Renal Replacement Therapies 241

Ravindra L Mehta

14 Problems of Solute Removal in Continuous Renal Replacement Therapies 251

William R Clark, Michael A Kraus, and Bruce A Mueller

15 Cardiac Disease in Hemodialysis and Peritoneal Dialysis Patients 269

Patrick S Parfrey and Norbert Lameire

16 Hematological Problems and Their Management in Hemodialysis and Peritoneal Dialysis Patients 303

Iain C Macdougall

17 Coagulation Problems in Dialysis Patients 327

Paola Boccardo and Giuseppe Remuzzi

18 Arthropathies and Bone Diseases in Hemodialysis and Peritoneal Dialysis Patients 343

Alkesh Jani, Steven Guest, and Richard A Lafayette

19 Acid–Base Problems in Hemodialysis and Peritoneal Dialysis 361

F John Gennari and Mariano Feriani

20 Infectious Problems in Dialysis Patients 377

Raymond C Vanholder and Renaat Peleman

21 Immune Dysfunction in Hemodialysis and Peritoneal Dialysis Patients 389

Walter H Ho¨rl

22 Nutritional Complications in Chronic Hemodialysis and Peritoneal Dialysis Patients 405

T Alp Ikizler and Jonathan Himmelfarb

23 Nutritional Problems, Including Vitamins and Trace Elements, and Continuous Renal Replacement

Therapy Treatments 427

Wilfred Druml

24 Endocrine and Sexual Problems in Adult and Pediatric Hemodialysis and Peritoneal Dialysis Patients 441

Ahmed Mahmoud, Frank H Comhaire, Margarita Craen, and Jean Marc Kaufman

25 Dermatological Problems in Dialysis Patients, Including Calciphylaxis 455

Jean Marie Naeyaert and Hilde Beele

26 Hypertension in Dialysis Patients 471

Steve Fishbane, John K Maesaka, Muhammed A Goreja, and Edward A Kowalski

27 Pulmonary Problems in Hemodialysis and Peritoneal Dialysis 485

Eric E O Gheuens, Ronald Daelemans, and Marc E De Broe

28 Quality of Life and Functional Status in Chronic Hemodialysis and Peritoneal Dialysis 497

Maruschka Patricia Merkus and Raymond T Krediet

29 Dyslipoproteinemia Associated with Chronic Renal Failure 517

C H Barton and N D Vaziri

30 Disturbances in Carbohydrate, Protein, and Trace Metal Metabolism in Uremia and Dialysis Patients 557

Norbert Lameire, Raymond Vanholder, and Bernadette Faller

31 Neurological Complications of Dialysis 573

Stefano Biasioli

32 Psychiatric and Psychosocial Complications in Chronic Dialysis 591

Bum-Hee Yu and Joel E Dimsdale

33 Gastrointestinal Complications in the Dialysis Patient 605

Pradeep Ramamirtham and Thomas J Savides

34 Ocular Complications in Dialysis Patients 613

Jean-Jacques De Laey, Anita Leys, and Bart Lafaut

35 Complications of Renal Replacement Therapy in the ICU 625

Claudio Ronco, Aldo Fabris, and Mariavalentina Pellanda

36 Complications of Acute and Chronic Dialysis in Children 643

Timothy E Bunchman and Norma J Maxvold

37 Dialysis in Patients with Human Immunodeficiency Virus Infections 657

Jorge Diego and Jacques J Bourgoignie

38 Hepatitis and Dialysis 673

Geert Leroux-Roels and Annemieke Dhondt

39 Complications of Dialysis in Diabetic Patients 697

Anne Marie Miles and Eli A Friedman

40 Problems of Women on Dialysis 705

Susan S Hou and Susan Grossman

41 Complications During Plasma Exchange 721

Norbert Lameire, Wim Van Biesen, and Maria Wiedemann

44 Dialysis Delivery in Canada: Can Systemic Shortcomings Cause Complications? 777

David C Mendelssohn

45 Outcomes and Intermodality Transfers in Patients on Renal Replacement Therapy in Canada and

Europe 791

Peter G Blake, Wim Van Biesen, Norbert H Lameire, and Rosario Maiorca

46 The Approach to Dialysis in Developing Countries 811

V Jha, Kirpal S Chugh, and Sumant Chugh

47 The Environmental Aspects of Dialysis 823

Rita De Smet, Norbert Fraeyman, Nicholas Andrew Hoenich, and Peter George Blain

48 Perioperative Anesthetic Management of the High-Risk Renal Patient 839

William C Wilson and Ravindra L Mehta

Index 861

C H Barton, M.D. Department of Medicine, Division of Nephrology, University of California, Irvine, Irvine,California

Texas; LSU Medical School, Shreveport, Louisiana; University of Texas Health Science Center, Houston, Texas;University of Texas Medical Branch, Galveston, Texas

United Kingdom

Western Ontario, Ontario, Canada

Florida

Veterans Affairs Medical Center, Salt Lake City, Utah

Research, Chandigarh, India

Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana

Cardiff, United Kingdom

Gent, Belgium

Gent, Belgium

Ronald Daelemans, M.D., Ph.D. Nephrology, Hypertension, and Medical Intensive Care Unit, General

Hospital Stuivenberg, Antwerp, Belgium

Kingdom

Stoke-on-Trent, United Kingdom

Belgium

Davis, Sacramento, California

Gent, Gent, Belgium

Brooklyn, New York

Vermont

Hospital Stuivenberg, Antwerp, Belgium

Kingdom

Little Rock, Arkansas, and Renal Disease Management, Inc., Youngstown, Ohio

New York

Austria

Nashville, Tennessee

Alkesh Jani, M.D. Department of Medicine, Stanford University Medical Center, Stanford, California

Chandigarh, India

Farmington, Connecticut

Gent, Gent, Belgium

Missouri

Netherlands

Indiana

Center, Amsterdam, The Netherlands

Belgium

University Hospital of Gent, Gent, Belgium

Netherlands

Gerhard Lonnemann, M.D Department of Nephrology, Medicinische Hochschule, Hannover, Germany

Hospital, London, United Kingdom

Ahmed Mahmoud, M.D Medical Centre for Andrology, University Hospital of Gent, Gent, Belgium

Rosario Maiorca, M.D. Institute and Division of Nephrology, University and Civil Hospital, Brescia, Italy

Arbor, Michigan

of California, San Diego, San Diego, California

Toronto, Toronto, Ontario, Canada

Amsterdam, The Netherlands

Brooklyn, New York

Missouri

Lafayette, Indiana

Jean Marie Naeyaert, M.D., Ph.D. Department of Dermatology, University Hospital of Gent, Gent, Belgium

John’s, Newfoundland, Canada

Hospital of Gent, Gent, Belgium

Medical Center, Boston, Massachusetts

California, San Diego, San Diego, California

Pharmacological Research, Bergamo, Italy

San Diego, San Diego, California

Medical School, Boston, Massachusetts

Nicholas Topley, B.Sc., Ph.D. Institute of Nephrology, University of Wales College of Medicine, Cardiff,United Kingdom

Columbia, Missouri

Medicine, and Veterans Affairs Medical Center, Albuquerque, New Mexico

Maastricht, The Netherlands

Belgium

Irvine, Irvine, California

Complications of Vascular Access

Gerald A Beathard

Capital Nephrology, U.S Vascular Access Centers, Inc., Austin, Texas

LSU Medical School, Shreveport, Louisiana

University of Texas Health Science Center, Houston, Texas

University of Texas Medical Branch, Galveston, Texas

Nowhere in clinical medicine is there a better example

of the benefits of biomedical engineering to patient care

than that offered by chronic hemodialysis This

tech-nology, using a machine to maintain and preserve the

life of the patient, has been and continues to be

suc-cessful Unfortunately, the interface between the two is

defective The vascular access is associated with

com-plications These complications result in patient

morbid-ity and mortalmorbid-ity and add considerably to the cost of

managing chronic renal failure The annual cost of

main-taining vascular access in the United States is

approach-ing one billion dollars (1) This represents only the tip

of the iceberg, however Problems that derive both

di-rectly and secondarily from these complications result

in a major proportion of the hospitalizations required in

this frequently hospitalized population of patients (2)

Vascular access can be divided into three types:

tunneled-cuffed catheters (TCCs), prosthetic bridge

grafts (PBGs), and autologous native fistulas (AVFs)

Each of these has an important role to play in

hemo-dialysis, but each has the potential for complications

Since their introduction in the 1980s (3–5), TCCs have

come to play an increasingly important role in the

de-livery of hemodialysis to patients with chronic renal

failure Data collected by the United States Renal Data

System indicates that in 1996, 18.9% of all new

he-modialysis patients were being dialyzed with a TCC 60

days after starting dialysis (2) These catheters are usedfor a variety of reasons, as shown in Table 1 Unfor-tunately as we have learned all too well, the TCC is adouble-edged sword The tremendous advantages that

it brings can also carry a tremendous cost

As listed in Table 2, a variety of complications canoccur at the time of catheter placement The major de-terminant for problems at the time of insertion is theexperience of the operator (6) Even in the hands ofexperienced surgeons in the operating room, blind in-sertion results in complication rates as high as 5.9%(7,8) These complications include (3–5,7–14): pneu-mothorax (0–1.8%), hemothorax (0–0.6%), hemome-diastinum (0–1.2%), recurrent laryngeal nerve palsy(0–1.6%), and bleeding that required reexplorationand/or transfusion (0–4.7%) This contrasts with theseries reported by Trerotola et al (15) using real-timeultrasound guidance Their complication rate was lim-ited to 2 cases (0.8%) of clinically silent air embolism

in 250 catheter placements The use of ultrasound hasresulted in a substantial decrease in procedural com-plications (16,17) and is strongly recommended (18)

In general, flow problems that occur early are related

to catheter position, while those that occur late are

re-Table 1 Uses of the Tunneled-Cuffed Catheter

As a temporary vascular access (more than a few days of dialysis required)Acute renal failure

Immediate transplantationImmediate peritoneal dialysis

As a back up vascular accessFailure of vascular accessDialysis access graft revision or replacementRemoval of peritoneal catheter

Bridge access to allow time for maturation of permanent accessNative fistula

PTFE graftPermanent vascular accessSevere peripheral vascular diseaseMorbid obesity?

AIDS?

Table 3 Classification ofCatheter Thrombosis

ExtrinsicMural thrombusCentral vein thrombosisAtrial thrombusIntrinsic

IntraluminalCatheter tip thrombusFibrin sheath

Table 2 Complications of Tunneled-Cuffed Catheters

Limited ability to provide sufficient blood flow

Complications of initial placement

Exit site infection

Central vein stenosis

lated to thrombosis Thrombosis is a common problem;

the mean patency rate for these catheters has been

re-ported to range from 73 to 84 days (19,20) The specific

factors leading to catheter thrombosis in an individual

case are seldom obvious Rarely one encounters a

pa-tient with a definable hypercoagulability state From a

study of central venous catheters, Francis et al (21)

reported evidence to indicate that thrombin is locally

deposited on catheter surfaces in vivo Although this

phenomenon was not correlated with identifiable

thrombosis, under favorable conditions it could

pre-dispose to thrombus formation Catheter-associated

thrombosis can be classified as extrinsic and intrinsic

(Table 3)

1 Extrinsic ThrombosisThe magnitude of the problem presented by this cate-gory of thrombosis is not as great as that of the intrinsiccategory

a Central Vein Thrombosis

The presence of a catheter within the central veins canprecipitate thrombosis of the vein How often this oc-curs is not clear Agraharkar et al (22) suggested that

it is not common They reported an incidence of only2% in a series of 101 percutaneously inserted catheters.Karnik et al (23), in a study of 63 patients with centralvenous catheters (not dialysis), found an incidence of63.5% It is certainly clear that symptomatic centralvein thrombosis is not common, but when it does occurthe symptoms can be dramatic Diagnosis is based pri-marily upon the clinical picture presented by the pa-tient The patient presents with swelling of the ipsilat-eral extremity, which may also be tender and painful.The presence of central vein thrombosis may be con-

firmed by the use of ultrasound evaluation Treatment

consists of catheter removal and anticoagulation In

cases in which the potential sites for vascular access

are depleted or extremely limited, it may be possible

to preserve the catheter These patients must be

sys-temically anticoagulated and observed very closely,

however

b Mural Thrombus

This refers to a thrombus that is attached to the wall of

the vessel or the atrium at the point of contact by the

tip of the catheter It is presumed that catheter tip

move-ment causes damage, which results in thrombus

forma-tion The tip of the catheter is frequently attached to this

mural thrombus When this occurs, it can interfere with

catheter function Most of these thrombi are not

recog-nized unless there is catheter malfunction, at which time

they may be recognized at the time of angiographic

eval-uation When recognized, removal of the catheter is

in-dicated and represents adequate treatment

c Atrial Thrombus

Rarely a large intra-atrial thrombus may develop in

as-sociation with a dialysis catheter and present as a mass

within the right atrium as seen angiographically or with

an echocardiogram (24) This probably represents a

variant of the mural thrombus Removal of the catheter,

anticoagulation, and echocardiographic follow-up have

been used in these cases

2 Intrinsic Thrombosis

This type of thrombosis represents the major

compli-cation associated with these catheters

a Intraluminal Thrombus

Intraluminal thrombosis occurs when a thrombus forms

within the catheter lumen It results from either an

in-adequate volume of heparin being placed within the

catheter lumen, heparin being lost from the catheter

be-tween dialysis treatments, or the presence of blood

within the catheter When this occurs, the catheter

be-comes totally occluded This type of thrombus is not

very common because routine catheter maintenance

techniques are generally sufficient to prevent the

prob-lem

b Catheter Tip Thrombus

Many catheters have side holes at the tip of the arterial

limb Unfortunately, that portion of the catheter from

the side holes to the tip will not retain heparin and athrombus can form A tip thrombus may be occlusive,

or it may act as a ball valve Preventative measuresthat are commonly used to avoid intraluminal throm-bosis are largely subverted by the presence of the sideholes It is probable that forcible flushing before andafter dialysis does aid in clearing poorly attached cath-eter tip thrombi

c Fibrin Sheath Thrombus

This is the most common type of thrombus that forms

in association with the TCC The term fibrin sheathrefers to a sleeve of fibrin that surrounds the catheterstarting at the point where it enters the vein Thissheath is only loosely attached to the catheter It isprobable that all central venous catheters become en-cased in a layer of fibrin within a few days of insertion.Hoshal et al (25) reported a fibrin sheath in 100% of

55 patients with central venous catheters at autopsy.These are not always symptomatic The incidence ofcatheter dysfunction secondary to fibrin sheath hasbeen reported to be 13–57% (19) When a catheter isremoved, gentle angiography of the catheter can dem-onstrate a ‘‘wind sock’’ of residual fibrin sleeve (Fig.1) in approximately 40% of cases (26)

As the sheath extends downwards, it eventuallycloses over the tip of the catheter In this position, itcan be disrupted by inward pressure to create a flapvalve that will allow injection but prevents withdrawal

of blood and fluid The TCC moves up and downwithin the vein and in and out at the point where thecatheter enters the vein This occurs to a greater degree

in patients that have large breasts or a thick layer offat on their chest at the point of the exit site Whetherthis plays any role in promoting the formation of afibrin sheath is not clear

Fibrin sheath formation generally causes catheterdysfunction weeks or months after catheter placement.However, it has been seen as early as 48 hours It isnot clear whether or not prevention of the formation of

a fibrin sheath is possible There is considerable dotal experience to suggest that chronic systemic an-ticoagulation with warfarin is beneficial, at least in se-lected patients

anec-3 Treatment of Catheter ThrombosisThe first step in the management of catheter malfunc-tion is the recognition of the problem Early malfunc-tion is usually due to improper placement with poor tippositioning or subcutaneous kinking of the catheter Al-though it is possible for a catheter to become displaced

Fig 1 Fibrin sheath thrombus: The catheter (narrow

por-tion) has been partially removed, leaving the sheath (broader

portion) hanging below its tip having the appearance of a

‘‘windsock.’’

Table 4 Protocol for Urokinase Administration

1 Attempt to aspirate the occluded catheter lumen toremove heparin

2 Inject 1 mL of urokinase (5000 IU/mL) into theoccluded catheter lumen

3 Fill the remainder of the catheter lumen with saline(e.g., for a 1.9 catheter lumen use 1 mL urokinase and0.9 mL saline)

4 Wait 10 minutes, then add 0.3 mL saline every 10 min

⫻ 2 to move active urokinase to the distal catheter

5 Ten minutes after the final 0.3 mL of saline is added,aspirate the catheter

6 Repeat procedure if necessary

after it has been in satisfactory use for a period of time,

later cases of malfunction are generally due to

throm-bosis (5,10,19)

Catheter malfunction is defined as failure to attain

and maintain an extracorporeal blood flow sufficient to

perform hemodialysis without significantly lengthening

the hemodialysis treatment Sufficient extracorporeal

blood flow is considered to be 300 mL/min (27) Once

catheter malfunction is recognized, it should be

im-mediately treated Treatment can be categorized as

pri-mary and secondary

a Primary Treatment of Catheter Malfunction

Primary treatment of catheter malfunction refers to the

treatment that can be immediately applied in the

he-modialysis facility

Urokinase Numerous protocols for urokinase

ad-ministration are in use, an effective example of which

is given in Table 4 Proper use of intraluminal nase has been shown to be successful in restoring cath-eter function in 74–95% of cases (3,19) The advan-tages of the urokinase technique are that it has a highrate of success, produces no systemic effect and istherefore safe, and can be performed by the nurse inthe hemodialysis facility

uroki-Urokinase is not a good solution for the treatment

of a fibrin sheath Thrombolysis only occurs within thecatheter and at its tip There is no systemic effect and

no mechanism by which the enzyme can come intocontact with the major portion of the sheath

Mechanical Mechanical treatment to remove theoccluding thrombus has been reported Shrivastava et

al (28) reported an 88% success rate using a 25 cmwire The same basic procedure can be followed using

a Fogarty catheter if the TCC will permit its passage.The advantages of the mechanical technique are that ithas a high rate of success, produces no systemic effect,and is therefore safe and is relatively inexpensive Ithas the disadvantages of not being a permanent solu-tion to the problem, and in general, a physician mustperform the procedure If a fibrin sheath is the cause

of catheter dysfunction, mechanical removal of the clusion will not provide a long-term solution

oc-b Secondary Treatment of Catheter Malfunction

If the primary treatments are unsuccessful or if theproblem quickly recurs, a radiographic study usingcontrast should be performed Further secondary treat-ment should be performed based upon the radiographicfindings

Fibrin Sheath Stripping The fibrin sheath can bestripped using a snare catheter The snare is introducedthrough the femoral vein, from where it is advanced up

to the level of the dialysis catheter The reported

suc-cess of this procedure ranges from 92 to 98%

(19,26,29) The reported duration of patency has varied

from a mean of 20 days to a mean of 90 days Fibrin

sheath stripping generally results in asymptomatic

em-bolization of the fibrin sheath

Advantages of this technique are its (1) high success

rate, (2) safety, (3) preserving of the catheter and (4)

reasonable duration patency Disadvantages of the

pro-cedure include the cost of the snare and the propro-cedure

and the fact that it is not a permanent solution to the

problem

Catheter Exchange Over Guidewire This technique

can be effectively used to eliminate the problem of

catheter thrombosis (20,30,31) This can be done using

a technique that preserves both the exit site and the

venotomy site It is important that the patient be

checked for a fibrin sheath prior to inserting the new

catheter It is possible to place the new catheter back

into the retained sheath and have the same problem

within a short time

Advantages of this procedure are that (1) it preserves

the exit and venotomy site and it is safe, (2) it is less

expensive than fibrin sheath stripping, and (3) it has a

high rate of success A disadvantage of this technique

is that you create a new catheter exit wound with its

associated risks of bleeding and infection

Urokinase Infusion Treatment of catheter

throm-bosis by prolonged administration of urokinase has

been used (20) This involved the administration of

20,000 units of urokinase per hour for 6 hours Lund

et al (20) reported a success rate of 79.5% with this

technique This dose of urokinase is not large enough

to result in systemic effects and does not require

hos-pital admission

Advantages of this technique are that (1) it is safe,

(2) it preserves the catheter, and (3) it is less expensive

than either fibrin sheath stripping or catheter exchange

The primary disadvantage lies in the fact that it has a

lower success rate Since there is no systemic

throm-bolytic effect, a fibrin sheath would not be exposed to

the enzyme

4 Catheter-Related Infection

Infection is a very common complication in

hemodi-alysis patients using a catheter Infection rates ranging

from 14 to 54% have been reported (9,10,19,20)

Sec-ondary complications of hemodialysis catheter-related

bacteremia (CRB) and sepsis such as septic arthritis,

endocarditis, and epidural abscess have dire

conse-quences and can result in death (10,32)

a Nature of Infections

In a series of 488 catheters, we observed a 28.5% CRBrate with new catheter insertions and a 15.6% rate withcatheter replacements The overall incidence of infec-tion was 0.51 per 100 catheter days (1.87 per catheteryear) Within the cases of CRB, 26% had an associatedexit site infection and 2% had a tunnel infection.The most commonly reported isolate in cases of

CRB has been Staphylococcus aureus (10,33) In a

se-ries of 101 cases of CRB, we observed gram-negativeorganisms in 29% Multiple organisms were isolated in17% of these cases

b Risk Factors

In addition to the foreign body effect of the TCC, anumber of factors have been identified as risk factorsfor the development of CRB (34–36) These include

skin and nasal colonization with Staphylococcus,

cath-eter hub colonization, duration of cathcath-eterization,thrombosis, frequency of catheter manipulation, dia-betes mellitus, iron overload, immunoincompetency,use of a transparent dressing, and the conditions ofcatheter placement

c Prevention of Infection

Prevention of catheter-associated infection involvesthree areas: technique of catheter placement, daily cath-ether exit site care, and catheter management in thehemodialysis facility First, it is critically important thatmaximal barrier precautions be used when a catheter isplaced (17) If not done in an operating room, the en-vironment should simulate an operating room

Care given to the catheter after placement is of equalimportance The use of either mupirocin or povidone-iodine ointment at the exit site until it is healed hasbeen advocated (37) The use of a transparent dressingocclusive dressing has been indicated as a risk factorfor CRB (35) since it promotes skin colonization Nev-ertheless, the question as to whether it is best to usegauze or a plastic dressing remains unresolved and con-troversial (38)

Most cases of catheter associated infection occur at

a point in time distant from the time of insertion Thissuggests that factors related to pathogenesis are mostlikely to be located within the hemodialysis facility Itappears that bacterial colonization plays an importantrole Colonization of the patient’s nares, the patient’sskin, and the catheter hub have been examined Zi-makoff et al (39) found that catheter-related staphy-lococcal infection occurred most often in patients who

Table 5 Protocol for Catheter Care in the

Hemodialysis Facility

1 Wrap the catheter caps with povidone-iodine solution

soaked gauze for 5 min prior to removal of caps

2 Patient and nurse must weak a mask

3 Nurse handling hubs of catheter must wear a fresh pair

of disposable gloves

4 After removing caps, wipe the hubs with a fresh

povidone-iodine pledget

5 Connect the catheter immediately

6 Repeat this procedure when the catheter is disconnected

from the blood lines at the end of the dialysis treatment

or any time that catheter manipulation is necessary

7 Never permit catheter hubs to remain open to the air

had nasal colonization, and in more than half of the

cases it was with the same strain Nasal carriage can

be eliminated (40), but it is not permanent Continuous

treatment is necessary Additionally, there is very little

evidence to suggest that elimination of nasal

coloni-zation has a beneficial effect on the incidence of

cath-eter infection

Skin colonization was found by Moro et al (36) to

be present in 16.2% of patients undergoing central

ve-nous catheterization They concluded that this was the

source of infection in 56% of their cases, but most of

these were localized to the exit site Catheter hub

col-onization was less frequent (3.5%) but was responsible

for systemic infections more frequently When systemic

infection was considered, the risk associated with hub

colonization was substantially higher than that

associ-ated with skin colonization

The strategy applied in the hemodialysis facility

should be to minimize the effects of bacterial

coloni-zation by minimizing the chances of exposure to these

sources of potential contamination The catheter hub

must be protected Table 5 lists a suggested protocol

for the prevention of catheter-related infection When

this protocol was instituted in our hemodialysis facility,

we observed a decrease in the CRB rate from 1 every

123 catheter days to 1 every 345 catheter days

(unpub-lished data)

d Treatment of Infection

Infection associated with TCCs can be classified into

three categories: exit site infection, tunnel infection,

and catheter-related bacteremia (CRB) The therapeutic

approach to each of these is somewhat different

Exit Site Infection This is defined as infection

lo-calized to the catheter exit site It is characterized by

localized redness, crusting, and exudate If the patienthas systemic symptoms and a positive blood culture,the case should be managed as for CRB below An exitsite infection is a local infection and should be treatedwith local measures (41) Since the great majority ofthese are staphylococcal, mupirocin (Bactraban,SmithKline Beecham, Inc.) generally works well Sys-temic antibiotics are necessary only in more severecases characterized by worsening of the local signs ofinflammation and the appearance of increasing amounts

of drainage Cases that fail to respond quickly to localmeasures may necessitate catheter removal Patientswith exit site infection should be monitored for the de-velopment of tunnel infection or systemic symptomssuggesting the appearance of a CRB

Tunnel Infection A tunnel infection is defined asinfection within the catheter tunnel above the Dacroncuff Involvement of the tunnel below the cuff is com-monly seen as part of the exit site infection When thetunnel is infected above the cuff, it is a serious problembecause the catheter moves back and forth within thisportion of the tunnel and there is direct communicationwith the blood stream Appropriate treatment consists

of parenteral antibiotics according to culture results andcatheter removal The catheter should not be immedi-ately replaced at this site

Catheter-Related Bacteremia When a TCC patientpresents with a positive blood culture, immediate andprolonged antibiotic treatment is essential The antibi-otic used must be based upon culture and sensitivitydata The empiric use of vancomycin should be avoidedbecause of the risk of inducing vancomycin-resistant

Enterococcus Antibiotic therapy should be continued

for a minimum of 3 weeks Blood cultures should berepeated a week following therapy to assure that theinfection has been eradicated Routine evaluation forvalvular vegetations by echocardiography should beconsidered Appropriate management of the cathetermust also be addressed There are several choices:leave the catheter in, change the catheter over a guide-wire, change the catheter over a guidewire with a newtunnel and exit site, remove the catheter and delay re-placement until the infection has been treated Thereare several issues that affect this choice

The presence of a biofilm on the surface of the eter may play an important role in catheter-related sep-sis (42,43) Bacteria adhere and become embedded inthe glycocalyx of the biofilm making them more resis-tant to antibiotics than those floating in the circulation(42,44) Passerini et al (43) demonstrated the presence

cath-of a biofilm on the surface cath-of 100% cath-of the central

venous catheters removed from 26 ICU patients Some

of these catheters had been in place for only 1 day

Bacteria were demonstrated within 88% of these

biofilms

From a purely infectious disease viewpoint, removal

of the catheter appears to be important (45,46), and

where possible this course of action should be

fol-lowed However, in the dialysis patient the issue is

complicated by the fact that patient must continue to

receive dialysis treatments Removal of the catheter

creates a requirement for the use of temporary catheters

and the risk of their associated complications It

man-dates multiple procedures, a period of hospitalization,

and increased costs Additionally, removal of the

cath-eter may be associated with a loss of the central venous

entry site Saltissi and Macfarlane (47) suggested

treat-ing the patient with the catheter in place However, in

an attempt to treat catheter-related bacteremia with the

catheter in place, Marr et al (48) observed a failure

rate of 68% even with prolonged antimicrobial therapy

Their study suggests that this approach should not be

considered as a therapeutic option

Unfortunately, when the catheter is removed, the

en-try site may be permanently lost Replacement may

ne-cessitate using an alternative venous site that is less

desirable

Central venous stenosis, an occurrence that can

ren-der the extremity virtually unusable for a permanent

vascular access, is well known (49) Many patients

with catheter-related sepsis have no external evidence

of infection or inflammation In these patients, there is

no local indication for risking the loss of the site

Sev-eral studies have recommended treating infection

as-sociated with short-term, nontunneled central venous

catheters by changing the catheter over a guidewire

un-der antibiotic coverage (50–53) Carlisle et al (54) and

Shaffer (31) demonstrated that hemodialysis

catheter-related sepsis in the absence of exit site or tunnel

in-fection could be managed successfully by guidewire

catheter exchange and antimicrobial coverage In a

se-ries of 46 patients with minimal symptoms and no exit

site infection, we have observed an 86% cure rate for

CRB treated by catheter exchange over a guidewire

24–48 hours after initiation of antibiotics followed by

3 weeks of continued antibiotic treatment

In patients who have exit site infections, the catheter

must be removed and a new tunnel and exit site must

be created when it is replaced In patients who are ill

with severe symptoms of sepsis, there is no choice but

to remove the catheter and leave it out until the patient

has been treated To do otherwise exposes the patient

The right internal jugular is the preferred initial cess site for catheter placement The second choice forplacement of a catheter is not at all clear It appearsthat the left internal jugular is a very poor access site.For the catheter to reach the right atrium it must tra-verse two curves, in contrast to the single curve re-quired of the subclavian catheter Not only does a cath-eter in this position risk stenosis, it also has a highermalfunction rate (4) If the epsilateral arm is to never

ac-be used for a permanent vascular access, the subclavian

is a better choice for catheter placement than the leftinternal jugular

6 Tunneled Cuffed Catheters VersusTemporary Catheters

Noncuffed, double-lumen catheters are frequently used

by nephrologists as a temporary vascular access Thesecatheters are suitable for bedside insertion and providemarginally acceptable blood flow rates (250 mL/min)for short-term dialysis When compared to TCCs, thesecatheters have a higher incidence of infection, higherincidence of loss of function, and higher incidence ofdislodgement It is recommended that their use be lim-ited to no more than 3 weeks and if placed in the fem-oral vein, their use should be limited to no more than

5 days (60) When everything is taken into account, theonly advantage that the noncuffed temporary catheterpossesses is that it can be inserted at the bedside

7 Tunneled Cuffed Catheters Versus PeripheralVascular Access

Tunneled cuffed catheters are relatively high-resistancedevices and therefore have a restricted ability to pro-vide adequate flow for efficient dialysis in comparison

to when peripheral vascular access is used (PBG orAVF) Resistance to flow is inversely proportional tocatheter diameter raised to the fourth power and di-

Table 6 Complications ofProsthetic Bridge Grafts

Venous stenosisThrombosisInfectionPseudoaneurysmIschemia

rectly related to its length For this reason catheters

should be selected that have the greatest available

di-ameter and the shortest length compatible with proper

tip placement In this regard, it is interesting to note

that a 19% increase in catheter diameter will

compen-sate for a doubling of length

Because resistance to pumped blood flow is

gener-ally higher, prepump pressures are likely to be lower

when catheters are used for access Low prepump

pres-sures can cause partial collapse of the blood line pump

segment, rendering the pump flow meter of the dialysis

machine highly inaccurate as a measure of dialyzer

blood flow To prevent this from creating an error in

the dialysis prescription, prepump pressures should not

be allowed to fall below ⫺200 to ⫺250 mmHg

Under ordinary circumstances, there is little or no

recirculation when arterial and venous catheter ports

are connected normally and the catheter tip is

posi-tioned correctly If the catheter tip is located in the

superior vena cava or higher, it is possible to get some

recirculation (5–10%) since the blood flow is not

con-tinuous in the central veins in many patients When

radiographic contrast media is injected into the

subcla-vian, it is frequently seen to move forward very slowly

in a back-and-forth fashion synchronous with the

car-diac cycle This pattern of flow is conducive to some

degree of recirculation if the catheter tip is in this

lo-cation When arterial and venous lines are reversed,

recirculation may vary from 4 to 10% Femoral

cath-eters frequently recirculate This is especially true with

shorter catheters A femoral catheter should be more

than 19 cm in length (60)

Cardiopulmonary recirculation occurs when a

pe-ripheral vascular access is used (PBG or AVF) This is

caused by dialyzed blood recirculating through the path

of least resistance back to the dialyzer

Cardiopulmo-nary recirculation accounts for approximately 30% of

postdialysis BUN rebound in patients dialyzed with

pe-ripheral A-V access devices and can reduce urea

clear-ance up to 10% This phenomenon is absent when

cath-eters are used for access unless a peripheral vascular

access is also present Clearance is therefore slightly

enhanced with a catheter, and blood flow need not be

as high to achieve the same clearance in a comparable

patient Adjustments for cardiopulmonary recirculation

are not required for catheters

The development of the polytetrafluoroethylene (PTFE)

prosthetic bridge graft (PBG) 21 years ago (61) made

it possible to provide chronic hemodialysis to virtuallyany patient Unfortunately, these grafts are particularlyprone to problems, especially venous stenosis andthrombosis These problems occur at a rate of approx-imately 1–1.5 times per patient per year (62) Cumu-lative patency rates for PBGs in most centers are only55–75% as one year and 50–60% at 2 years (62–67).The major complications seen in association with thePBG are shown in Table 6

The most common complications associated with thePBG are venous stenosis and thrombosis In most casesthese two problems share the relationship of diseaseand symptom Venous stenosis results in problems thathave the net effect of inadequate dialysis, loss of PBGs,and frustration for patients, nephrologist, and the staff

of the dialysis unit For all of these reasons, it hasbeen recommended that venous stenosis be activelyscreened for and treated prospectively (68)

1 Nature of Venous Stenosis LesionStenosis occurs most frequently at the venous anasta-mosis but may occur anywhere within the system com-posed of the PBG, the anastamosis, and its drainingveins, both peripheral and central In a review of 536cases of venous stenosis (69), the following distribution

of lesions was reported: venous anastamosis 58.4%, ripheral veins 48.2%, central veins 5%, within the graft27.8%, and multiple locations 33.2%

pe-2 Screening for Venous Stenosis

It is important that all hemodialysis facilities have inplace a system designed to detect venous stenosis sothat it can be diagnosed and treated prospectively (68).Monitoring should be performed at intervals of 1month or less The best method to assess the PBG forvenous stenosis is an angiogram However, this is notpractical as a screening test The nephrologist must relyupon less direct techniques for this purpose Several

Table 7 Screening Techniques for Venous Stenosis

Primary techniques

Dynamic venous pressure

Static venous pressure

Prolonged bleeding post-treatment

Difficulty with needle placement

Pain in access arm or hand

Recirculation

Unexplained decreases in URR or Kt/V

Doppler ultrasound imaging

approaches to the screening for venous stenosis have

been advocated As shown in Table 7, these techniques

have been divided into primary and supplemental

categories

a Monitoring Venous Pressure on Dialysis

For many years it has been recognized that an elevation

of the venous pressure measured on dialysis (VPm) was

indicative of venous outflow stenosis (70) Schwab et

al (71) and Beathard (69) demonstrated that VPm

could be utilized as a diagnostic test if it was

stan-dardized by measurement early in dialysis at a low

blood flow (200 mL/min) This measurement is referred

to as the dynamic venous pressure (dynamic VPm) An

elevation of 150 mmHg or greater is considered to be

significant Because there are other factors that can

af-fect this measurement, single measurements are not

re-liable The pattern observed over time is important, and

it is essential that elevation be persistent for it to be of

predictive value (69) These measurements are not

re-liable in cases of stenosis within the graft Measuring

dynamic VPm is the easiest method for monitoring

ve-nous pressure

Approximately 75% of the pressure measured under

dynamic conditions is related to factors external to the

graft, i.e., the needle and tubing Even when measured

under standardized conditions, dynamic VPm is higher

than the actual intra-access pressure as measured by an

external pressure transducer at zero blood flow (72,73)

Besarab et al (73) have shown that, although more

difficult to do, the measurement of static VPm is perior to the dynamic measurement as a screening toolfor the diagnosis of venous stenosis For this measure-ment, the blood pump is turned off and the blood linebetween the blood pump and the prepump pressuremonitor is clamped The pressure is then read from theprepump pressure monitor An offset factor to compen-sate for the difference in heights of the access and pres-sure transducer is added The value obtained is divided

su-by the patient’s systolic pressure to obtain a ratio Aratio greater than 0.5 is considered to be abnormal

b Monitoring Intra-access Flow

Venous stenosis causes increased resistance that results

in decreased flow leading to thrombosis The ment of intra-access blood flow appears to be the bestpredictor of incipient thrombosis All of the other tech-niques used for screening represent attempts to deter-mine decreased flow secondary to increased resistance

measure-by indirect means A direct measurement of flow viates the need for other modalities May et al (74)measured flow prospectively in a cohort of 172 patientswith PTFE grafts and found an average flow of 1134mL/min Using this as the reference access blood flow,they observed a relative risk for graft thrombosis of1.23 at a blood flow of 950 mL/min, 1.67 at 650 mL/min, and 2.39 at 300 mL/min Intra-access flow can beperformed by either Doppler ultrasound (75,76) or ul-trasound (77,78) Doppler ultrasound is operator de-pendent and is prohibitively expensive for routinescreening assessments Currently, ultrasound measure-ment requires specialized devices that are cumbersome

ob-to operate and require excessive time Although themeasurement of intra-access blood flow looks verypromising, it is not yet suitable for routine screening

in most dialysis facilities (68) As the technology proves this will change

im-c Measurement of Recirculation

Percent recirculation refers to the amount of dialyzedblood that is rewithdrawn from the access for repeateddialysis without entering the central pool This occurswhen there is retrograde flow from the venous needle

to the arterial needle during dialysis It results whenthe access inflow is not sufficient to meet the demands

of the blood pump The measurement of dialysis accessrecirculation has been advocated as a guide to detectingvenous stenosis (79,80) There are three methods formeasuring recirculation: the three-needle method, thestop flow or slow flow method, and the dilutionmethod Each of these gives a different answer The

Table 8 Protocol for Urea-Based Measurement

of Recirculation

1 Draw arterial (A) and venous (V) line samples

2 Immediately reduce blood flow rate (BFR) to 120 mL/

min

3 Turn blood pump off exactly 10 sec after reducing BFR

4 Clamp arterial line immediately above sampling port

5 Draw systemic arterial sample (S) from arterial line

port

6 Unclamp line and resume dialysis

7 Measure BUN in A, V, and S samples and calculate

percent recirculation (R)

three-needle technique using arterial, venous, and

sys-temic samples with peripheral venous blood used for

the systemic sample is grossly inaccurate and should

be abandoned (81) The peripheral venous BUN

ex-ceeds that in arterial blood as a result of arteriovenous

disequilibrium due to cardiopulmonary recirculation

(82–85) and venovenous disequilibrium secondary to

regional blood flow inequalities (86–88)

The stop flow or slow flow technique (89), in which

arterial, venous, and a second arterial sample obtained

30 seconds after the blood pump has been slowed or

stopped, also gives erroneous results This is due to the

variability in urea measurement (90) and to the

30-second delay in sampling after slowing or stopping the

blood pump The BUN in the arterial line blood will

begin to rebound within about 15 seconds of slowing

or stopping dialysis If the third blood sample

(sys-temic) is drawn from the arterial ports exactly 10

sec-onds after the blood flow is abruptly reduced to 120

mL/min (Table 8), a valid test can be obtained (81)

The normal values obtained with this technique are⫺5

to ⫹5%, with an average of 0% Recirculation values

that are 10% or greater should be investigated

The dilutional method for measuring recirculation

avoids the problem of cardiopulmonary recirculation

and is the most accurate of the three approaches When

this method is applied, recirculation should be 0% in a

properly cannulated, well-functioning PBG

Recircu-lation values that are 5% or greater should be

investi-gated (81) Although it is more accurate, its utility is

compromised by the fact that special devices are

re-quired

Actually, recirculation measurement has poor

pre-dictive power for the diagnosis of venous stenosis in

PBGs (73,74) It is much better in AVFs The reason

for this relate to the fact when the flow in a PBG drops

below 600–700 mL/min, it is at a substantial risk for

thrombosis (74,91–95) Recirculation does not occuruntil flow is less than the blood pump rate In otherwords, as venous stenosis causes a decrease in flow,thrombosis generally occurs before recirculation

d Clinical Parameters

Rather than rely on a single screening test, some havefelt that a more broad-based approach to screening ofdialysis patients for venous stenosis was appropriate.This has involved using the combination of a group ofclinical indicators and a physical examination of thePBG to determine the need for an angiogram (96–99).These clinical indicators have included swelling of theaccess arm (central vein stenosis), frequent clotting ofthe access, prolonged bleeding from the needle sitesposttreatment (high venous pressure), difficulty withneedle placement (intra-access stenosis), and pain inthe access arm or hand (with heparin injection—ret-rograde flow into artery) In examining the PBG andarm above the PBG, careful attention should be paid

to the presence and location of thrills, the tics of bruit, and the nature of the pulse In a retro-spective study of 328 angiograms performed afterscreening the patients using these criteria (96), Be-athard found a 91.7% incidence of significant venousstenosis (>50%) In their study Safa et al (99) foundabnormal physical examination findings to be the mostcommon sole indicator of graft dysfunction This ap-proach is inexpensive, easily performed, noninvasive,and reliable

characteris-3 Selection of Cases for TreatmentBecause of the frequency and the recurrent nature ofvenous stenosis, some standard must be applied to de-termine when a case should be treated It seems rea-sonable at this point in our knowledge to use 50% orgreater stenosis plus evidence of a clinical or physio-logical abnormality, e.g., elevated venous pressure ordecreased flow this standard (100) An exception to thisprinciple might be applied in the case of the throm-bosed PBG Any stenosis found at the time of throm-bosis should be considered as a candidate for treatment

4 Treatment of Venous StenosisThe preferred method of treatment has not been estab-lished There are two choices: surgical revision andpercutaneous angioplasty The choice of therapeuticmodality should depend upon the expertise of the treat-ment facility (100)

Fig 2 Venous stenosis: The venous anastomosis is edly narrowed.

mark-a Surgical Therapy

There are no good reports concerning the systematic,

prospective treatment of venous stenosis by surgical

means Evaluation of 84 cases of surgical graft revision

in the absence of thrombosis at our institution revealed

a primary (unassisted) patency of 81% at 1 month, 56%

at 3 months, 41% at 6 months, and 23% at 1 year by

life table analysis (unpublished data)

There are certain problems that are intrinsic to

sur-gical therapy It is invasive, creates a risk of infection,

and the blood loss associated with the procedure may

be significant (101) Temporary vascular access with

all of its associated complications is frequently

re-quired This may be because of postoperative swelling

of the arm or the need to replace the PBG and the

necessity of avoiding its use during a maturation period

(102)

Many patients require hospitalization in association

with surgical therapy for access dysfunction (103)

Sur-gical therapy of venous stenosis also results in the loss

of potential vascular access sites Nevertheless, surgery

offers the most definitive treatment for this problem

b Percutaneous Angioplasty

In recent years, angioplasty has developed into a

rea-sonable alternative to surgical therapy for venous

ste-nosis affecting PBGs This is undoubtedly due to an

increased awareness of the problem and its

conse-quences, but also due to the fact that it has been shown

to be a safe, effective, and easily performed procedure

(69,104–106) Percutaneous angioplasty treatment of

venous stenosis affecting the PBG is an outpatient

pro-cedure that does not prohibit the immediate use of the

access for dialysis Lesions in all locations within the

PBG and its draining veins, both peripheral (Figs 2,

3) and central, can be easily, effectively, and safely

treated (69)

Initial success rates for angioplasty therapy of

ve-nous stenosis in this setting have ranged from 80 to

94% (69,105–107) The highest rate of technical

fail-ure has occurred in the treatment of central lesions

Long-term success rates have ranged from 41 to 76%

at 6 months and 31 to 45% at one year (69,105–109)

Treatment of central lesions has been met with poor

long-term success In a series of 50 cases of central

vein stenosis, a 6-month patency of only 25.4% was

reported (96) Lumsden et al (110) attempted to do a

prospective randomized study comparing the results of

angioplasty with no treatment in a group of 64 patients

with 50% or greater stenosis They reported no

differ-ences in patency rates between the two groups,

how-ever, 53% of their treatment group had central vein incontrast to only a 22% incidence in the control group.This divergence between the two groups makes theirresults impossible to interpret Since venous stenosislesions tend to recur, repeat therapy plays an importantrole in their management Initial and long-term successrates for repeat treatments have been identical to thosewith the primary treatment (69)

5 Benefits of Prospective Treatment ofVenous Stenosis

The prospective treatment of venous stenosis hasproven to be cost effective because it decreases theincidence of thrombosis and preserves the life of thePBG (71–73,108,109) In one facility, a program toprospectively identify and treat venous stenosis re-sulted in a fall in thrombosis rate from 0.58 per patientper year to 0.19 per patient per year (73) and in anotherfrom 0.48 to 0.17 (99) Since all of the methods forscreening are aimed at the early detection of access-

Fig 3 Postangioplasty: This is the graft as shown in Fig.

2; the stenotic lesion has been treated with angioplasty

related stenoses, prospective detection and treatment

will not prevent thrombosis that is not related to

stenosis

An inescapable relationship exists between the use of

a PBG as a dialysis access and thrombosis When this

occurs there are two choices for therapy—surgical and

percutaneous Two prospective randomized trials have

been reported in which thrombolysis was compared

with surgical therapy (111,112), both of which

con-cluded that surgical therapy was superior to

thrombol-ysis However, in one the initial success rate for

throm-bolysis was only 67% and in the other it was 72%

Reports in which such low initial success rates for

thrombolysis were obtained must raise questions

con-cerning the performance of the procedure At this time

no conclusions concerning the superiority of either of

these therapeutic modalities can be made The choice

of therapy should be based on the expertise of the localfacility (113) Regardless of the choice of therapeuticmodality, it is essential that treatment be provided asquickly as possible in order to avoid the use of tem-porary catheters Every attempt should be made to pro-vide treatment as an outpatient under local anesthesia.Venous stenosis must be treated and the access must

be evaluated angiographically for residual stenosisposttreatment It is important, regardless of the treat-ment modality used, that any abnormal monitoring testsused to screen for venous stenosis return to normal fol-lowing the treatment of a thrombosed PBG (113)

1 Surgical TherapyUntil recently surgical therapy has been the standardtreatment for a patient with a thrombosed PBG Thistherapy consists of either thrombectomy alone, throm-bectomy with graft revision, or graft replacement Inmost cases thrombectomy alone is inadequate therapybecause it ignores venous stenosis, which is generallypresent (114)

Long-term patency rates for thrombectomy alonewithout revision are not well defined In one report(115) the values obtained were: one month—64%; 2months—37%; 3 months—29%; 6 months—15%;and one year—5% In the same series long-term pa-tency rates for thrombectomy with revision were: 68%

at one month; 56% at 2 months; 51% at 3 months; 33%

at 6 months; and 14% at one year The values for graftreplacement performed following thrombosis were: onemonth—69%; 2 months—55%; 3 months—45%; 6months—34%; and one year—17%

The type of surgical revision performed varies cording to the location and character of the stenoticlesion If the stenosis is at the anastamosis and short,

ac-a pac-atch ac-angioplac-asty using ac-an ovac-al-shac-aped piece ofPTFE is affected If the lesion is longer, extending upthe vein, a jump graft to an area beyond the stenosis

or to an alternative vein is performed The same type

of procedure is done if the lesion is more proximally(upstream) located (101) Graft revision always results

in the loss of at least a small portion of vein Centralvenous lesions are difficult to treat surgically (49) Abypass across the shoulder from the access graft or thecephalic vein to the ipsilateral internal jugular has beenused successfully (116)

2 Percutaneous TherapyAlthough several mechanical devices are available, theterm percutaneous therapy is generally used to refer tothrombolysis Three lytic agents have been used for

thrombolysis in association with PBGs: streptokinase,

urokinase, and tissue plasminogen activator

Strepto-kinase is an unsatisfactory agent for this purpose

be-cause it is associated with an erratic response, drug

resistance, and allergic reactions (117,118) Even

though tissue plasminogen has been used with success

(119,120), its high cost and the fact that better results

have been reported using less expensive alternatives

(119,121) should eliminate it from consideration

Uro-kinase is the agent of choice

Thrombolysis as applied to PBGs can be divided

into three types: pharmacological,

pharmacomechani-cal, and mechanical

a Pharmacological Thrombolysis

Pharmacological thrombolysis (PT) refers to thrombus

dissolution using only the effects of a fibrinolytic

en-zyme Lytic enzymes that have been used include

strep-tokinase (117,122,124,125), tissue plasminogen

acti-vator (119,120), and urokinase (123,126–128) The

lytic agent has been given as a continuous infusion

(117,126,128), an initial bolus injection followed by a

continuous infusion (123,124), and as intermittent

in-jections (125,127) Treatment times have ranged from

2 to 72 hours The patients have generally been

ad-mitted to the intensive care unit The rate of success

has varied from a low of 14.3% (124) to a high of

100% (126) Complication rates have ranged from none

to 85.7% Although most of these complications have

been local due to bleeding at needle puncture sites,

some have been more serious In one report, 6.3% of

the patients experienced an embolus to the peripheral

artery (122), and in another 12% of the cases required

blood transfusions (128) Because of the large doses of

enzyme used, systemic fibrinogen depletion has been

routinely seen PT is unsatisfactory as a treatment for

thrombosed PBGs and should not be used

b Pharmacomechanical Thrombolysis

Pharmacomechanical thrombolysis (PTA) is composed

of two phases The first is pharmacological, consisting

of enzymatic lysis The second phase involves

me-chanical maceration and removal of the residual clot

In the initial attempts at PMT, referred to as

lacing-maceration (129,130), highly concentrated urokinase

was injected through two hook-shaped catheters as they

were rotated and withdrawn through the clotted graft

This was combined with angiographic evaluation of the

graft-vein circuit and angioplasty of any stenotic lesion

that was found Using this method, Valji et al (129)

reported 96% success with only a 3% rate of minor

complications They were able to accomplish lysiswithin a mean time of 86 minutes

Subsequently these investigators adopted a cation of their technique that they referred to as thepulse-spray method of PMT (119,129,131) This util-izes a catheter design that produces a penetrating spray

modifi-of concentrated enzyme The spray produced by thiscatheter macerates the clot and increases its contactarea with the lytic agent while simultaneously treatingthe entire length of the graft The proponents of PMTuse a combined approach consisting of angiography tovisualize the graft and draining veins, thrombolysis bypulse-spraying concentrated urokinase, and angioplasty

to macerate residual thrombus and dilate any venousstenosis that is present In this manner diagnosis andtreatment of the stenosis and treatment of the throm-bosis are combined into a single procedure Valji et al.(132) reported a series of 284 cases treated using thistechnique with a success rate of 92% A mean time of

67 minutes was required for the procedure in this ries Long-term primary patency following PMT hasbeen in the range of 68% at one month and 26% at oneyear (129) The quickness, safety, and effectiveness ofPMT make it attractive as a nonsurgical means of re-storing function to a PBG

se-c Mechanical Thrombolysis

Several investigators (121,133,134) have questionedwhether the pharmacological component of pharma-comechanical thrombolysis is necessary to safely rees-tablish flow in a thrombosed PBG This gave rise to atechnique that has come to be referred to as mechanicalthrombolysis (MT) The technique is actually more ac-curately referred to as percutaneous endovascularthrombectomy No lytic enzyme is used with this tech-nique; only mechanical means are applied to restoreflow to the thrombosed PBG

In a prospective randomized trial comparing MT andPMT (121), the initial success rate, complication rate,and long-term patency of treated PBGs were statisti-cally the same for the two techniques and were com-parable to those reported by others for PMT (119,129).The type of MT used in this study consists of angi-ography to visualize the PBG and draining veins, clotmaceration by pulse-spraying heparinized saline, fol-lowed by endovascular thrombectomy with an embo-lectomy catheter and angioplasty to macerate residualthrombus and dilate any venous stenosis that is present

In this manner diagnosis and treatment of the stenosisand treatment of the thrombosis are combined into asingle procedure as with PMT

When compared with surgical treatment of the

thrombosed PBG (25), the initial failure rates for MT

and surgery were the same Long-term primary patency

for grafts treated by MT was superior to that for

sur-gical thrombectomy and comparable to those for

thrombectomy-revision and graft replacement In a

se-ries of 1176 cases treated with mechanical

thrombo-lysis (114), an initial success rate of 96% was obtained

The primary patency at 3 months was 52% and was

39% at 6 months Other investigators (133–135) have

applied their own variations of mechanical

thrombol-ysis to the problem of the thrombosed PBG with

equally satisfactory results

d Mechanical Devices

A number of mechanical devices that macerate or

re-move thrombus have been developed and are currently

being investigated (136–138) While these devices in

general are effective, their cost is a major detraction

since the simpler methods have such a high success

rate and have proven to be safe

e Pulmonary Embolization with Thrombolysis

Concern has been expressed that pulmonary emboli,

even though relatively small, could represent a risk to

the patient undergoing MT (139) Even though the

long-term effects of recurrent treatment are not known,

this immediate fear has not been realized No instance

in which clinical signs or symptoms suggest acute

pul-monary embolization has been encountered in MT

studies (114,121,133–135) Beathard et al (114)

re-ported finding multiple small perfusion defects in five

of six patients undergoing lung scans These cleared by

2 weeks with no adverse sequelae The occurrence of

small emboli is not unique to MT These occur with

removal of central venous catheters, percutaneous

cath-eter stripping (26,29), surgical thrombectomy of dialysis

access (133), and pharmacological thrombolysis

(123,127) Two fatalities have been described in a cohort

of 31 patients treated by Swan et al (140) using the

PMT technique The intervals between the procedures

and the death of the patients were 2 and 4 days Both

patients had co-morbid conditions These occurrences

are difficult to explain in view of the nature and volume

of clot associated with a thrombosed PBG The occluded

PBG contains two types of thrombus, a firm arterial

plug, and soft, friable thrombus that disintegrates easily

Most of the thrombus is of the latter type The arterial

plug consists of firm, laminated, organizing thrombus It

is resistant to enzyme lysis and embolizes to the lung

regardless of the technique used for percutaneous

ther-apy The total thrombus volume removed from an cluded PBG at the time of surgical thrombectomy hasbeen shown to average only 3.2 mL (141,142)

oc-3 Comparison Between Percutaneous Therapyand Surgery

In comparing these two approaches—percutaneous andsurgical—several parameters should be considered.These include risk to the patient (e.g., pain, infection,blood loss), complications of therapy, timeliness (e.g.,how quickly the patient can be returned to dialysis),effectiveness (e.g., initial success rate and duration ofpatency posttherapy), and economic factors Since it is

a percutaneous technique, thrombolysis is associatedwith less patient discomfort, risk of infection, andblood loss than is involved with a surgical thrombec-tomy Surgical therapy is associated with very fewcomplications during the procedure, however, this isalso true for thrombolysis—both are relatively safe.Basically the timeliness with which any procedurecan be accomplished is dependent upon the availability

of the operator and the facility (143) For this reasonthere is great value in having a dedicated laboratory formanaging vascular access problems Unfortunately,when dialysis patients with clotted grafts are forced tocompete for facility space and operator time in eithersurgery or radiology, treatments are frequently delayedand missed unless central venous catheters are used Insome centers delay and hospitalization are routine.The effectiveness of endovascular procedures must

be evaluated from two viewpoints: immediate and longterm Immediate effectiveness relates to both the op-erators’ ability to remove the thrombus and their ability

to deal with any anatomical lesions that are present.Long-term effectiveness, or long-term patency, relates

to the management of anatomy lesions (i.e., venous nosis) The various thrombolysis techniques are asso-ciated with immediate success rates in order of 90–95% Immediate surgical failure rates, defined as theneed to replace the graft, have been reported to be 6.9%(121) and 18% (112) In a study that compared theimmediate success rate for 537 cases of thrombosedaccess graft treated surgically with the results obtained

ste-in 473 cases treated by MT, no statistically significantdifference was seen (115)

Data on long-term patency following surgical bectomy are difficult to find In one study (115) se-quential data were collected comparing surgical ther-apy with MT therapy In 380 cases treated with onlysurgical thrombectomy, primary (unassisted) patencyrates of 64% at one month, 29% at 3 months, 15% at

throm-6 months, and 5% at 1 year were reported Primary

(unassisted) patency rates for MT were 66% at 1

month, 44% at 3 months, 31% at 6 months, and 10%

at one year The differences between surgery and

thrombolysis were highly significant statistically In the

same study, when long-term primary patency rates for

graft revision or for graft replacement used to treat

thrombosed grafts were compared to that for MT, no

statistically significant difference was seen

The surgical treatment of venous stenosis always

re-sults in a loss of vein to some degree Since venous

stenosis is a recurrent condition, this loss leads to a

progressive depletion of potential access sites The type

of surgical revision performed varies according to the

location and character of the stenotic lesion Regardless

of the procedure used there is always some loss of vein

In reviewing a series of 282 episodes of graft

throm-bosis, Raju (144) reported that some type of revision

was performed in two thirds of the cases In another

series (115), 21.8% of the cases required a graft

revi-sion and in 6.8% of the access was replaced with a

new graft All of these resulted in venous losses It must

be noted that when a thrombosed access graft is treated

surgically by simple thrombectomy, without graft

re-vision or replacement, it has a 90–95% chance of being

inadequate therapy since that is the frequency of

ve-nous stenosis

Economic factors are important in any therapeutic

consideration Reliable cost figures for surgery and

en-dovascular therapy are difficult to obtain, and there are

significant regional differences Sands et al (145)

re-ported charge figures of $6,802 (n = 71) for

thrombo-lysis compared to $12,740 (n = 75) for surgical

throm-bectomy Vesely et al (146) discovered charges of

$6,062 (n = 10) for thrombolysis and $5,580 (n = 10)

for surgery in their institution When Marston et al

(112) reviewed their cost data, they found that

throm-bolysis charges ranged from $3,104 to $11,646 (n =

15) and surgical treatment ranged from $6,711 to

$11,430 (n = 15) They concluded that there were no

significant differences between the two, but their data

suggest at least the potential for performing

thrombo-lysis more economically than surgery Additionally,

thrombolysis is an outpatient procedure It is rare for

the patient to require admission In many centers,

pa-tients having surgical treatment for a thrombosed graft

are routinely admitted This adds considerably to the

cost of management Delayed and missed treatments

also have an economic effect on the dialysis facility

Any procedure that will minimize this problem will

have a positive economic effect The costs of large

quantities of urokinase and the price of a mechanical

device must also be added to the equation when a parison is made between techniques that utilize theseitems and surgery

Infection of the PBG is a serious complication It hasbeen reported to account for 20% of all dialysis accesscomplications (147) and to be the second leading cause

of graft loss Infection has been reported to occur at afrequency of 1.3 episodes per 100 dialysis-months and

to be associated with bacteremia at a rate of 0.7 cases

per 100 dialysis-months (148) S aureus is the most

common organism involved The personal hygiene ofthe patient appears to be the most important risk factorfor the development of access-related infection (149).Therefore, hemodialysis patients with poor personalhygiene habits should be given special attention.Cannulation of an access site places the hemodial-ysis patient at risk for infection via bacterial contami-nation At times an episode of infection can be traced

to an individual member of the dialysis facility staffand to be related to poor needle-insertion technique(150) This underscores the importance of staff training

in infection-control measures Dialysis staff shouldcomply with OSHA regulations, including hand wash-ing and use of clean gloves during needle cannulation.Washing the access site with soap and water will de-crease the skin microflora that can be introduced in-advertently into the blood stream during needle can-nulation (148,149) The skin should be further cleansedwith either 70% alcohol or 10% povidone iodine im-mediately prior to cannulation (151)

When infected, a PBG must be treated aggressively

An untreated access infection can lead to bacteremia,sepsis, hemorrhage, and even death (152,153) Al-though a superficial infection that does not involve thegraft directly may respond to antibiotic therapy alone,effective treatment generally requires both antibioticand surgical therapy (154,155)

Localized infection should be treated with ate antibiotics based on culture results and by localizedresection of the infected portion of the PBG Extensiveinfection may require total resection of the graft In-fection of a newly placed PBG should be treated withantibiotics and removal of the PBG, regardless of theextent of the infection (155)

When inserted into a PBG, the dialysis needle creates

a defect that will seal but does not heal (156,157)

De-generative changes occur within the PBG and the

ov-erlying skin with long-term use or, more often, with

repetitive use in the same spot This can result in

pseu-doaneurysm formation, a situation in which there is an

enlarged area overlying a defect in the PBG Insertion

of dialysis needles into a pseudoaneurysm may result

in prolonged bleeding following needle withdrawal and

should be avoided With progressive enlargement, a

pseudoaneurysm can eventually compromise

circula-tion to the skin covering the PBG and may ultimately

lead to rupture and severe hemorrhage Large

pseudo-aneurysms can also prevent access to the adjacent areas

of the PBG for needle placement, thereby limiting

po-tential puncture sites

A pseudoaneurysm is most effectively treated by

graft revision and segment interposition Delorme et al

(157) report that pseudoaneurysm formation is the

pri-mary cause of surgical removal of a PBG more than 2

years after implantation A pseudoaneurysm should be

treated surgically when (1) it exceeds twice the

diam-eter of the graft, (2) it is rapidly increasing in size, (3)

severe degenerative changes of overlying skin are

pres-ent, (4) there is risk of graft rupture due to poor eschar

formation, (5) there is evidence of spontaneous

bleed-ing, or (6) puncture sites are limited due to its size

(158,159)

1 General

When a vascular access is created in the arm, it offers

a low resistance route for blood to bypass the higher

resistance circuit of the hand This anomaly can lead

to ischemia, a serious and occasionally devastating

complication Ischemia may take one of two forms:

primary ischemia and vascular steal syndrome Primary

ischemia refers to the process that occurs secondary to

inadequate distal extremity blood flow Vascular steal

syndrome occurs when blood destined for the hand is

shunted through the graft, depriving the hand of

per-fusion Both of these problems are more likely to occur

when the radial artery is used for the graft construction

Diabetics, elderly individuals, patients with severe

pe-ripheral vascular disease, and those who have had

mul-tiple access attempts are at high risk for these

compli-cations Ischemia is most often seen early after access

construction, but it can occur at any time If not treated

promptly it can result in loss of digits, the hand, or the

extremity Severe ischemia can cause irreparable injury

to nerves within hours and should be considered a

sur-gical emergency

2 DiagnosisFor the first 24 hours the patient with a newly createdaccess should be monitored for subjective complaints

of sensations of coldness, numbness, tingling, and pairment of motor function (not limited by postopera-tive pain) Skin temperature, gross sensation, move-ment, and distal arterial pulses in comparison to thecontralateral side should also be assessed Patients with

im-an established PBG should be assessed monthly Aninterval history of distal pain or coldness during dial-ysis, decreased sensation, reduction in function, or skinchanges should be obtained Patients demonstrating ab-normalities should be further evaluated immediately(160)

Lin et al (161) reported that comparing digital ygen saturation (SaO2) in the normal arm and the ac-cess arm was helpful in identifying patients that de-veloped ischemia of their hand on dialysis Afterstudying the SaO2before and 20 minutes after the ini-tiation of dialysis using the normal arm as a control,they found that a predialysis SaO2difference of 4% ormore between the arms predicted decreased SaO2 ofthe arm with the access during hemodialysis A highpercentage of the patients with decreased SaO2 on di-alysis were symptomatic

ox-Electrophysiological detection of a conduction blockshortly after the onset of symptoms of neuropathy hasbeen reported to be early indicator of reversible ische-mic nerve injury associated with a vascular access(162) Plethysmography has been used to evaluate pa-tients for vascular steal syndrome (163) A positivefinding consists of showing a flat waveform converting

to pulsatile waveform when the proximal PBG is pressed Arteriography of the access arm will generallyidentify the nature and the extent of the vascular prob-lem and may be indicative of the appropriate therapy

com-in some cases (164)

3 TreatmentMild ischemia manifested by subjective coldness andparesthesias and objective reduction in skin tempera-ture but with no loss of sensation or motion generallyimproves with time Patients with mild ischemia shouldundergo symptom-specific therapy (e.g., wearing aglove) and frequent physical examination, with specialattention to subtle neurological changes and musclewasting Failure to improve may require surgicalintervention

Surgical intervention consists of either graft ligation,banding, or an arterial ligation-bypass procedure Withligation the access is sacrificed Banding represents an

Table 9 Complications ofNative Fistulae

Poor inflowPoor developmentIschemia

Venous stenosisThrombosisAneurysm formationInfection

attempt to increase the resistance in the vascular access

in order to force blood to circulate into the hand (165)

The arterial ligation-bypass procedure consists of two

parts: ligation of the radial artery below the origin of

the PBG and creating a bypass from the artery proximal

to the point of origin to a site distal to the point of the

ligation (166–168)

Haimov et al (168) reported a series of

hemodial-ysis patients with severe ischemia in their access

ex-tremity secondary to vascular steal syndrome In this

series of patients they compared ligation, banding, and

the arterial ligation-bypass procedure Of seven patients

who underwent ligation, five had complete resolution

of symptoms, one had persistent pain, and one patient

had residual ischemic neuropathy Of four patients who

underwent banding, three lost their access due to

thrombosis shortly after the banding procedure, and

in one patient partial resolution of symptoms was

achieved Of 23 patients who underwent arterial

liga-tion-bypass procedure, all showed immediate signs of

improvement They concluded that the arterial

ligation-bypass procedure gave results superior to either ligation

or banding

In instances in which stenotic lesions are found in

the vessel proximal to the origin of the access by

ar-teriography, either surgical treatment or percutaneous

angioplasty (164) may result in amelioration of the

problem and permit salvage of the access

FISTULA

Either a wrist (radial-cephalic) or elbow

(brachial-cephalic) autologous arteriovenous fistula (AVF)

cre-ated using the patient’s native vein provides the

best possible vascular access for hemodialysis

(62,66,67,150,169–174) Compared to the PBG, the

AVF has better long-term patency and fewer

compli-cations, including lower incidence of venous stenosis,

infection, and vascular steal syndrome Additionally,

there is lower morbidity associated with creation, and

performance (i.e.,flow) improves over time

An AVF provides superior access survival relative

to a PBG (175,176) This is true even after adjusting

for the effect of age, race, sex, diabetes, and peripheral

vascular disease on access survival The magnitude of

the benefit of the AVF is greatest among younger

tients, but the advantage of an AVF persisted for

pa-tients older than 65 years The relative risk of access

failure for a patient with an AVF, compared with a

pa-tient of the same age with a PBG, has been shown to

be 67% lower at the age of 40 years, 54% lower at theage of 50 years, and 24% lower at the age of 65 years(176)

Unfortunately the AVF does have some tages; the vein may fail to mature, a period of 1–4months must elapse following creation before the AVFcan be used, some AVFs are difficult to cannulate, andthe enlarged vein may be cosmetically unattractive(177) Taking all of this into account, however, the AVF

disadvan-is far superior to any other type of vascular access Inspite of its obvious advantage, the relative number ofAVFs being created has been decreasing Patients start-ing dialysis had a 70% greater chance of receiving aPBG instead of an AVF in 1990 than they did in 1986(178) In 1996 only 17.9% of hemodialysis patientswere using an AVF 60 days after the intiation of ther-apy (2)

The complications associated with an AVF (Table 9)are somewhat the same as for the PBG (see Table 6),however; there are several distinct differences Thesecomplications are seen with less frequency and, in gen-eral, less severity The overall complication rate forPBGs is twice as high as that for AVFs Specifically,PBGs have 6 times the rate of thrombosis and 10 timesthe rate of infection as AVFs (179)

Both blood flow and fistula development are essentialfor a successful AVF access These are separate prob-lems in one sense, but they are so closely linked thatthey must be discussed together An AVF can remainpatent in the face of relatively low blood flow (93) Foreffective dialysis, the AVF only has to deliver a bloodflow that is marginally greater than the pump rate Un-fortunately, dialysis may not be technically possible inthese cases with lower flow because the pulsatile pres-sure that is applied to the vein wall is not sufficient for

it to dilate to a size adequate for cannulation The

pres-sure necessary for fistula development is dependent

upon the inflow pressure and the upstream resistance

of the draining vein For any given flow rate, vein

en-largement will depend upon resistance In ideal

circum-stances, inflow pressure is great enough for fistula

de-velopment to occur, although the upstream resistance

is very low In less than ideal circumstances fistula

de-velopment may fail either because of low inflow

pressure, decreased upstream resistance caused by a

branching vein, or a combination of the two

Most cases of primary nonfunction are the result of

arterial abnormalities causing low flow into the vein

used to create the AVF (174) Arteries that are either

anatomically small or atherosclerotic can cause this

These problems can usually be diagnosed before

sur-gery is performed through physical examination and

other noninvasive procedures Of the two major types

of AVF, the radiocephalic and the brachiocephalic, the

former is more often associated with poor inflow (177)

The optimum venous anatomy for AVF development

is a single cephalic vein stretching from the wrist to

the antecubital space In many instances, however, this

is not the case The cephalic vein has one or several

side branches Each of these accessory veins diverts

blood flow from the main channel This has the effect

of reducing resistance and reducing blood flow to the

vein above the branch(es) This in turn reduces the

pressure on the vein wall that is essential for expansion,

dilation, and arterialization to occur Ligation of these

accessory veins will redirect flow and may promote the

development of a usable AVF (187) Retrograde flow

into distal veins of the hand can also prevent adequate

AVF maturation It can also be a harbinger of upstream

venous lesions eventually resulting in late AVF loss

This phenomenon often causes hand pain, edema, and

limitation of motion Retrograde venous flow can be

corrected by distal vein ligation (174)

Inadequate development of an AVF can also be

caused by venous abnormalities Small vein caliber

may result from poor vascular development or from

deeply imbedded vessels, especially in obesity This

sit-uation can restrict the necessary expansion, dilation,

and arterialization of the veins once the AVF is created

Vein caliber can be easily assessed before surgery by

performing a physical examination of the arm with a

tourniquet In selected cases venography (180) or

Doppler ultrasound (91,181–185) will allow the

iden-tification of veins suitable for attempted access creation

and can be used to exclude unsuitable sites Doppler

studies may be preferred to venography in patients with

residual renal function in whom contrast agents should

be avoided

A situation more difficult to diagnose is the presence

of fibrotic veins Fibrosis can result from prior venous catheter placement as well as venipuncture orintravenous drug use Since venous fibrosis is generallyfocal, this condition may not become apparent untilafter the AVF has been created All patients who arelikely to develop end-stage renal failure should be ex-amined early in the course of their disease to determinethe presence of veins suitable for AVF creation Armveins suitable for placement of vascular access should

intra-be preserved, regardless of arm dominance, by makingthat arm off-limits for venipuncture or intravenouscatheters (186)

Ischemia is not as frequent with AVFs as it is withPBGs Susceptibility to the development of ischemiacan usually be diagnosed before surgery is performedthrough physical examination and other noninvasiveprocedures Absent distal pulses, a positive Allen testresult, or vascular calcifications shown on plain radio-graphs increase the risk of the steal phenomenon Use

of vascular Doppler can increase the effectiveness ofthe Allen test in predicting collateral arterial perfusion

of the hand If collateral flow is adequate, the Dopplershould detect augmented pulsation in the palmar archduring occlusion of either the radial or ulnar artery.Failure to do so suggests inadequate collateral circu-lation in the hand and predicts a higher risk for vascularsteal if the dominant artery is used for AVF formation(174) Once ischemia occurs, immediate treatment isimportant The treatment principles discussed for dial-ysis access PBGs also hold for AVFs

As with other complications, venous stenosis is not acommon phenomenon However, when it does occur itmay be more problematic than with a PBG Romero et

al (188), in evaluating all causes of late (beyond 6weeks) AVF loss in a large dialysis patient population,found that 87% had some type of stenosis The greatmajority of these lesions were in the vein at or justbeyond the anastomosis (Figs 4, 5) The success rate

of percutaneous angioplasty in the treatment of venousstenosis associated with an AVF is significantly lowerthan that obtained in PBGs Hunter et al (189) wereable to obtain only a 43% patency for more than 24hours in treating 28 cases of AVF occlusion Theyfound that stenoses associated with occlusion were fre-quently difficult to cross with a wire and were ex-

Fig 4 Stenosis of arteriovenous fistula: This is a

radioce-phalic fistula The vessel on the right is the radial artery On

the left is the cephalic vein At the apex of the V is the

anastomosis The vein immediately above the anastomosis is

stenotic

Fig 5 The same fistula as shown in Fig 4: The stenoticlesion has been treated with angioplasty

tremely resistant to dilation An AVF should be

surgi-cally revised when its blood flow is inadequate to

sustain adequate dialysis Treatment of

hemodynami-cally significant venous stenosis can prolong the

use-life of the AVF

Unlike the situation for dialysis PBGs, pressure and

flow measurements are not very sensitive for the

de-tection of stenosis associated with AVFs (190) Blood

entering the venous system of the AVF can return

through multiple collateral veins originating peripheral

to a stenosis This can decrease the degree of pressure

elevation despite the presence of significant stenosis

Detection of recirculation, on the other hand, is

valu-able for screening because most AVFs can maintain

patency at very low flow rates, less than those needed

for dialysis When the flow in the AVF is less than that

of the blood pump, recirculation occurs

Even though AVFs have one sixth the thrombosis rate

of PBGs, once the access is successfully established,thrombosis is the most common mechanism of loss.The causes of this complication can be divided intotemporally related groups: early thromboses—occur-ring within the first 4–6 weeks—and late thromboses.Early thrombosis is generally related to poor inflow,proximal venous stenotic lesions, and venous fibrosiscaused by prior episodes of phlebitis In addition, earlycannulation of the AVF before it has had the opportu-nity to mature can lead to access loss Repetitive at-tempts to cannulate an infiltrated AVF carries a highrisk of inaccurate cannulation, which may further ex-acerbate the existing swelling and possibly lead to per-manent loss of the access An infiltrated AVF should

be rested until the swelling has subsided and the vessel

is sufficiently mature to allow successful cannulation(187)

Late AVF thromboses are generally associated with

some type of anatomical lesion The great majority of

these are in the vein at or just beyond the anastamosis

Problems in the arterial side of the AVF account for

17% of AVF thrombosis (188)

Thrombosis of an AVF is associated with a poor

prognosis As with the treatment of stenosis, the

suc-cess rate for AVF thrombosis treated percutaneously is

poor (188) Surgical thrombectomy and revision should

be attempted

Blood flow in the AVF increases with time (177) As a

consequence of this, it has a tendency to continue to

increase in size Over a period of years the AVF can

dilate to aneurysmal proportions Generally this is not

a problem In addition, localized aneurysm formation

can occur along the arterialized vein after repeated

nee-dle punctures at the same site In general, this is not a

problem unless it is associated with stenosis or thinning

of the overlying skin Progressive enlargement of an

aneurysm can eventually compromise the skin above

the AVF, leading to possible rupture This can result in

severe hemorrhage, exsanguination, and death (191)

Large aneurysms can prevent access to the adjacent

AVF for needle placement, thereby limiting potential

puncture sites Eventually, aneurysm formation may

re-quire ligation of the AVF Usually this is necessary only

after years of use (188)

Infection is an uncommon occurrence in AVFs (174)

It occurs at a rate of about one-tenth that seen in PBGs

The most common organism found in association with

infection is S aureus AVF infections can be treated

with systemic antibiotic therapy alone and do not

gen-erally require excision The exception to this rule

oc-curs in AVFs that have associated anatomical

abnor-malities such as aneurysms, perigraft hematomas, or

associated abscesses from infected needle puncture

sites These lesions require surgical drainage or

exci-sion with access reviexci-sion There is no need to abandon

the access entirely unless the associated lesion causes

complete loss of vascular integrity (174)

Vascular access is essential for hemodialysis; without

effective access dialysis can not be done However,

ac-cess also accounts for many of the complications seen

in hemodialysis patients The hemodialysis communityhas a great need for a better solution for the manage-ment of vascular access and an organized strategy todecrease the incidence of complications and to handlethem appropriately when they occur At a minimum,this strategy must include a plan to maximize the use

of native fistulae, a policy for appropriate use of ysis catheters, a quality-assurance program to detect theaccess at risk, implementation of procedures to increaseaccess longevity, and a system to manage graft throm-bosis effectively and efficiently In addition, the ne-phrologist involved with hemodialysis should become

dial-an expert on vascular access, develop the strategy, dial-andoversee its operation

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