ARTERIOVENOUS ACCESS FAILURE Putu Chandra Wibawa

ARTERIOVENOUS ACCESS FAILURE

AV FISTULA

Direct connection between an artery and a vein, created surgically or occurring as a

result of pathology.
The principal indication for surgically created arteriovenous fistulas is to provide
access for haemodialysis.
PRE OP EVALUATION
History and Physical Examination
 dominant extremity
 recent history of peripheral intravenous lines
 sites of indwelling
 previous central lines including pacemakers and defibrillators,
 all previous access procedures, any history of trauma or previous
 and current medications
Medical Assesment
 diabetes mellitus (DM)
 peripheral vascular disease (PVD)
 smoking, obesity, hyperparathyroidism (hPTH),anemia, and medications.
 PRE OP EVALUATION
Medications
improvement of autogenous access secondary patency (RR 0.56)
with angiotensin-converting enzyme (ACE) inhibitors, improved
prosthetic AV access primary patency (RR 0.86) with calcium
channel blockers, an improved prosthetic AV access secondary
patency (RR 0.70) with aspirin, and a decreased prosthetic AV
access primary patency (RR 1.33) with warfarin.

Arterial Assesment
Venous Assesment
 MEDICAL FACTORS AFFECTING ARTERIOVENOUS
ACCESS PATENCY
Factor Level of Best Evidence Best Evidence Suggests Effect of Patency
Age Meta-analysis Yes
Gender Meta-analysis No
Diabetes Melitus Prospective series Yes
Atherosclerosis Prospective series Yes
Smoking Prospective series Yes
Obesity Prospective series No
Parathyroid hormone Prospective series Yes
Anemia Prospective series Yes
Medications Systematic review Yes
SELECTION OF ACCESS LOCATION
1. Due to easier accessibility and lower infection rates, upper extremity access sites
are used first, with the nondominant arm given preference over the dominant arm.
2. AV accesses are placed as far distally in the extremity as possible to preserve
proximal sites for future accesses.
3. As long as the patient is deemed appropriate, given their superior patency rates
and lower complication rates, autogenous AV accesses should always be attempted
before a prosthetic AV access.
4. These autogenous access configurations should include, in order of preference,
direct AV anastomosis, venous transpositions, and venous translocations.
SELECTION OF ACCESS LOCATION
Configurations of Arteriovenous Access
Forearm
Autogenous
• Posterior radial branch–cephalic wrist direct access (snuffbox
fistula)
• Radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula)
• Radial-cephalic forearm transposition
• Brachial (or proximal radial)–cephalic forearm looped
transposition
• Radial-basilic forearm transposition
• Ulnar-basilic forearm transposition
• Brachial (or proximal radial)-basilic forearm looped transposition
• Radial-antecubital forearm indirect femoral vein translocation
• Brachial (or proximal radial)-antecubital forearm indirect looped
femoral vein translocation
• Radial-antecubital forearm indirect saphenous vein translocation
• Brachial (or proximal radial)-antecubital forearm indirect looped
saphenous vein translocation
Prosthetic
• Radial-antecubital forearm straight access
• Brachial (or proximal radial)-antecubital forearm looped access
SELECTION OF ACCESS LOCATION
Configurations of Arteriovenous Access
Upper Arm
Autogenous
• Brachial (or proximal radial)–cephalic upper arm direct access
• Brachial (or proximal radial)-cephalic upper arm transposition
• Brachial (or proximal radial)-basilic upper arm transposition
• Brachial (or proximal radial)-brachial vein upper arm transposition
• Brachial (or proximal radial)-axillary (or brachial) upper arm
indirect femoral vein translocation
• Brachial (or proximal radial)-axillary (or brachial) upper arm
indirect saphenous vein translocation
Prosthetic
• Brachial (or proximal radial)-axillary (or brachial) upper arm
straight access

Adapted from Sidawy AN, Gray R, Besarab A, et al. Recommended standards for
reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg.
2002;35:603-610.
ALGORITHM
 FOREARM
Cephalic Vein
ACCESS

Basilic Vein
Alternate Vein
When the cephalic and basilic forearm veins are not felt to be adequate for
autogenous AV access, translocations of the femoral and saphenous veins are appropriate
alternatives.
 FOREARM
Prosthetic Graft
ACCESS
UPPER ARM ACCESS
Cephalic Vein

Basilic Vein
Alternate Vein
When the cephalic or basilic veins are felt to be inadequate for upper arm
autogenous access, brachial vein transpositions as well as femoral and saphenous vein
translocations are appropriate alternatives.
Prosthetic Graft
TECHNIQUE FOR PERMANENT ACCESS
Autogenous Access
1. After identification of the vein, the distal end is transected and flushed with heparinized saline. This
allows for evaluation of the caliber and extent of the vein and to identify any side branches.
2. With transposition accesses, the vein is completely dissected and mobilized, ligating all side
branches, to its origin.
3. After controlling the artery, an arteriotomy of 4 to 6 mm maximal length is made. The length of the
arteriotomy is limited to decrease the incidence of arterial steal.
4. The artery is flushed proximally and distally with heparinized saline to avoid thrombosis during the
anastomosis.
5. The AV anastomosis is performed between the side of the artery and the end of the vein; this
configuration decreases the subsequent risk of venous hypertension.
6. The AV anastomosis is performed using a 6-0 or 7-0 monofilament nonabsorbable continuous suture
to avoid subsequent anastomotic dilation.
7. With nontransposed access, after completion of the anastomosis, large venous branches can be
ligated through stab incisions. This encourages flow in the main venous segment, which may promote
earlier maturation.
 TECHNIQUE
Prosthetic Access
FOR PERMANENT ACCESS
1. The length of the arteriotomy does not have to be limited to 4 to 6 mm. The diameter of
the graft will limit the incidence of arterial steal.
2. The artery is flushed proximally and distally with heparinized saline to avoid thrombosis
during the anastomosis.
3. A 6-mm polytetrafluoroethylene (PTFE) prosthetic graft is used for conduit (see
considerations further on).
4. The anastomoses are performed using a 6-0 or 7-0 monofilament nonabsorbable suture in
a continuous manner.
5. Careful attention to sterile technique is paramount to avoid graft infections.

Choice of Prosthetic Material

FOLLOW-UP
POSTOPERATIVE FOLLOW-UP
LONG-TERM FOLLOW-UP
RESULTS
AV access is functional only if it can deliver a flow rate of 350 to 400 mL/min without
access recirculation to maintain a dialysis treatment time of less than 4 hours.
Primary patency is the interval between the time of access placement and any
intervention designed to maintain or reestablish patency, access thrombosis, or the
time of measurement of patency.
Assisted primary patency is the interval between the time of access placement and
access thrombosis or the time of measurement of patency, including any intervening
surgical or endovascular manipulation.
Secondary patency is the interval between the time of access placement and access
thrombosis, access abandonment, or the time of measurement of patency, including
any intervening surgical or endovascular manipulations designed to reestablish
functionality after access thrombosis.
ARTERIOVENOUS ACCESS FAILURE
ARTERIOVENOUS ACCESS FAILURE
PREDICTORS PRIMARY FAILURE
Age
Sex
Race
Diabetes
History of coronary artery disease
Peripheral vascular disease
Obesity
Location of the fistula
site for stenosis in grafts occurs at the graft-vein anastomosis in 80% to 85% of the
time followed by intragraft stenosis 11% to 15% and the graft-artery anastomosis
2% to 5% of the time.
Fistulas tend to develop stenosis most commonly either at the juxta-anastomotic site
and the outflow vein (70%-85%).
In the remaining 15% to 30% of the time, the lesion develops on the arterial site,
which includes the feeding artery and anastomosis.
STENOSIS AVF
Initiated by endothelial cell injury which leads to smooth muscle proliferation and
neointimal hyperplasia.
Factors lead to endothelial injury : shear stress from turbulent blood flow, mechanical
trauma from venepuncture, angioplasties.
The primary cause of fistula and graft thrombosis
AVF : MOLECULAR AND SYSTEMIC
PATHOPHYSIOLOGY
Abnormal high flow connection between an artery and vein which allows blood to flow directly
from an artery into a vein, thus bypassing the capillary bed.
A direct connection between a high pressure artery and a low pressure vein short circuits the
capillary bed and results in a marked increase in blood flow in the afferent artery. This results
in high wall shear stress and compensatory enlargement of the afferent artery with ultimate
normalization of wall shear stress levels as the artery dilates. This adaptive enlargement is
endothelial dependent and is mediated by endothelial nitric oxide (NO) release. In addition
there is up-regulation of proinflammatory gene expression, endothelial and smooth muscle
proliferation and restructuring of the elastincollagen extracellular matrix. On the venous side,
the increase in intraluminal blood pressure and flow velocity induces up-regulation of
monocyte chemoattractant protein-1, plasminogen activator inhibitor-1, endothelin-1 and
transforming growth factor-B1. Intimal and smooth muscle proliferation results in thickening of
the wall of the vein and neointimal hyperplasia.
DIAGNOSTIC MODALITIES
Duplex ultrasound
MRI
CT scanning with contrast
Catheter based angiography
 MANAGEMENT
Percutaneus Angioplasty : 90% initial technically success rate for both graft and
fistula stenosis.
Option for percutaneous angioplasty of recurring stenotic lesion : ultrahigh pressure
ballons, cutting balloon, drug-eluting balloon, angioplasty with stents.

Prevention: Role of antiplatelet and anticoagulation medication.

Antiplatelet agents (aspirin, ticlopidine, and clopidogrel)
Fish oil appears to have a protective role for graft thrombosis
TREATMENT OPTIONS
Autogenous AV Fistule Stenosis
 Relevant Stenosis : if diameter reduced by >50% and accompanied with reduction in access flow or in
measured dialysis dose
 Stenosis of the Anastomotic area : surgical treatment, alternatively PTA
 Venous outflow stenosis : PTA 1st treatment
 Balloon angioplasty : 1st line treatment of stenosis
 Persistent stenosis : cutting balloon or ultrahigh pressure balloons
 Recurring stenosis : radiologically, with or without stent plac,ent, or surgically
 Autogenous AV Fistule Thrombosis : should be treated as soon as possible (within 48hours)
 Interventional thrombolysis : can be performed mechanically or pharmacomechanically
 Surgical thrombectomy : performed with thrombectomy catheter
THANK’S
1. Jennifer m. macrae, christine dipchand, et all, on behalf of the canadian society of
nephrology vascular access work group, arteriovenous access failure, stenosis, and
thrombosis, canadian journal of kidney health and disease, 2016
2. Robyn a. macsata and anton n. sidawy, hemodialysis access: general considerations and
strategies to optimize access placement, section 27, rutherford’s vascular surgery and
endovascular therapy, 9th Edition, 2014