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SURGICAL MANAGEMENT OF DIALYSIS ACCESS

SURGICAL MANAGEMENT OF DIALYSIS ACCESS. STEVE WORATYLA, MD SURGICAL SPECIALISTS OF LANCASTER. TYPES OF ACCESS FOR DIALYSIS. 1. CENTRAL VENOUS CATHETERS TEMPORARY TUNNELLED (CUFFED) 2 ARTERIAL VENOUS GRAFTS PROSTHETIC PTFE (GORTEX) VECTRA (immediate access) HeRO graft BIOPROSTHESIS

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SURGICAL MANAGEMENT OF DIALYSIS ACCESS

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  1. SURGICAL MANAGEMENT OF DIALYSIS ACCESS STEVE WORATYLA, MD SURGICAL SPECIALISTS OF LANCASTER

  2. TYPES OF ACCESS FOR DIALYSIS • 1. CENTRAL VENOUS CATHETERS • TEMPORARY • TUNNELLED (CUFFED) • 2 ARTERIAL VENOUS GRAFTS • PROSTHETIC • PTFE (GORTEX) • VECTRA (immediate access) • HeRO graft • BIOPROSTHESIS • BOVINE CAROTID ARTERY • 3. ARTERIAL VENOUS FISTULAS • 4. PERITONEAL CATHETERS

  3. THE CREATION AND MAINTENANCE OF A DIALYSIS ACCESS IS CRUCIAL TO THE ONGOING CARE OF A PATIENT WITH END-STAGE RENAL DISEASE

  4. Peritoneal Dialysis

  5. Historical Background Era of modern dialysis began in the 1960’s with the creation of the radio-cephalic av fistula

  6. Modern hemodialysis access consists of a well created autologous AV fistula • Use best vein and best artery available • Usually upper extremity (vein map preop) • Cephalic vein and Basilic vein • Radial artery and Brachial artery • Start distal and work proximal in the arm • Requires 6-8 weeks for maturation • Allows vein to dilate and thicken • 80-85% success rate (supports dialysis) • May be improved with aggressive followup program • Physical exam, ultrasound, Fistulogram

  7. Maturation Process

  8. National Kidney FoundationKidney Disease Outcome Quality Initiative1997 and 2006

  9. 2/3’s of Hemodialysis patients should have AV fistula • Lower cost • Lower morbidity • Lower mortality

  10. Types of AV Fistulae • Nomenclature : Artery-Vein • Radial-Cephalic • Radial-Basilic • Brachial-Cephalic • Brachial-Basilic • Brachial-Brachial • Transposing Vein to more superficial and accessible location • Basilic Veins • Deep Veins

  11. Radial-Cephalic AVF

  12. Brachial Cephalic AVF

  13. Brachial Basilic AVF

  14. Surgical Technique

  15. AV Grafts • Brachial artery to antecubital vein • Forearm loop graft • Radial artery to antecubital vein • Brachial artery to Axillary vein • Axillary artery to Axillary vein

  16. Dialysis Catheters

  17. Dialysis Catheters(HeRO Catheter)

  18. How Does Hemodialysis Work

  19. How Does Hemodialysis Work

  20. AVF Complications/Problems • Thrombosis • Stenosis • Pseudoaneurysm • Infiltration • Infection • Bleeding • Poor maturation • Tortuosity • Depth of AVF • Steal syndrome

  21. AVF Maintenance

  22. AVF Maintenance

  23. Steal Syndrome

  24. Steal Syndrome

  25. Conclusions • Autologous AV Fistula is best • Requires good communication and planning between Nephrologist, Patient, and Surgeon • Peritoneal dialysis catheter is viable alternative to hemodialysis in most patients • Requires more active patient involvement • Avoid CVC’s and PICC’s • Central venous stenosis is achilles heel of upper extremity AV access

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