C H A P T E R
87  
Vascular Access for Dialytic Therapies
Jan H. M. Tordoir
Functional vascular access is needed for all extracorporeal
dialytic therapies and remains the lifeline for patients with end-
stage renal disease who need chronic intermittent hemodialysis
(HD) therapy. The ideal HD access should have a long length
of a suitable superficial vein for cannulation in two places more
than 5 cm apart with a sufficient blood flow for effective dialysis,
usually in excess of 400 ml/min. A vascular access should have
good primary patency, have a low risk of complications and side
effects, and leave opportunities for further procedures in the
event of failure. Ideally, a first access should be an arteriovenous
(AV) fistula placed peripherally at the wrist. However, upper arm
and lower limb access sites are increasingly used because the
aging dialysis population, with multiple comorbidities, has poor
and diseased arm vessels that may be unsuitable for the creation
of a simple wrist fistula.
Vascular access should be performed with minimal delay by
a surgeon experienced in vascular access creation and, wherever
possible, in advance so that dialysis may start with permanent
access rather than with use of a central venous catheter. Central
venous catheter use should be minimized because of the increased
risk of sepsis, the increased mortality, and the development of
central venous stenosis or thrombosis, which compromises
further access in the upper limbs. Unfortunately, many patients
require a central venous catheter either to start dialysis or as a
bridge between the failure of a permanent access and the creation
of a new AV fistula.1
The need for revisional procedures because of access-related
complications, including thrombosis, central venous obstruction,
and ischemia, is increasing. A multidisciplinary approach to
access creation and maintenance, involving nephrologists, inter-
ventional radiologists, access surgeons, and dialysis nurses, is
mandatory to meet the burden of HD vascular access on health
care facilities and costs.
EVALUATION OF THE PATIENT
FOR VASCULAR ACCESS
The earlier a patient with chronic kidney disease (CKD) is seen
by a vascular access surgeon, the better the chance for the patient
to have a well-functioning access at the initiation of HD. An
early decision on the type, side, and site of the first vascular
access will be based on the following:
n Clinical examination with careful palpation of arterial
pulses and venous vasculature. Particular attention is paid
to the venous filling capacity, with use of a blood pressure
cuff and variable pressures, and to the presence of venous
collaterals and swelling. The dominant arm is not neces-
sarily the preferred side, and the decision should be based
on the quality of the vessels.
n Vascular mapping by Doppler ultrasound. This provides infor-
mation about the venous vasculature, particularly in obese
patients and in the upper arm, and about the diameter of
the brachial, radial, and ulnar arteries; detects vascular cal-
cifications; and reveals the blood flow volume in the bra-
chial artery. The resistance index, a measure of arterial
compliance, can be calculated from the differences between
the high-resistance triphasic Doppler signal with clenched
fist and the low-resistance biphasic waveform after the fist
is released. A preoperative resistance index of 0.7 or higher
in the feeding artery indicates insufficient arterial compli-
ance (often associated with arterial calcification) so that the
chance of successful creation of an AV fistula is reduced.
Current guidelines recommend ultrasound mapping in all
patients. Additional angiography is needed only in very
difficult cases; the use of radiocontrast media should be
minimized.
Preservation of veins during the earlier stages of CKD is
crucial for the success of vascular access. Patients should be
instructed to protect their veins, restricting blood sampling to
the dorsum of the hand whenever possible.
PRIMARY AUTOGENOUS VASCULAR ACCESS
Radiocephalic AV Fistula
A well-functioning distal radiocephalic AV fistula in the non-
dominant arm is the ideal permanent access for HD. This usually
gives an adequate blood flow and a long length of superficial vein
for needling. It also leaves proximal sites for further procedures
in the event of failure. A distal radiocephalic AV fistula should
be possible in a majority of incident patients but may be com-
promised if the cephalic and antecubital fossa veins are unusable
because of thrombophlebitis from previous intravenous cannulae
or venipunctures. For this reason, it is essential that these veins
be avoided for intravenous cannulae, which should be restricted
to the dorsum of the hand in all patients with CKD, except in
the emergency situation when rapid access to the circulation is
required.
A radiocephalic AV fistula is usually created at the wrist (Fig.
87.1) but can be performed more proximally in the forearm if
distal vessels are inadequate. On occasion, three or four radioce-
phalic AV fistulas can be created at progressively more proximal
sites in the forearm before resorting to a brachiocephalic AV
1031
1032 SECTION XVI  Dialytic Therapies
fistula. The radiocephalic AV fistula at the wrist was initially
described by Brescia and Cimino in 1966 as a side-to-side
anastomosis, but an end-to-side configuration is preferred by
most to reduce the risk of venous hypertension in the radial
aspect of the hand. An end-to-end anastomosis is advocated by
some surgeons to eliminate the small risk of steal.
The primary patency of radiocephalic fistulas varies from
center to center, but recent publications report high primary
failure rates varying from of 5% to 41% and 1-year primary
patencies from 52% to 71% (Fig. 87.2).2-7 Early thrombosis and
nonmaturation of an AV fistula in the older comorbid popula-
tion, who have poor upper limb vessels, are the major causes of
these high primary failure and low patency rates. The patency of
radiocephalic AV fistulas is poorer in women, so a proximal AV
fistula might be preferable if the cephalic vein or radial artery
is small.
Nonmaturation of Radiocephalic AV Fistula
The autogenous radiocephalic AV fistula needs time to mature
and for the vein to enlarge to a size at which it can be needled
for dialysis. Usually 6 weeks for maturation is advised. Earlier
cannulation can damage the thin veins. Nonmaturation rates
vary from 25% to 33%. The essential components of a successful
AV fistula are a sufficient vein diameter of 4 to 5 mm for nee-
dling and a high blood flow so that blood can be drawn from the
fistula at between 300 and 400 ml/min. In reality, this requires
a fistula flow of about 600 ml/min to prevent excessive recircula-
tion and to permit adequate dialysis within the usual 4-hour time
Standard Radiocephalic
AV Fistula at the Wrist
Cephalic vein
Radial artery
Figure 87.1  Standard radiocephalic AV fistula at the wrist. Anas-
tomosis of end of vein to side of artery.
Early Failure and 1-Year Patency Rates of Radiocephalic AVF
Author
Wolowczyk et. al.
Figure 87.2  Early failure and 1-year
patency rates of radiocephalic AV Gibson et. al.
fistulas. Allon et. al.
Ravani et. al.
Roijens et. al.
Biuckians et. al.
frame of a HD treatment. Fistulas that fail immediately are the
consequence of poor selection of vessels or poor technique.
Regular duplex ultrasound investigation early after AV fistula
formation, especially in fistulas that are not maturing, can detect
poor flow, stenosis, and accessory branches, guiding the inter-
ventional radiologist and surgeon to the appropriate treatment.
SECONDARY AUTOGENOUS VASCULAR ACCESS
Although a primary radiocephalic AV fistula is preferable, the
first-choice procedure is increasingly an upper arm AV fistula
with use of an autogenous deeply located arm vein, especially in
the dialysis population with associated comorbidities such as
diabetes mellitus, coronary artery disease, and peripheral arterial
occlusive disease.1
The upper limb is preferred to the lower limb for vascular
access because of the ease of cannulation, comfort for the patient,
and considerably lower incidence of complications. Similarly,
autogenous conduits are preferable to the use of prosthetic grafts
because of improved patency and lower risk of infection.
Forearm Cephalic and Basilic Vein Transposition
and Elevation
Superficial vein transposition or elevation increases the possibili-
ties of creating a forearm fistula. The cephalic vein is preferred,
but if it is unsuitable, the basilic vein can be transposed from the
ulnar to the radial side along a straight subcutaneous course from
the elbow to the radial artery. Alternatively, a basilic vein to ulnar
artery anastomosis can be performed with additional volar trans-
position to facilitate needling for dialysis.
Different surgical techniques, with or without transposition,
have been advocated according to the forearm artery and vein
location. In one study,8 91% fistula maturation was achieved with
a range of techniques; 15% were suitable for a straightforward
AV fistula, 33% required vein transposition from dorsal to volar
for anastomosis to the appropriate artery, and the remaining
52% required superficial transposition of a vein on the volar
aspect of the forearm before arterial anastomosis. Primary
patency rates were 84% at 1 year and 69% at 2 years.
Needle cannulation may be difficult, particularly in obese
patients. A forearm cephalic vein that is too deeply located may
be made accessible for cannulation by transposition or elevation.
In one study, the elevation technique was applied in obese
patients with radiocephalic AV fistulas and cannulation difficul-
ties; primary failure rate was 15%, with a 1-year patency rate of
84%. After operation, all patients could be successfully cannu-
lated for dialysis.9
Year No. Fistulae Early Failure (%) 1-Year Patency (%)
2000 208 20 65
2001 130 23 56
2001 139 46 42
2002 197 5 71
2005 86 41 52
2008 80 37 63
 CHAPTER 87  Vascular Access for Dialytic Therapies 1033

comparable to that of radiocephalic fistulas. The early failure and

Elbow and Upper Arm Cephalic Vein AV Fistula
The brachiocephalic and antecubital fistulas are two possible AV
anastomoses in the elbow region. In addition, anastomosis
between the transposed cephalic vein and brachial artery 2 cm
proximal to the elbow may be executed, which provides an
optimal situation for cannulation along the cephalic vein (Fig.
87.3). The outcome of the brachiocephalic AV fistula is usually
good, with a high primary function rate and good long-term
patency; studies showed a 10% early failure rate due to nonmatu-
ration and an 80% 1-year patency rate.10,11 Two-year primary,
assisted primary, and secondary patency rates were 40%, 59%,
and 67%, respectively. (Primary patency is functioning access
without any intervention; assisted primary patency is functioning
access after preemptive intervention for flow decline; secondary
patency is functioning access after intervention for thrombosis.)
Predictors of failure include diabetes mellitus and a history
of contralateral forearm AV graft (indicating poor vessels).
Therefore, the primary patency of brachiocephalic fistulas is
1-year patency rates of brachiocephalic AV fistulas are shown in
Figure 87.4.10-14
Upper Arm Basilic Vein AV Fistula
The upper arm basilic vein is usually inaccessible for dialysis
cannulation because of its medial and deep position. Therefore,
the basilic vein needs to be superficialized and transposed to an
anterolateral position. The original technique of brachiobasilic
AV fistula construction is a two-step approach. First, a brachio-
basilic anastomosis is constructed, and in the second operation,
usually after 6 weeks, the arterialized vein is mobilized into a
subcutaneous position, becoming accessible for needling (Fig.
87.5); nowadays, the brachiobasilic AV fistula may be performed
as a one-stage surgical procedure, with elevation or transposition
of the vein to a subcutaneous and anterolateral position at the
time of creation of the AV anastomosis. A nonrandomized study
comparing the different techniques of brachiobasilic AV fistula

Options for the Creation of Elbow AV Fistulas

Median
cubital
Accessory
vein
cephalic
vein Figure 87.3  Options for the cre-
Basilic ation of elbow AV fistulas. A, Brachio-
vein cubital AV fistula. B, Brachiocubital AV
B fistula with ligation of proximal cubital
Perforating Cephalic vein. C, Brachiocephalic AV fistula.
vein vein

Brachial
artery

A C

Early Failure and 1-Year Patency Rates of Brachiocephalic AVF

Author Year No. Fistulae Early Failure (%) 1-Year Patency (%)

Murphy et. al. 2002 208 16 75 Figure 87.4  Early failure and 1-year
patency rates of brachiocephalic AV
Zeebregts et. al. 2005 100 11 79 fistulas.
Lok et. al. 2005 186 9 78
Woo et. al. 2007 71 12 66
Koksoy et. al. 2009 50 10 87
1034 SECTION XVI  Dialytic Therapies

Transposed Brachiobasilic AV Fistula

Figure 87.5  Transposed brachio-

basilic AV fistula. A, Dissection of the Basilic vein
basilic vein. B, Anterolateral transposi-
tion and brachial artery anastomosis.
Median cubital
vein
A
Basilic vein

Brachial artery
B

Early Failure and 1-Year Patency Rates of Brachiobasilic AVF

Author Year No. Fistulae Early Failure (%) 1-Year Patency (%)

Figure 87.6  Early failure and 1-year Segal et. al. 2003 99 23 64
patency rates of brachiobasilic AV
fistulas. Wolford et. al. 2005 100 20 47
Harper et. al. 2008 168 23 66
Keuter et. al. 2008 52 2 89
Koksoy et. al. 2009 50 4 86

creation reported 86% to 90% 1-year patencies in all groups,
with only 5% to 7% nonmaturation rates.15 Primary failure rates
of 2% to 23% with 1-year patencies varying from 55% to 89%
have been reported (Fig. 87.6).12,16-19 In comparison with bra-
chiocephalic fistulas, brachiobasilic AV fistulas are more likely to
mature, although they are more susceptible to late thrombosis.
However, a randomized study showed similar patencies of bra-
chiocephalic and brachiobasilic AV fistulas.12
The technique of subcutaneous placement of the basilic vein
has several advantages over forearm or upper arm graft implan­
tation, with less infection and thrombosis. A meta-analysis
comparing brachiobasilic AV fistulas with prosthetic grafts has
shown superiority of the brachiobasilic AV fistula in primary and
secondary patency rates, and it should therefore be used early in
difficult access cases before the use of prosthetic grafts.20
NONAUTOGENOUS PROSTHETIC
VASCULAR ACCESS
When autogenous AV fistula creation is impossible or the fistulas
have failed, graft implantation should be considered as a vascular

Non-Autogenous Prosthetic Graft (PTFE) Vascular Access
Brachial
Cephalic artery
vein
Radial Ulnar
artery PTFE artery
PTFE
Figure 87.7  Nonautogenous prosthetic graft (PTFE) vascular access. Straight and loop configuration in upper limb.
access conduit. Xenografts such as the ovine sheep (Omniflow)
and bovine cow ureter graft (SynerGraft) are popular materials
as an alternative access conduit, with acceptable patency and low
infection rates. The most frequently used implants are prosthetic
grafts made of either polyurethane (Vectra) or polytetrafluoro-
ethylene (PTFE). These prosthetic grafts can be implanted in a
wide variety of locations and configurations in the upper limb
(Fig. 87.7). Short-term functional patency is usually good, but
stenosis (mostly at the graft-vein anastomosis) may lead to
thrombotic occlusion within 12 to 24 months. The primary
patency rates of prosthetic AV grafts vary from 60% to 80% at
1 year and from 30% to 40% at 2 years of follow-up. Secondary
patency ranges from 70% to 90% and from 50% to 70% at 1
and 2 years, respectively.21-24 Intimal hyperplasia, with smooth
muscle cell migration and proliferation and matrix deposition, is
the major cause of stenosis formation and thrombosis. The etiol-
ogy of the intimal hyperplasia is uncertain, although the high
wall shear stress, caused by the access flow, may denude the
endothelial cell layer, resulting in platelet adhesion and initiation
of a cascade of proteins that stimulate the smooth muscle cells
to proliferate and to migrate.
Measures to Improve Graft Patency
Numerous experimental and clinical studies have defined the
influence of graft material and graft design on AV graft patency.
Modulating the geometry of the arterial inlet or venous outlet
of the graft may have a beneficial effect on intimal hyperplasia.
Clinical studies using tapered (at the arterial side of the graft)
grafts did not improve patency rates, nor did cuff implantation
at the venous anastomosis.25,26 However, primary patency did
improve with the use of a cuff-shaped prosthesis (Venaflo).27
Grafts such as polyurethane, which are more distensible, could
in principle influence intimal hyperplasia by the better matching
of the stiff prosthesis with the compliant vein at the anastomotic
site; however, in clinical studies, this feature was not of proven
benefit.28
CHAPTER 87  Vascular Access for Dialytic Therapies 1035
Axillary
Brachial artery
vein Axillary
PTFE vein
PTFE
Axillary
artery
PHARMACOLOGIC APPROACHES
FOR ACCESS PATENCY
Aspirin, ticlopidine, and dipyridamole have some beneficial
effect in maintaining patency of AV fistulas and grafts but
increase the risk of hemorrhage.29 Clopidogrel may also be effec-
tive in reducing thrombosis of AV grafts and fistulas. Warfarin
reduces AV graft thrombosis but increases the risk of hemor-
rhage.30 A recent large trial showed that dipyridamole plus aspirin
had a significant but modest effect in reducing the risk of stenosis
and improving the duration of primary unassisted patency of
newly created AV grafts.31 In a large randomized study, clopido-
grel improved primary radiocephalic fistula function but not
maturation.32 On the available evidence, antiplatelet agents
should be used routinely in patients with AV grafts but not
fistula. Warfarin should be considered only when there is recur-
rent thrombosis in the absence of anatomic stenosis.
There have been suggestions that other drugs, such as calcium
channel blockers and angiotensin-converting enzyme inhibitors,
might be associated with improved AV fistula patency, but this
requires confirmation with randomized studies.33 Fish oil reduced
AV graft thrombosis in one randomized trial.34
Efforts have been made to inhibit the development of intimal
hyperplasia pharmacologically with the cytotoxic agent pacli-
taxel. Paclitaxel wraps have been shown to reduce prosthetic
graft intimal hyperplasia in animal models but have yet to be
clinically evaluated.
LOWER LIMB VASCULAR ACCESS
Probably the only indication for lower limb vascular access is
bilateral central venous or caval obstruction, which endangers
the outflow of upper limb AV fistulas. Saphenous and superficial
femoral vein transposition is a primary option for thigh AV fis-
tulas, although this carries a relatively high risk of distal ischemia.
If clinical evaluation indicates incipient ischemia, primary flow
1036 SECTION XVI  Dialytic Therapies
reduction by tapering of the anastomosis is indicated to prevent
ischemia.35 Prosthetic graft implantation in the thigh bears a high
risk of infection and septicemia.
VASCULAR ACCESS COMPLICATIONS
Nonmaturation of AV Fistulas
Fistulas that fail immediately are the consequence of poor selec-
tion of vessels, poor technique, or postoperative hemodynamic
instability. Vascular abnormalities, including stenoses, occlu-
sions, and accessory veins, will be identified in virtually all early
failures, and more than half of the stenoses are in the perianas-
tomotic area of nonmatured fistulas. Arterial inflow stenoses of
more than 50% coupled with poor flows are seen in less than
10% of nonmaturing fistulas, but if identified, they should
undergo angioplasty. If this fails to improve fistula flow rates, it
is unlikely that surgical bypass will be of help. Anastomotic and
swing segment (where the vein has been mobilized and swung
over to the artery) stenosis may be treated percutaneously or
surgically, depending on local expertise.
The diameter of the angioplasty balloon is chosen to corre-
spond to the diameter of the vessel next to the stenotic or occlu-
sive lesion and is usually not smaller than 5 mm for venous
stenoses and not smaller than 4 mm for arterial or anastomotic
stenoses. Ultrahigh-pressure balloons inflatable up to 30 atm are
used when necessary to abolish the waist of the stenosis on the
balloon. Apart from local infection, contraindications to balloon
angioplasty are anastomotic stenoses in fistulas less than 4 to 6
weeks after surgical construction, which increases the risk of
anastomotic disruption at angioplasty. Percutaneous balloon
angioplasty is further discussed in Chapter 88.
The surgical approach is to reconstruct the AV fistula, usually
under local anesthesia. The anastomosis is exposed and ligated;
the vein can then be divided, mobilized proximally, and reanas-
tomosed to the proximal radial artery.
A prospective nonrandomized study of 64 patients showed
that outcomes were similar with angioplasty or surgery.36 Reste-
nosis rates were significantly higher after angioplasty, but overall
costs of treatment were similar.
Nonmatured fistulas are rescued by angioplasty of stenoses or
occlusions, ligation of accessory veins, or both. Accessory veins
can be obliterated through coil embolization, percutaneous liga-
tion, or surgical ligation. The use of coils with a diameter of
1 mm in excess of the target vessel diameter will prevent coil
dislocation. Although ligation of accessory veins is usually per-
formed in a single surgical intervention, three variants of vein
ligation in a stepped approach have also been described.37 By use
of this approach, surgery is limited to ligation of the accessory
veins if the AV fistula appears to be of adequate size to allow
cannulation. If the fistula is still considered to be too small, the
median cubital vein is ligated. If the AV fistula is still believed
inadequate, temporary banding of the main venous channel is
performed. Apart from surgical ligation, accessory veins can also
be ligated percutaneously.
Stenosis and Thrombosis
The development of vessel stenosis in both autogenous AV fis-
tulas and prosthetic AV grafts is usually initiated by intimal
hyperplasia due to migrating and proliferating vessel smooth
muscle cells, which form extracellular matrix. Progressive
stenosis leads to access flow deterioration and subsequently
thrombotic occlusion. Prophylactic repair of access stenoses may
prevent thrombosis and prolong access patency.
Autogenous Fistula Stenosis or Thrombosis
AV fistula stenosis should be treated if the vessel diameter is
reduced by more than 50% and is accompanied by a reduction
in access flow (25% flow decline between measurements or abso-
lute flow below 500 ml/min) or in measured dialysis dose. Other
indications for intervention are difficulties in cannulation and
prolonged bleeding time after decannulation, indicating high
intra-access pressure due to outflow vein stenosis. In AV fistulas,
55% to 75% of the stenoses are close to the AV anastomosis,
25% in the venous outflow tract and 15% in the arterial inflow.
In brachiocephalic and brachiobasilic AV fistulas, the typical
location for stenosis (besides the anastomosis) is at the junction
of the cephalic with the subclavian vein and the basilic with the
axillary vein (junctional stenosis).
Endovascular treatment by percutaneous transluminal angio-
plasty (PTA) is the first option for arterial inflow and venous
outflow stenoses and junctional stenoses, with the option of stent
placement.38 These techniques are discussed further in Chapter
88. Some stenoses may not be sufficiently dilated by conven-
tional balloons (12 to 16 atm), and in these patients, cutting
balloons or ultrahigh-pressure balloons (up to 32 atm) may be
applied. Anastomotic stenoses in forearm and upper arm fistulas
are primarily treated with PTA; however, surgical revision with
a more proximal reanastomosis for swing segment stenosis is
indicated in failed PTA of radiocephalic AV fistula.
Fistula thrombosis should be treated as soon as possible
because timely declotting allows immediate use of the access
without the need for a central venous catheter; fistula salvage
usually requires intervention within 6 hours (grafts may be sal-
vaged up to 24 hours). The duration and site of AV fistula
thrombosis as well as the type of access are important determi-
nants of treatment outcome. Thrombi become progressively
fixed to the vein wall, which makes surgical removal more dif-
ficult. When the clot is localized at the anastomosis in radioce-
phalic and brachiocephalic fistulas, the outflow vein may remain
patent because of continuing flow in its tributaries, making it
possible to create a new proximal anastomosis.39
Thrombolysis can be performed mechanically or
pharmacomechanically.40-42 Whereas the immediate success rate
is higher in AV grafts than in autogenous AV fistulas (99% versus
93% in forearm fistulas), the primary patency rate of the forearm
AV fistula at 1 year is much higher (49% versus 14%). One-year
secondary patency rates are 80% in forearm and 50% in upper
arm AV fistulas.
In AV fistulas, the combination of a thrombolytic agent (uro-
kinase or tissue plasminogen activator [tPA]) with balloon angio-
plasty resulted in an immediate success rate of 94%.41
AV Graft Stenosis or Thrombosis
The most common cause of graft dysfunction and thrombosis is
venous anastomotic stenosis. Because grafts should be implanted
only in patients with exhausted peripheral veins, vein-saving pro-
cedures like PTA or patch angioplasty are preferred to graft
extensions to more central venous segments. When a stent or a
patch fails, graft extension is still possible. Graft monitoring by
access flow measurement is recommended; with preemptive
endovascular treatment, this may diminish graft thrombosis but
does not extend graft patency.
Intra-graft (or mid-graft) stenoses are found in the cannula-
tion segment of grafts. They result from excessive ingrowth of

fibrous tissue through puncture holes. These stenoses can be
treated by PTA, graft curettage, or segmental graft replacement.
When only a part of the cannulation segment is replaced, the
access can be used for HD without the need of a central venous
catheter. When restenosis occurs in a nonexchanged part of the
graft, this can be replaced after healing of the new segment.
Prosthetic graft thrombosis can be treated with various per-
cutaneous techniques and tools, including combinations of
thromboaspiration, thrombolytic agents such as tPA, and
mechanical thrombectomy. An initial success rate of 73% and
primary patency rates of 32% and 26% at 1 and 3 months,
respectively, are reported.43-46 It is important to perform throm-
bolysis as soon as possible to avoid the need for a central venous
catheter and as an outpatient procedure to decrease costs, when-
ever possible. Postprocedural angiography to detect and to
correct inflow, intra-access, or venous outflow stenosis is
mandatory.
When endovascular treatment fails or is not possible, surgical
thrombectomy may be performed with a Fogarty catheter after
venotomy, with correction of the underlying obstruction.
On-table angiography should be performed after completion of
thrombectomy of both the arterial and venous limbs of the graft.
Central Venous Obstruction
In the majority of patients, central vein obstruction is due to
previously inserted central venous catheters or pacemaker wires.
In 40% of patients with subclavian vein and 10% with jugular
vein catheters, venous stenosis or occlusion will develop. Chronic
swelling of the access arm is the most important sign, usually
with prominent superficial collateral veins around the shoulder.
The indications for intervention, by PTA and stent placement,
are severe and disabling arm swelling, finger ulceration, and pain
or inadequate HD. Contrast angiography of the access and com-
plete venous outflow tract must be performed because the central
veins can be difficult to examine with ultrasound in their retro-
clavicular position.
Endovascular Intervention
Endovascular intervention is the first option for central venous
obstruction treatment. PTA alone results in low primary patency
rates of 10% or less at 1 year, and numerous restenoses may
develop. Primary or additional stent implantation gives much
better outcome, with 1-year patency rates up to 56% or more.47,48
Reinterventions are usually required to maintain patency and to
achieve long-term clinical success.
Stent placement should avoid overlapping the ostium of the
internal jugular vein because this vein is essential for future
placement of central venous catheters. Similarly, a stent placed
in the innominate vein should not overlap the ostium of the
contralateral vein; otherwise, contralateral stenosis may occur
and preclude future use of the contralateral limb for access
creation.
Surgical Intervention
When interventional treatment of central venous obstruction
fails, surgical revision with bypass grafting is indicated. Surgical
bypass to the ipsilateral jugular vein or contralateral subclavian
or jugular vein is the first option in these patients. Alternative
surgical approaches for upper limb vascular accesses with com-
promised venous outflow are axillary vein to femoral, saphenous,
or popliteal vein and right atrial bypasses.49 In case of bilateral
obstruction of the mediastinal veins, including the superior vena
CHAPTER 87  Vascular Access for Dialytic Therapies 1037
cava, it will not be possible to sustain upper limb access, and
lower limb access will be required.
Ultimately, ligation of the upper limb access can be consid-
ered, which will relieve local symptoms but loses a valuable
dialysis access.
Vascular Access–Induced Ischemia
Vascular access–induced upper limb ischemia is a serious com-
plication that without prompt intervention may lead to amputa-
tion. The incidence of symptomatic ischemia varies from 2% to
8% of the HD population.50 Elderly patients, diabetics, and
patients with peripheral or coronary arterial occlusive disease are
most at risk of ischemia. In addition, previous ipsilateral vascular
access increases the risk. Access-induced ischemia occurs more
often with proximally located fistulas. These high-flow AV fis-
tulas induce a steal phenomenon with lowering of distal perfu-
sion pressures, and when collateral circulation is inadequate,
symptoms may occur. Pain during HD is a characteristic early
symptom. A grade 1 to 4 classification for access-induced isch-
emia can be used to outline the severity of the disease; this ranges
from minor symptoms to finger necrosis.
Grade 1: pale/blue or cold hand without pain
Grade 2: pain during exercise or HD
Grade 3: ischemic pain at rest
Grade 4: ulceration, necrosis, and gangrene
For grades 1 and 2, ischemia conservative treatment is
advocated. With grades 3 and 4, interventional treatment is
mandatory.
Diagnosis of Ischemia
Physical examination, including observation and palpation of
peripheral vessels, may be inadequate and misleading for the
diagnosis of symptomatic ischemia. Additional noninvasive
testing with measurement of digital pressures and calculation of
the digit to brachial index, transcutaneous oximetry, ultrasound
of forearm arteries, and access blood flow measurement are
important steps in the diagnosis and decision-making process.
Finally, contrast angiography with visualization of the upper
extremity arterial tree from the proximal subclavian artery to the
distal palmar arches with and without AV fistula compression to
enhance distal flow is obligatory to outline the strategy for treat-
ment and to determine whether interventional or surgical options
are preferred.
Endovascular and Surgical Management of Ischemia
The treatment strategy depends on the etiology of the ischemia.
Inflow arterial obstruction and distal arterial lesions are recana-
lized with small-caliber balloons or stent placement51; high-flow
AV fistulas are suitable for flow-reducing procedures like access
banding (Fig. 87.8) and arterial inflow reduction by an interposi-
tion graft to a smaller forearm artery (revision using distal
inflow).52,53 Steal in itself may be cured by ligation of the artery
distal to the arteriovenous anastomosis (distal radial artery liga-
tion). In most patients, it is necessary to add a saphenous vein
or prosthetic graft bypass to the forearm arteries to augment
distal hand perfusion (distal revascularization and interval liga-
tion; Fig. 87.9). The results of these procedures are usually
good, with relief of symptoms and preservation of the access
site (Fig. 87.10).54-58 A simpler alternative to the distal
revascularization–interval ligation procedure is the proximal
arteriovenous anastomosis technique, in which the AV anasto-
mosis at the elbow is disconnected and moved to the axilla, with
1038 SECTION XVI  Dialytic Therapies
Surgical Techniques for Banding of a High Flow Vascular Access
Figure 87.8  Surgical techniques
for banding of a high-flow vascular
access. A, Open venoplasty; B, Inter-
rupted mattress suturing; C, Continuous
mattress suturing; D, PTFE banding; E, A B
PTFE interposition graft. The choice of
technique is made by the surgeon on a
case by case basis.
D E
anastomosis to the axillary artery by means of a graft inter­
position.59 Recently, the minimally invasive limited ligation
endoluminal-assisted revision procedure was described, using a
minimally invasive percutaneous technique with banding of the
access over a 4-mm balloon.60
Intraoperative digital pressure measurement or transcutane-
ous oximetry (TcPo2) is mandatory to guarantee an adequate
surgical intervention with acceptable outcome. A digital-brachial
pressure index above 0.60 or TcPO2 above 40 mm Hg is indica-
tive of sufficient distal hand perfusion. In some patients, AV
fistula ligation and transition to chronic catheter dialysis access
or a change in renal replacement modality to peritoneal dialysis
may be the only solution.
CENTRAL VENOUS CATHETER ACCESS
Central venous catheters are still widely used as vascular access
for HD. Data from the DOPPS study61 indicate that 25% of HD
patients in the United States are dialyzed with catheters; in other
countries, the use of catheters is even more common (Belgium,
41%; United Kingdom, 28%). Central venous catheters are the
preferred vascular access for patients presenting with acute
kidney injury and for chronic patients without permanent AV
access or with failed vascular access. Two types of catheters are
used in practice: nontunneled catheters for short-term dialysis,
with a limited use and high morbidity; and tunneled cuffed cath-
eters, which can be used up to several months or years with low
morbidity. The physical characteristics (i.e., design and geome-
try) not only influence the performance (blood flow rate, recir-
culation, and resistance) but also affect the overall efficiency of
the HD therapy and the morbidity risk (infection, thrombosis).
C
Nontunneled Catheters
Single- or double-lumen catheters are usually made of polymers
(polyethylene, polyurethane), enabling a simple and direct
implant possibility. The length of the catheter must be chosen
in accordance with the insertion site. The femoral route requires
catheters of 30 to 35 cm in length for the distal tip to be located
in the inferior vena cava. The internal jugular vein route needs
shorter catheters of 20 to 25 cm in length, with tip location at
the inferior vena cava–right atrium junction. The subclavian vein
should not be used because of the very high risk of subsequent
venous stenosis. For sufficient blood flow rates to be achieved,
the diameter of these catheters must be ideally between 12 and
14 French. It is recommended that the use of nontunneled cath-
eters not exceed 7 days.
Tunneled Catheters
Tunneled central venous catheters have two lumens, each having
a length of 40 cm, 10 cm of which is tunneled under the skin;
the cannulae are made of synthetic polymer with a large internal
lumen and a Dacron cuff to ensure subcutaneous anchoring. The
catheter characteristics rely on the type of polymer, design, and
geometry (double-lumen catheters, dual catheters, split cathe-
ters). The use of a tunneled central venous catheter is associated
with reduced morbidity as well as better and constant perfor-
mance compared with uncuffed catheters.62
Both tunneled and nontunneled catheters are inserted percu-
taneously by the Seldinger technique and ultrasound guidance.
These techniques are described in Chapter 88. The internal
jugular vein (Fig. 87.11) and femoral vein routes are preferred
 CHAPTER 87  Vascular Access for Dialytic Therapies 1039

because of ease of implantation and low risk of complications, that patients with central venous catheters have an increased
such as central vein stenosis. relative mortality risk of 3.4 compared with patients with AV
fistulas. Switching from central venous catheters to AV fistulas
decreases the relative mortality risk to 1.4.63 The most likely
Catheter Infection explanation for this increased mortality risk is infection and
Catheter-related blood stream infections are a significant cause sepsis related to the central venous catheter, including exit site
of mortality in HD patients. Results of the HEMO study indicate infection. Typical infection rates are 3 episodes of infection per
1000 tunneled catheter–days and higher with nontunneled cath-
eters.64 These localized infections can progress to metastatic
complications of osteomyelitis, septic arthritis, epidural abscess,
Distal Revascularisation-Interval Ligation and endocarditis. Various societies have issued recommendations
(DRIL) for Ischemia in an Upper Arm for the management of catheter infections.65 A recommended
treatment algorithm is shown in Figure 87.12.
Vascular Access
Infections Involving Temporary Catheters
When a temporary dialysis catheter becomes infected, it should
always be removed. There is no role for trying to salvage tem-
porary catheters.65

Exit Site Versus Tunnel Track Infections

An exit site infection is a localized cellulitis confined to the 1 to
2 cm where the catheter exits the skin. The majority of these
cases respond well to systemic antibiotics and meticulous exit site
AV graft care, and the removal of the catheter is generally not required.65
However, exit site infections can progress to tunnel track infec-
tions, which involve the potential space surrounding the catheter
more than 2 cm from the exit site (Fig. 87.13). Patients with a
tunnel track infection sometimes but not always have an associ-
ated exit site infection; untreated, they can rapidly develop bac-
teremia. Patients with a tunnel track infection present with fever
Arterial bypass
as well as local signs of pain, swelling, fluctuance, and erythema
along the track of the catheter. Because tunnel track infections
involve a potential space, in an area with limited vascular supply,
and an implanted synthetic material, they respond poorly to
antibiotics alone and require catheter removal.65

Catheter-Associated Bacteremia
When a patient with a dialysis catheter has a fever, catheter
Arterial
infection must always be considered. If the patient does not have
ligature a clear and convincing alternative explanation for the fever,
blood culture specimens should be obtained peripherally as well
as through the catheter, and the patient should be started on
antibiotic therapy, which is subsequently adjusted on the basis
of culture results.65 The most common organism is Staphylococcus,
although a wide range of gram-positive and gram-negative
organisms have been reported (Fig. 87.14). The percentage of
Figure 87.9  Distal revascularization–interval ligation for ischemia patients with methicillin-resistant Staphylococcus aureus (MRSA)
in an upper arm vascular access. varies greatly between centers, with higher rates associated with

Results of the DRIL Procedure for Angio-Access Related Ischemia

Author Year No. fistulae Ischemia Ischemia Ischemia not Access
cured (%) improved (%) improved (%) patency (%)
Figure 87.10  Results of the distal
Haimov et. al. 1996 23 86 14 – 95 revascularization–interval ligation
(DRIL) procedure for vascular access–
Knox et. al. 2002 55 55 25 11 86 related ischemia. NS, not stated.
Waltz et. al. 2007 36 100 – – 54
Yu et. al. 2008 24 96 – 4 88
Huber et. al. 2008 64 78 – NS 68
1040 SECTION XVI  Dialytic Therapies
greater antibiotic use. An aminoglycoside or a cephalosporin is
a good choice for gram-negative coverage; however, local micro-
biologic epidemiology must be taken into consideration, espe-
cially concerning antibiotic resistance.
Catheter Removal
The decision to remove a tunneled cuffed dialysis catheter for
an episode of catheter-associated bacteremia is not straightfor-
ward. The clinical condition of the patient and response to initial
therapy, the presence of metastatic complications, the infecting
Tunneled Cuffed Double-Lumen Central
Venous Catheter Inserted in the
Right Internal Jugular Vein
Figure 87.11  Tunneled cuffed double-lumen central venous cath-
eter inserted in the right internal jugular vein.
Management of Central Venous Dialysis Catheter Infections
Figure 87.12  Algorithm for the Temporary catheter
management of central venous dialy-
sis catheter infections. (Modified with
permission from reference 65.)
Remove catheter
organism, and the availability of other vascular access sites must
all be taken into consideration before deciding on a treatment
plan (see Fig. 87.12).
The conventional approach is to remove the catheter with
interval replacement at a different site after the infection has
resolved. Although this is effective, it leads to an additional tem-
porary catheter if dialysis is needed before the catheter can be
replaced. Attempts to “salvage” an infected catheter with sys-
temic antibiotic therapy lead to resolution of infection in only
about 30% of cases. Another treatment option is to combine
systemic antibiotics with antibiotic “lock” solutions. Many dif-
ferent cocktails of antibiotics mixed with either heparin or citrate
have been tested; a popular regimen is vancomycin 2.5 mg/ml,
gentamicin 1 mg/ml, and heparin 2500 U/ml. Infection clear-
ance rates of between 50% and 70% are reported with antibiotic
locking.
Several studies have reported that exchange of the catheter
over a guide wire 48 hours after initial antibiotic treatment is
more effective then treatment with antibiotics alone and is as
effective as removal of the catheter and delayed replacement,
with the advantages of only one invasive procedure and preserva-
tion of the venous access site. Randomized trials of antibiotic
locking and catheter exchange over a guide wire are not yet
available.
Prevention of Infection
The most important measure to prevent catheter infection is
meticulous handling of the catheter at all times. The catheter
should be inserted with use of maximal sterile precautions. The
dialysis nurses need procedures for accessing the catheters under
strict sterile conditions, and it is of the utmost importance that
these catheters are never accessed by untrained personnel. Pre-
liminary data suggest that antibiotic lock solutions significantly
reduce the incidence of infection, but large randomized trials
demonstrating both safety and efficacy are awaited before this
can be recommended. Topical application of mupirocin
Clinical suspicion of infection
Obtain cultures and start antibiotics
Type of catheter Tunneled catheter
Tunnel tract infection
or
Yes Metastatic infection
or
Poor clinical response
to treatment
May proceed with antibiotic
lock or exchange over No
guidewire
 CHAPTER 87  Vascular Access for Dialytic Therapies 1041

catheter clot formation while increasing risk of hemorrhage.

Regular use of low-dose warfarin or antiplatelet agents has failed
to improve catheter function in dialysis patients in randomized
trials.
To prevent or to correct catheter dysfunction, it is recom-
mended that the catheter lumen be cleaned periodically by
applying a fibrinolytic agent (urokinase or tPA) as a lock solution
or by continuous infusion on both arterial and venous lines.
Occluded catheters are reopened either by means of a mechani-
cal method (brush) or pharmacologically (urokinase or tPA).
Removal of the fibrin sleeve may be achieved by lasso wire strip-
ping or by infusion of a fibrinolytic solution (urokinase, tPA)
during 3 to 6 hours. Alternatively, the catheter may be exchanged
over a guide wire.

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