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Chapter 33. Vascular Access for Dialysis

Frank C. Vandy, MD; Peter K. Henke, MD

  • End-stage renal disease; recommendations from the Kidney Dialysis Outcomes Quality Initiative:
    • Creatinine clearance < 25 mL/min.
    • Serum creatinine > 4.0 mg/dL.
    • Dialysis anticipated within 1 year.
  • Long-term plasmapheresis.

  • Ipsilateral proximal venous and arterial occlusion or stenosis.
  • Systemic or local infection.
  • Multiple comorbidities precluding safe intervention.

  • The patient should be supine with the operative arm extended on an arm board and supinated.
  • The arm should be prepared circumferentially from the fingers to the axilla, and the hand covered with a sterile towel.

  • The operation should be performed as an outpatient procedure.
  • The patient may remove the dressing after 48 hours.
  • A sling may be offered for the patient's comfort, although it is not necessary.
  • The patient should return for follow-up examination in 4 weeks.
    • The wound is checked for signs of infection or poor healing.
    • The vein is palpated for a thrill.
    • Distal radial and ulnar pulses are palpated.
  • Most autogenous fistulas will be ready for use in 8–12 weeks.
    • The vein is assessed to determine if the caliber is large enough to accommodate dialysis access.
  • Prosthetic grafts are usually ready for use in 4 weeks.

  • Early thrombosis.
    • Technical error.
    • Hypercoagulable state.
    • Low cardiac output.
    • Poor inflow.
    • Poor outflow.
  • Late thrombosis.
    • Intimal hyperplasia causing progressive outflow venous stenosis.
    • Hypotension during hemodialysis.
    • Worsening inflow stenosis.
    • Poor puncture technique with excessive pressure.
  • Arteriovenous access steal syndrome.
    • Diagnosed by clinical examination and history.
    • Cool hand.
    • Diminished distal pulses.
    • Hand pain.
    • Confirmed by Doppler finger waveforms and pressures.
  • Ischemic monomelic neuropathy.
    • Acute and potentially irreversible dysfunction of the radial, median, and ulnar nerves.
    • Pain, paresthesia, and diminished motor function of the wrist and hand.
    • Absence of tissue ischemia.
    • Preserved distal palpable radial pulse or Doppler signal.
    • Presumably caused by alteration in blood flow to the vasa vasorum of the above-mentioned nerves.
  • Venous hypertension.
    • Hand and upper extremity swelling with pain.
    • Usually secondary to undiagnosed or recently formed central venous stenosis or occlusion; however, severe valvular incompetence with retrograde flow can also produce these symptoms.

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