Comparison of Different Thoracic Trauma Scoring Systems in Regards To Prediction of Post-Traumatic Complications and Outcome in Blunt Chest Trauma

CHAPTER 73
Hemodialysis Access:
General Considerations
THOMAS S. HUBER
Based on a chapter in the seventh edition by Robyn A. Macsata and Anton N. Sidawy
nd-stage renal disease (ESRD) is a huge public health

problem with signicant morbidity, mortality, and cost. The
national initiatives and guidelines have helped dene the
standard of care for vascular access and have emphasized
the role of autogenous arteriovenous (AV) hemodialysis
access. Although a mature autogenous access likely represents
the optimal access choice, the real goal is a functional access
with minimal associated complications. The construction
and maintenance of hemodialysis access represent a signicant component of many vascular practices. Despite their
relatively minor magnitude, permanent access procedures are
associated with signicant perioperative morbidity and mortality, underscoring the patients underlying comorbidities.
Maintaining effective hemodialysis access is a lifelong
challenge that requires a long-term plan and committed
providers.
END-STAGE RENAL DISEASE

Epidemiology
ESRD, and the maintenance of hemodialysis access, is a tremendous public health problem that has reached almost epidemic proportions in the United States. In 2010, there were
594,374 prevalent (prevalence = patient count at a single
point in time) and 116,946 incident (incidence = new
patients over a time interval) cases of ESRD.1 Notably, this
represents more than tenfold increase from 1980, and it has
been estimated that this trend will continue, with estimated
prevalent and incident counts of 784,613 and 150,772,
respectively by 2020 (Fig. 73-1).2 The majority of patients
with ESRD are on hemodialysis (hemodialysis 65%, transplantation 30%, peritoneal dialysis 5%).1 Approximately
17,000 kidney transplants were performed in 2010, but the
number of patients awaiting transplant has continued to
increase and has outstripped the number of available organs.
Indeed, more than 87,000 patients in the United States were
awaiting a kidney transplant in 2010, with the median time
on the transplant list of 1.71 years.1 This gap between the
supply and demand of kidney transplants is expected to continue to widen. The majority of patients initiated dialysis in
1082
2010 (i.e., rst dialysis session) using a catheter as the sole

access (catheter 81%, stula 16%, graft 3%).1 However,
claims data suggest that there was some reduction in catheter
usage within the rst 4 months (catheter 53%, stula 17%,
graft 3%, unknown 27%).1
Morbidity and Mortality

The mortality and morbidity associated with ESRD and
maintaining access are signicant. The unadjusted 1-year
mortality rate for hemodialysis patients in the United States
was 22% as reported from the Dialysis Outcomes and Practice
Patterns Study (DOPPS) with the incident mortality rate
highest within the rst 120 days after initiation.3,4 The majority of the early deaths are related to cardiovascular and infectious causes, with the presence of a central venous catheter
and hypoalbuminemia identied as predictors.1,5 The mean
life expectancy for all patients with ESRD in the United
States is 5.8 years and, predictably, varies by age, gender, race,
and renal replacement therapy.2 Notably, the life expectancies for patients 50 to 54 years and 80 to 84 years of age are
6.3 and 2.3 years, respectively.2 Patients whose initial ESRD
treatment is a transplant are 2.3 times more likely to survive
5 years (survival probability: transplant 0.74, hemodialysis
0.33, peritoneal dialysis 0.33).1 Patients undergoing dialysis
(both hemodialysis and peritoneal) are admitted to the hospital approximately twice per year whereas those with transplants are admitted once.1 These admissions account for a
mean 12.1 hospital inpatient days per year for the dialysis
patients and 5.5 days for those with transplants.1 The corresponding principal admission diagnoses are dialysis-related
infection > bacteremia/septicemia > pneumonia > cellulitis.1
Patients on hemodialysis are more likely to be admitted with
each of these diagnoses than those on peritoneal dialysis or
with a transplant.1 The annual event (i.e., removal, replacement with catheter, replacement with internal device) and
complication (i.e., infection, sepsis) rates for hemodialysis
catheters exceed those for autogenous and prosthetic AV
accesses, with reported values of 0.7 and 2.1 episodes/year,
respectively.1 The event (i.e., replacement with prosthetic
access, replacement with autogenous access, replacement
CHAPTER 73 Hemodialysis Access: General Considerations
160
120
terms of establishing and maintaining access for hemodialysis.

However, it is important to emphasize that there are
other alternatives for renal replacement therapy. Kidney
transplantation is likely the best option for most patients,
provided that they are suitable candidates. Indeed, in almost
every single outcome measure (e.g., life expectancy, quality
of life, inpatient admission), kidney transplantation is superior to hemodialysis and peritoneal dialysis. Peritoneal dialysis is also an attractive alternative to hemodialysis and has
many advantages. It allows a more exible lifestyle but
requires a committed patient and/or family. Although the
focus of this chapter and section is hemodialysis access, these
other alternatives should be addressed with the patient and
the nephrologist, particularly those patients with limited (or
exhausted) AV access options.
Incident
Original projection: 136,882 (2015)
New projection: 150,772 (2020)
Actual: 110,854 (2006)
Number of patients (in thousands)
80
40
0
800
600
1083
Prevalent
Original projection: 713,531 (2015)
New projection: 784,613 (2020)
Actual: 506,256 (2006)
GUIDELINES AND NATIONAL INITIATIVES

400
Hemodialysis access care over the past 2 decades has been

largely shaped by the national guidelines and initiatives.
200
National Kidney Foundation

0
80
84
88
92
96
04
08
12
16
20
Figure 73-1 The projected incidence and prevalence for patients

with ESRD for years 1980 to 2020 is shown. Note the continued growth
of both patient cohorts. (From U.S. Renal Data System: USRDS 2008
annual data report: atlas of end-stage renal disease in the United States,
vol 2, Bethesda, MD, 2008, National Institutes of Health, National Institute
of Diabetes and Digestive and Kidney Diseases. Available at http://
www.usrds.org/atlas08.aspx.)
with catheter, revision, removal) and complication (i.e.,

infection, sepsis, declot, angioplasty) rates are lowest for
patients with autogenous accesses (event rate 0.25 vs. 0.13,
complication rate 0.77 vs. 0.44) although the values are comparable to rates for those with prosthetic accesses.1
Cost
The Medicare costs associated with ESRD are staggering.
Although ESRD accounts for only 1.3% of the general Medicare population, it accounted for 7.5% ($25.7 billion) of the
general Medicare costs in 2010.1 Notably, Medicare is the
primary payer for patients with ESRD in the United States
and is responsible for more than 80% of the patients.1 The
Medicare expenditure per patient with ESRD in 2006 was
greatest for patients on hemodialysis (hemodialysis $71,889,
peritoneal dialysis $53,327, transplant $24,951).2 Among
those patients undergoing hemodialysis, the expenditure
(patient per year) was greatest for those with catheters (catheters $77,093, grafts $71,616, stulae $53,470).2
RENAL REPLACEMENT THERAPY

Vascular surgeons are predominantly involved in the care of
patients with chronic kidney disease (CKD) and ESRD in
Foremost among the initiatives and guidelines is the National

Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Recommendations for
Vascular Access.6 The recommendations were originally published in 1997 as the Dialysis Outcome Quality Initiative
(DOQI) and then updated in 2000 and 2006 as KDOQI to
reect the expanded emphasis on quality improvement for
kidney disease. The KDOQI recommendations were developed through the use of an evidence-based approach encompassing an exhaustive, critical review of the literature by a
panel of experts. The stated goals included increasing the
number of autogenous AV accesses and detecting access dysfunction prior to thrombosis. The KDOQI recommendations
comprised a series of individual guidelines (Box 73-1) that
address the various components of access care, including the
selection of a specic access conguration, access placement
BOX 73-1
KIDNEY DISEASE OUTCOMES QUALITY INITIATIVE CLINICAL

PRACTICE RECOMMENDATIONS
Guideline 1: Patient preparation for permanent hemodialysis access
Guideline 2: Selection and placement of hemodialysis access
Guideline 3: Cannulation of stulae (autogenous access) and grafts
(prosthetic access) and accession of hemodialysis catheters and
port catheter systems
Guideline 4: Detection of access dysfunction: monitoring,
surveillance, and diagnostic testing
Guideline 5: Treatment of stula complications
Guideline 6: Treatment of arteriovenous graft complications
Guideline 7: Prevention and treatment of catheter and port
complications
Guideline 8: Clinical outcome goals
SECTION 13 HEMODIALYSIS ACCESS
00
Year
1084
SECTION 13 Hemodialysis Access
goals, and the management of complications. These guidelines emphasize autogenous AV access, as might be suspected
by the overarching goals, with the generic recommendations
that autogenous access should be used before prosthetic
access and that dialysis catheters should be avoided. The
expert panel dened the autogenous radial-cephalic, brachialcephalic, and brachial-basilic AV accesses as preferred and
stated that the prosthetic AV access was acceptable. The
latest version of the KDOQI guidelines established a 65%
goal for autogenous access among prevalent dialysis patients
with a catheter rate of less than 10% in the absence of a
maturing autogenous access. The expert panel stated that the
patency rate for autogenous access should be more than 3
years by life-table analysis with thrombosis and infectious
rates of less than 0.25 episodes/patient-year at risk and less
than 1% over the lifetime of the access, respectively. Similarly, the patency rates for prosthetic accesses should be more
than 2 years with a thrombosis rate of less than 0.5 episodes/
patient-year and an infection rate of less than 10% over the
lifetime of the access.
Centers for Medicare and Medicaid Services

The National Vascular Access Improvement Initiative, or
Fistula First Breakthrough Initiative, was a Centers for Medicare and Medicaid Services (CMS) project, initially spanning
2003 through 2006, that was designed to increase the proportion of hemodialysis patients using autogenous AV access as
the primary mode of dialysis.7 The stated mission of the
Fistula First was to maximize autogenous access in all suitable
patients, minimize catheter use, and avoid all types of complications. These laudable goals were implemented through
the ESRD networks using a series change concepts (Box
73-2). Notably, there were 11 initial change concepts, with
two others added later. A variety of different tools was used
BOX 73-2
FISTULA FIRST BREAKTHROUGH INITIATIVE CHANGE CONCEPTS

Routine quality review for vascular access
Timely referral to a nephrologist
Early referral to a surgeon for arteriovenous stula (AVF =
autogenous AV access) evaluation and timely placement
Surgeon selection based on best outcomes, willingness, and ability
to provide access services
Full range of appropriate surgical approaches for AVF evaluation
and placement
Secondary AVF placement in patients with AV grafts (AV grafts =
prosthetic AV access)
AVF placement in patients with catheters when indicated
Cannulation training for AVFs
Monitoring and maintenance to ensure adequate access function
Education for care givers and patients
Outcome feedback to guide practice
Modication of hospital systems to detect chronic kidney disease
and promote AVF placement
Support of the patients efforts to live the best quality of life
through self-management.
United States Prevalent Vascular Access Rates

July, 2003December, 2011
70%
60%
AVFs placed
AVFs in use
AV Grafts
All CVCs
CVCs >90 days
50%
40%
30%
20%
10%
0%
2003 2004 2005 2006 2007 2008 2009 2010 2011
Figure 73-2 The prevalent rates for the various vascular access congurations in the United States are shown for the time period from
7/2003 to 12/2011. Note the dramatic increase in the autogenous
[arteriovenous (AV) accesses] (AVFs [AV stulae] in use) and the corresponding decrease in the rates of prosthetic AV accesses (AV Grafts).
The rates of the patients dialyzing with a dialysis catheter have
remained relatively stable. CVCs, Central venous catheters. (From the
Fistula First: National Vascular Access Improvement Initiative website,
http://www.stularst.org/AboutFistulaFirst/FFBIData.aspx.)
to implement these concepts, including multimedia resources

and provider-specic education and feedback. The initial
autogenous AV access goals of the Fistula First Initiative were
identical to those of the original DOQI (incident 50%, prevalent 4), but were raised to 66% prevalence rate by 2009. A
later report suggests that these efforts have been largely successful across the United States as reected by the trend in
autogenous and prosthetic accesses (Fig. 73-2).7 In 2012,
however, the leadership of the Fistula First suggested that the
focus of the initiative should likely be catheter last, given
the high prevalence of dialysis catheter use, particularly
among incident patients.8
The Centers for Medicare and Medicaid Services has
implemented a Quality Improvement Program or pay-forperformance initiative that places up to 2% of dialysis center
payments at risk.9 This program was implemented in 2012 for
the payment year 2014 and is designed to cut reimbursement
for dialysis centers not reaching the dened benchmarks. It
is based on six quality improvement measures (three clinical
and three reporting), including one for the type of vascular
access with the access measure based on the percentages of
dialysis patients using an autogenous AV access and those
using a tunneled catheter.
Society for Vascular Surgery

The Society for Vascular Surgery also assembled a multidisciplinary group and commissioned a systematic review of the
literature to examine the timing of referral for vascular access,
the type of access to be placed, and the role of access surveillance. The multidisciplinary group then formulated seven
practice guidelines.10 Similar to KDOQI and Fistula First
guidelines, the Society for Vascular Surgery guidelines emphasized early referral to an access surgeon, the use of autogenous
1085
CHOICE OF ARTERIOVENOUS ACCESS TYPE

General Considerations
Patency
Improved patency has been cited as a major justication for
the preferential use of autogenous access. The patency rates
for upper extremity autogenous and prosthetic AV accesses
in adults were dened by Huber et al14 in their systematic
review of the literature (Fig. 73-3). Although the primary and
secondary patency rates for the autogenous access were superior, the quality of the underlying evidence was limited and
likely included a selection and publication bias. Notably, the
reported patency rates for both the autogenous and prosthetic
accessess were signicantly less than the outcome measures
dened by KDOQI. Disbrow et al15 compared the patency
rates between autogenous and prosthetic AV accesses among
incident dialysis patients with suitable veins for autogenous
access. The investigators concluded that the patency and
intervention rates for the two access types were comparable
although the patients with autogenous accesses required the
use of a tunneled catheter for a longer period. Schild et al16
reported that the long-term patency rates for prosthetic and
autogenous AV accesses were comparable, concluding that
prosthetic access should be placed in patients who were not
candidates for autogenous access. The secondary patency
80
Auto 2
60
PTFE 2
Auto 1
40
PTFE 1
20
0
0
12
15
18
21
24
27
Months
Figure 73-3 The patency rates for the autogenous (Auto) and prosthetic (PTFE) upper extremity arteriovenous (AV) accesses are plotted
against time (months) with the positive standard error bars. Both the
primary (Auto 1, PTFE 1) and secondary (Auto 2, PTFE 2) patency rates
for the two access types are shown. The patency rates for the autogenous accesses were better than their corresponding prosthetic counterparts with the one exception of the initial (1.5-mo) time point for
the primary patency comparison. PTFE, Polytetrauoroethylene. (From
Huber TS, et al: Patency of autogenous and PTFE upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg 38:10051011, 2003.)
rates for prosthetic access were 75% at 1 year in a multicenter,

randomized trial examining the role of dipyridamole, although
a comparable percentage (i.e., 75%) of patients required an
intervention to maintain patency.17 Notably, these patency
rates were comparable to those reported for autogenous access
by Huber et al14 in their systematic review.
Autogenous Access Maturation

The construction of autogenous AV access requires an obligatory time for the access to mature or to become suitable for
dialysis, with a median of 98 days in the United States as
reported from the Dialysis Outcomes and Practice Patterns
Study.18 During this maturation period, the vein that constitutes the access dilates, the wall thickens (or becomes arterialized), and the ow through the access circuit increases.
The KDOQI guidelines have dened the rule of 6s as the
criteria for access maturation and/or suitability for cannulation; they include a vein diameter of 6 mm, an access ow
rate of 600 mL/min, and an access depth of 6 mm below the
skin.6 Unfortunately, a signicant proportion of the autogenous accesses fail to mature to suitability for cannulation.
Dember et al19 reported that the autogenous access nonmaturation rate was 62% in the Dialysis Access Consortium
(DAC) trial, a multicenter, randomized, National Institutes
of Health (NIH) trial examining the effect of clopidogrel on
early patency. Similarly, Huijbregts et al20 reported that the
implementation of guidelines to increase the autogenous
access rate in the Netherlands was associated with a nonmaturation rate ranging from 8% to 50% among the contributing centers. The DAC trial has been criticized for the
high nonmaturation rate, the relatively low rate of remedial
procedures, and the large number of participating surgeons.
The requirements for an ideal AV access include a ow

rate sufcient for effective dialysis, excellent long-term
patency, minimal access-related complications, and a cosmetic appearance acceptable to patients. Unfortunately, no
access type fullls all of these requirements. A mature
autogenous AV access satises most of these criteria and
is likely the optimal access choice, as emphasized by
the national guidelines and initiatives previously detailed.
Indeed, most developed countries outside the United States
have already achieved the KDOQI targets.13 However, it
is important to emphasize that the ultimate goal is a functional access with minimal complications, not necessarily
an autogenous access.
100
Percent Patent
access, and the role of access surveillance and monitoring.

However, the systematic review that constituted the basis for
the recommendations emphasized the limitations in the supporting evidence. The researchers concluded that low
quality evidence from inconsistent studies with limited protection against bias shows that autogenous access for hemodialysis is superior to prosthetic access.11 Similar statements
qualifying the recommendations for early referral and access
surveillance were published in the guidelines. Indeed, there
has been some resistance or pushback with regard to several
of the KDOQI guidelines, as reected by the evolution from
stula rst to catheter last and the focus on a functional
access rather than an autogenous access. Hiremath et al12
performed a decision analysis examining the strategy of early
referral as recommended by the guidelines and concluded
that a wait strategy may be associated with greater qualityadjusted life expectancy.
1086
However, it was a well-designed randomized, controlled trial

conducted primarily at academic medical centers.
This inability of some autogenous AV accesses to mature
represents the major limitation. This inability to mature
can be multifactorial and related to early thrombosis, failure
of the vein to dilate, or the inability to cannulate. Review of
the DAC trial found that among the accesses that failed to
mature, roughly half were abandoned, a quarter were followed
up but never cannulated, and a quarter failed cannulation
attempts. Some surgeons believe that the greater emphasis on
autogenous access from KDOQI and Fistula First has resulted
in the unintended consequence of increasing the nonmaturation rate, raising the number of remedial procedures to facilitate maturation (and associated costs), and extending the
period of catheter dependence.21,22 The National Institutes of
Health recognized the nonmaturation issue identied by the
DAC trial and has funded a follow-up study, the Hemodialysis
Fistula Maturation Study, to examine the predictors of maturation, including anatomy, biology, patient-specic factors,
and processes of care. Rosas and Feldman23 performed an
analysis comparing autogenous and prosthetic AV access for
incident dialysis patients and found that there were minimal
differences in the quality-adjusted life years saved (QALYS),
with an autogenous access choice being the dominant strategy if the maturation rate was greater than 69%. Xue et al,24
performing a similar decision analysis among incident dialysis
patients, found that autogenous accesses were favored but
that the observed differences were less that those suggested
by the literature; they concluded that patients with a high
risk for autogenous access failure may be better served with
other access options.
Morbidity, Mortality, and Cost

The overall morbidity, mortality, and costs associated with
maintaining hemodialysis access also strongly favor both
autogenous and prosthetic AV accesses over tunneled dialysis
catheters, as highlighted previously.25-28 There is likely an
incremental benet in favor of autogenous access over prosthetic accesses in terms of infectious complications, but the
differences in terms of the other measures are somewhat
equivocal.23,25,26
Role of Prosthetic Arteriovenous Accesses

and Catheters
Despite the strong emphasis on autogenous AV access, several
advantages of prosthetic access and tunneled catheters merit
discussion. Prosthetic accesses afford a large surface area
(depending on conguration) and are easier to cannulate
than autogenous accesses. Indeed, a survey of provider preferences reported that the dialysis nurses and technicians preferred prosthetic accesses because of the ease of cannulation,
whereas physicians preferred autogenous accesses because of
the better patency and lower complication rates.29 The obligatory maturation period for prosthetic accesses is shorter
(commonly 3-6 weeks), and there are a few commercially
available prosthetic accesses that can be cannulated immediately after implantation. Prosthetic accesses are more
amenable to remedial therapies in the presence of a failing

or thrombosed access than autogenous accesses. Additionally,
the prosthetic accesses come in a variety of lengths and congurations and there is essentially an unlimited supply. The
major advantage of tunneled dialysis catheters is the relative
ease associated with insertion (and removal). Indeed, they
can provide an immediate life-saving access for the patient
without a functional permanent access.
Patient-Specic Considerations
The goal for the individual patient is to establish the most
functional access with good long-term patency and minimal
complications. As outlined previously, this is an autogenous
AV access for most patients. However, a variety of concerns
should be addressed in this complex decision process about
the most appropriate access for a specic patient, including
age, gender, life expectancy, anatomy, comorbidities, likelihood of success (i.e., autogenous maturation rate, long-term
prosthetic access patency), urgency of dialysis, and patient
preference. In most cases, the question about the most appropriate access can be distilled down to whether the patient is
suitable for an autogenous AV access and whether the access
is likely to be successful. The important distinction between
the emphasis on a functional access and an autogenous access
is illustrated by the prospective, longitudinal study by Solesky
et al,22 who tracked outcome after access creation. They were
able to achieve the national target rate for autogenous access
of 66%, but a signicant portion of the dialysis support over
the study period was provided by catheters, with a 27% catheter prevalence rate. This experience led them to conclude
that the current algorithms are problematic and rely heavily
on catheters.
Predicting Autogenous Access Outcome

A variety of factors have been identied to predict whether
an autogenous AV access will mature and/or maintain
patency. Unfortunately, the reports in the literature have
been somewhat contradictory and/or inconsistent, and it is
the collective hope that the Hemodialysis Fistula Maturation
Study, which ended enrollment in August 2013, will provide
further insight. In 2012, Smith et al30 published an exhaustive
systematic review of the available literature in which they
identied several nonmodiable and modiable factors.
The nonmodiable factors include increased age, diabetes,
predialysis hypotension, artery diameter, arteriosclerosis, vein
diameter, and vein distensibility. The modiable factors
include smoking, timing of referral for access, preoperative
ultrasound imaging, anastomotic conguration, anastomotic
technique, ow assessment, antiplatelet agents, far-infrared
therapy, and the timing of cannulation. Notably, gender, body
mass index, access surveillance, and the various needle cannulation techniques were not found to be predictive of autogenous access success.
Age. Advanced age has consistently been associated with
autogenous AV access failure, particularly with regard to the
radial-cephalic conguration.31-34 Indeed, it has been suggested that the national initiatives may need to be reevaluated for elderly patients.35 Advanced age and life expectancy
are interrelated in terms of access choice because the improved
long-term patency attributed to autogenous accesses may not
be as relevant for elderly patients, particularly if one considers
that the obligatory period from access creation to cannulation can be prolonged. Vachharajani et al36 examined the role
of the Fistula First Initiative in octogenarians and emphasized
that life expectancy and functional status should be considered, given the poor long-term outcome, high mortality, and
high discharge rate to a chronic care facility of the patients
in the study. Tunneled dialysis catheters may be a reasonable
option in some elderly patients.
Obesity. Obesity has not been shown to be a consistent

predictor of autogenous access failure except perhaps for
patients in the highest quartile.41 However, the presence of
obesity clearly affects the decision about the most appropriate
access choice and increases the likelihood of postoperative
complications, particularly wound complications. Obese
patients have been found to have the same number of autogenous access options on noninvasive imaging.42 However, the
cephalic vein, which usually courses supercially, may be
somewhat deep relative to the skin and mandate elevation
and/or transposition in an obese patient.43
Vessel Characteristics. The quality of the inow artery and
the outow vein has consistently been associated with AV
access success. Indeed, the quality of the inow artery has
likely been underappreciated as a signicant component. The
absolute diameter thresholds have been somewhat variable
and series dependent. However, arterial diameters smaller
than 2 mm have consistently been associated with poor
autogenous maturation rates.44-46 This nding is relevant to
the radial artery because the brachial artery is consistently
above this threshold, even in small women. These threshold
radial artery diameters and their associated poor maturation
rates likely reect the presence of forearm arterial occlusive
disease and the inability of the forearm vessels to dilate in
response to the AV stula rather than the absolute diameter
measurement, because smaller-diameter arteries in children
(without atherosclerosis) can frequently yield successful,

mature autogenous AV accesses. The early or high bifurcation
of the brachial artery (i.e., early takeoff of the radial artery),
seen in up to 20% of individuals, has also been associated
with lower success rates for both autogenous and prosthetic
accesses.47,48 The success rate for brachial arterybased autogenous access have been consistently shown to be greater than
those originating off the radial artery, likely reecting the
vessels absolute diameters and the distribution of arterial
occlusive disease as noted previously.20,49,50 The absolute vein
diameter that has been predictive of a successful autogenous
access have varied, with minimum criteria ranging from more
than 2.0 mm to more than 3.0 mm.51-53 Notably, Mendes
et al51 reported that veins with a diameter less than 2 mm
were associated with a 16% maturation rate for radial-cephalic
accesses. My colleagues and I, at the University of Florida,
have used 3.0 mm as our minimal vein diameter criteria for
adults, largely on the basis of our experience with lower
extremity revascularizations.54
Patient Preference. Patient preference should also be factored into the decision algorithm about the most appropriate
access type or conguration. As already noted, physicians
prefer the autogenous access because of its better long-term
outcome, whereas the dialysis staff prefers the prosthetic
access because the ease of cannulation.29 However, patients
prefer a supercial access in the forearm and are more
concerned about the ease of cannulation, cosmetic appearance, and impact on daily life than about the distinction
between autogenous and prosthetic accesses.29,55,56
Decision Making
The critical question remains as to how individual predictors
can or should be incorporated into the selection of the most
appropriate access choice for an individual patient. Such a
choice incorporates some potentially modiable (e.g.,
smoking, specic choice of artery/vein, obesity) and nonmodiable (e.g., age, gender, presence of peripheral vascular
disease) factors. Lok et al57 have developed a scoring system
to predict autogenous access maturation. They identied age
greater than 65 years (2 pts), peripheral vascular disease
(3 pts), coronary artery disease (2.5 pts), and white race
(3 pts) as signicant predictors. In their model, patients
were given 3 points as a baseline and then the individual
scores for the various comorbidities were summed. Successful
maturation was found to correlate with the point total, in
that patients in the highest-scoring group, with a score higher
than 9, had a failure rate of 69% (Fig. 73-4). Notably, a
70-year-old African-American woman (age 2 pts, race 0,
baseline 3 pts) with an above-knee amputation (peripheral
veno-occlusive disease 3 pts) and coronary artery disease
(CAD 2.5 pts) would have a score of 10.5, corresponding to
a 31% successful maturation rate. Interestingly, Lilly et al58
used data from the Centers for Medicare and Medicaid Services to examine the Lok model and concluded that the
model was not all that predictive, emphasizing that many
Diabetes. Diabetes has also been associated with failure of

autogenous access. As for advanced age, the negative predictor for the presence of diabetes has been associated primarily
with the radial-cephalic conguration.31,37,38 Indeed, the
overall success rate for this conguration has been somewhat
poor, particularly in the presence of advanced age, diabetes,
and female gender. Why the success rate for diabetic patients
is compromised is not completely clear, but the reason is
likely related to the characteristic distribution of arterial
occlusive disease in the forearm in such patients. Interestingly, diabetic patients have been shown to have comparable
success rates for autogenous access procedures in the upper
arm and comparable access options as shown by noninvasive
imaging.39,40
1087
1088

Risk of Fistula Failure to Mature
80
70
P0.0001
Percentage (%)
60
50
69
40
30
50
20
Low risk (2.0)

Moderate risk (2.03.0)
High risk (3.17.9)
Very high risk (8.0)
34
10
24
0
N = 88
N = 169
N = 161
N = 11
Risk categories
high-risk patients still had successful autogenous accesses.

However, their validation study was limited by the administrative database, the lack of the access history, and the inability to validate the data.
Lok et al57 have incorporated their scoring system into an
initiative entitled achieve appropriate access (personal
communication, 2012). Their comprehensive approach
includes selecting the most appropriate patient on the basis
of their scoring system, comorbidities, prior access history,
and stage of chronic kidney disease. It involves selecting the
most appropriate access for a patient with the least amount
of complications by selecting the most appropriate vessels.
Furthermore, it involves diligent follow-up with appropriate
interventions, all within the context of a multidisciplinary
team offering the full range of access options and encompassing experienced surgeons.
The role of prosthetic accesses in this patient-centric decision algorithm about the optimal access choice was further
dened by Cull (Table 73-1)59 and reects many of the issues
already identied. In his thoughtful discussion, this writer
emphasizes the balance between urgency of dialysis and the
likelihood of successful autogenous access maturation as part
of the clinical algorithm for selecting an autogenous or prosthetic access. Lacson et al60 have developed an alternative
approach, focusing on a catheter last algorithm that incorporates expanded use of peritoneal dialysis, use of early cannulation prosthetic accesses, judicious use of autogenous
accesses, careful use of existing accesses, and aggressive
follow-up with monitoring and surveillance.
ARTERIOVENOUS ACCESS CONSTRUCTION

The approach to dialysis patients is similar to the approach
to the larger cohort of patients with peripheral arterial occlusive disease, being based on adequate inow (arterial), adequate outow (vein), and an appropriate conduit (vein or
prosthetic) with a vein conduit being optimal in most
Figure 73-4 The risk that the autogenous

access will fail to mature is shown on the
basis of the risk categories and scoring
system proposed by Lok et al.57 Patients
were given 3 points at baseline and then
additional points on the basis of age >65
years (2 pts), peripheral vascular disease
(3 pts), coronary artery disease (2.5 pts), and
white race (3 pts). The individual scores for
the various comorbidities were summed
and then broken down into the following
risk categories: low risk (<2.0 pts), moderate
risk (2.0-3.0 pts), high risk (3.1-7.9 pts), and
very high risk (>8.0 pts). (From Lok CE, et al:
Risk equation determining unsuccessful cannulation events and failure to maturation in
arteriovenous stulas (REDUCE FTM I). J Am
Soc Nephrol 17:3204-3212, 2006.)
situations. Despite some resistance to the national guidelines

already outlined, an autogenous AV access is usually the best
choice for a functional access, and it has been our experience
that it is possible to achieve this end point for most patients,
as reported in our prospectively validated algorithm (Fig.
73-5).53 We have relied on a tunneled catheter as a bridge
until the permanent access is suitable for cannulation in
patients with ESRD (as opposed to CKD) and have assumed
an aggressive approach to failing or nonmatured accesses.
However, we have made every attempt to limit the use of
Table 73-1
Factors Inuencing Vascular Access

Selection and Success
Clinical scenarios
favoring autogenous
success
Clinical scenarios
favoring prosthetic
access
Factors that adversely

inuence autogenous
access maturation
Young patient age

Favorable vascular anatomy (artery
>2.0 mm; vein >3.0 mm)
Chronic skin diseases
History of multiple previous access
infections
Immunosuppression/human
immunodeciency virus
Hypercoagulability
Multiple prior prosthetic access failures
Imminent need for or currently
undergoing hemodialysis
Short life expectancy
Morbid obesity
Unfavorable vascular anatomy
Diabetes mellitus (radial and ulnarbased accesses)
Arterial diameter <2.0 mm
Calcied radial artery
Vein diameter <3.0 mm
Congestive heart failure
Advance patient age
Female gender
Reproduced from Cull DL. Role of prosthetic hemodialysis access following

introduction of the Dialysis OUtcome Quality and Fistula First Breakthrough
initiatives. Semin Vasc Surg 24:89-95, 2011.
Patient presenting for access
Noninvasive arterial/venous imaging
Potential autogenous access
Invasive arterial/venous imaging
Potential
autogenous access
No potential
autogenous access
Autogenous access
Adjuncts for
autogenous access
Serial assessment
Remedial imaging/
intervention
Mature access
Construct prosthetic access
catheters, in accordance with the national guidelines. Lastly,

we have not felt limited by the usual convention of using the
nondominant extremity before the dominant extremity or
the forearm before the upper arm, rather electing to use the
artery and vein combination most likely to result in a functional autogenous access.
Preoperative Evaluation
Early Referral
The KDOQI recommendations outline the preoperative
evaluation for patients requiring permanent hemodialysis
access.6 Ideally, patients should initiate dialysis with a functional autogenous access, albeit rarely achieved. This goal
requires early referral to an access surgeon and access placement well in advance of the target date so that the access
(autogenous or prosthetic) is suitable for cannulation when
required, allowing for the requisite time for maturation and
remedial interventions. Accordingly, the KDOQI panel recommends that patients with a glomerular ltration rate lower
than 30 mL/min/1.73 m2 (chronic kidney disease stage 4)
should be educated about the different renal replacement

therapies (i.e., transplantation, hemodialysis, peritoneal dialysis). The panel also recommends that an autogenous access
be placed at least 6 months prior to the anticipated dialysis
start date, and a prosthetic access should be placed 3 to 6
weeks in advance. Unfortunately, it is difcult to predict a
specic start date for hemodialysis, and thus, the timing of
the access procedures can be imprecise. From a practical
standpoint, it is reasonable to construct an autogenous access
well in advance of the anticipated start date, given the
requirement to achieve maturation and the excellent longterm patency of a mature autogenous access. We usually delay
placing a prosthetic access until patients are just about to
initiate dialysis because the access can be used shortly after
construction and the longer-term patency rate is somewhat
limited.
Preservation of Autogenous Options

Patients should be engaged about their imminent need for
dialysis, and appropriate precautions should be taken to
optimize the number of potential access options. All upper
extremity veins that are potentially suitable for an access
should be preserved, and both percutaneously inserted central
catheters (PICCs) and subclavian vein catheters should be
avoided. PICC lines have been reported to cause a central
vein stenosis or occlusion in up to 7% of cases and the adverse
event rate is as much as 40% for subclavian catheters.61,62
Notably, these central vein lesions potentially preclude an
ipsilateral permanent access. In the inpatient setting, we frequently post a sign above the patients bed recommending
against blood draws or intravenous catheters in the extremity
selected for the future access, and we have educated our PICC
team and intensivists about the complication of central vein
cannulation. Similarly, we have also avoided using arm veins
for lower extremity revascularizations in patients with CKD
and ESRD.
History and Physical Examination

Patients should undergo a complete history and physical
examination as for any other major vascular surgical procedure, and all medical comorbidities should be optimized.
Access procedures are often considered minor or add-on
cases by uninformed health care providers, but this attitude
is inappropriate. Patients with CKD and ESRD frequently
have multiple active comorbidities, as emphasized by the
22% annual mortality rate for patients starting dialysis.3 Not
surprisingly, the morbidity and mortality rates associated with
the various access procedures are also signicant. The history
should include documentation of prior access procedures,
revisions, and associated complications, with special attention to prior central vein cannulation, arm edema, and hand
ischemia. Physical examination should include a thorough
pulse examination with an Allens test to determine the
dominant blood supply to the hand along with examination
of the neck and chest to look for venous collaterals. The
operative procedure should be coordinated with the dialysis
schedule for patients with ESRD, and we prefer to operate
Figure 73-5 An algorithm for patients presenting for permanent

hemodialysis access. Note that invasive arterial/venous imaging now
includes both catheter- and CT-based arteriography and venography.
Patients with no potential autogenous access due to peripheral veins
that are insufcient diameter (<3 mm) either undergo re-imaging in
the operating room with ultrasound after induction of anesthesia or
dissection and direct exploration of the veins. Adjuncts for autogenous access include endovascular treatment of arterial inow/venous
outow lesions and composite access congurations. (From Huber TS,
et al: Prospective validation of an algorithm to maximize arteriovenous
stulae for chronic hemodialysis access. J Vasc Surg 36:452-459, 2002.)
1089
1090
on non-dialysis days if possible, given the logistics of coordinating both procedures (i.e., dialysis, access procedure)
and the fact that most patients are physically tired after
dialysis.
Noninvasive Imaging
Noninvasive imaging in the diagnostic vascular laboratory is
the cornerstone of our approach to permanent dialysis access.
It is also recommended by the KDOQI and likely represents
the current standard of care. Numerous studies have documented that preoperative noninvasive imaging increases
the percentage of patients undergoing autogenous access,
although whether it results in a higher autogenous access
maturation rate has been less clear.52,63-65 Notably, Ferring
et al66 performed a randomized, controlled trial and reported
that preoperative noninvasive imaging was associated with a
lower initial failure rate for autogenous access, improved
primary assisted patency at 1 year, but no difference in primary
patency at the same time point.
The noninvasive imaging in our practice includes the
evaluation of both the arterial and venous circulation. Specically, pressure measurements in the brachial, radial, ulnar,
and digital arteries are taken, and the corresponding Doppler
waveforms of all but the digital vessels are recorded. The
Allens test is repeated, and the diameters of both the radial
(at the wrist) and brachial (at the antecubital fossa) arteries
are measured. The cephalic and basilic veins are interrogated
with ultrasound from the wrist to the axilla, complete with
diameter measurements similar to the preoperative vein
survey obtained prior to infrainguinal arterial revascularization. The upper extremity central veins are also examined for
the presence of deep venous thrombosis, although the interrogation of the veins within the thoracic cavity is limited.
Notably, there is some variation in the vein diameter measurements, likely secondary to the variations in the patients
general state of hydration related to their dialysis cycle.67
This variation justies repeating the peripheral vein imaging
if the basilic and cephalic veins are deemed too small on the
initial study.
The preoperative noninvasive venous imaging has been
widely accepted, but the arterial imaging has not been as
widely adopted. We would contend that the arterial imaging
is equally important, given the high incidence of occlusive
disease in both the forearm and inow (i.e., subclavian, axillary, proximal brachial) vessels and the signicant anatomic
variants that can compromise the access choice and maturation rate.47,48,68-70
Access Conguration
A preliminary operative plan can usually be generated on the
basis of the results of the history, physical examination, and
noninvasive imaging. Our criteria for an adequate artery
include no hemodynamically signicant arterial inow stenoses and a diameter greater than 2 mm, and those for the vein
include no outow stenoses and a peripheral vein segment of
suitable length and diameter (>3 mm).53 Although these
criteria have been validated for autogenous access, they are
BOX 73-3
ARTERIOVENOUS ACCESS CONFIGURATIONS

FOREARM
Autogenous
Posterior radial branchcephalic wrist direct access (snuffbox
stula)
Radial-cephalic wrist direct access (Brescia-Cimino-Appel stula)
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
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, et al: Recommended standards for reports
dealing with arteriovenous hemodialysis accesses. J Vasc Surg 35:603-610,
2002.
also likely appropriate for patients being evaluated for a prosthetic access.
The possible access congurations are shown in Box 73-3,
as listed by the nomenclature recommended by the Society
for Vascular Surgery Reporting Standards.71 This exhaustive
list can be distilled down to autogenous radial-cephalic, other
forearm autogenous, autogenous brachial-cephalic, autogenous brachial-basilic, other upper arm autogenous, forearm
prosthetic, and upper arm prosthetic. Notably, this list reects
our preferences in descending order and is consistent with
the KDOQI guidelines (preferred: autogenous radial-cephalic,
brachial-cephalic, transposed brachial-basilic; acceptable:
forearm prosthetic, upper arm).
Distal Radial-Cephalic Autogenous Arteriovenous Access.
The autogenous radial-cephalic AV access at the wrist was
the earliest autogenous accesses described and can be an
excellent option for certain patients. Unfortunately, it is
Other Forearm Autogenous Arteriovenous Accesses. There

are a variety of other autogenous options in the forearm, as
outlined in Box 73-3. The radial-basilic conguration is a
reasonable option provided that the artery and vein are large
enough. Indeed, Silva et al80 have reported excellent patency
rates with the use of transposed forearm veins, superior to
those traditionally reported for the radial-cephalic conguration, whereas others have reported that the patency rates are
better than those for prosthetic AV accesses.81 The ulnar
artery can be used for autogenous access, but the reported
series are small, and access failure potentially puts the hand
at some risk, given the fact that most patients are ulnar
dominant.82-84 The radial artery in the forearm can also be
used to construct a radialmedian antecubital vein AV access
(i.e., middle-arm AV access), preserving bidirectional ow in
the vein with a side-to-side anastomotic conguration.85,86
Jennings87 has reported excellent results for a similar technique (i.e., side-to-side anastomosis with retrograde cephalic
ow) using the proximal radial artery. Alternatively, the
cephalic or basilic vein in the forearm can be transposed in
a loop conguration with the arterial anastomosis on the
brachial artery in the antecubital fossa. This is a potential
option for diabetic patients who have signicant forearm
occlusive disease, but the vein loop is usually quite short, and
the available sites for cannulation are somewhat limited.88
Upper Arm Autogenous Arteriovenous Access. The brachialcephalic and brachial-basilic are the traditional or common
upper arm autogenous access options and are associated with
better patency rates than the forearm autogenous AV accesses
as already noted. The proximal radial artery can be used as
an alternative to the brachial artery at the antecubital fossa,
and essentially all the same access congurations can be constructed. Access procedures based on the proximal radial
artery may have a lower incidence of access-related ischemia,
commonly referred to as steal syndrome (see Chapter 78),
than the brachial artery, although the obvious tradeoffs are
the absolute size of the artery and the quantity of arterial
inow. Both a randomized, controlled trial89 and a metaanalysis90 have reported that the autogenous brachial-basilic
access is superior to an upper arm prosthetic AV access in
terms of patency and reintervention rates. The basilic vein is
an attractive choice for an autogenous access because it is
relatively thick walled, large in diameter, and well preserved
in terms of cannulation for venipunctures and intravenous
catheters due to its relatively deep course. The transposed
brachial-basilic AV access can be performed as either a singleor a two-stage procedure (i.e., anastomosis/transposition or
anastomosis with subsequent transposition). El Mallah91
reported that the patency rates were superior for the twostage approach in a small, randomized trial, but the results
from other retrospective series have been contradictory.92,93
The two-stage procedure affords the obvious advantage that
the transposition is not performed unless that vein has
matured or dilated sufcient for cannulation, thus avoiding a
more complicated procedure (and the potential wound complications) unless there is some assurance that the access will
be successful. It has also been our anecdotal impression that
the maturation rate for the basilic vein is higher for the
two-stage approach.
The other autogenous AV access options in the upper
arm include the brachial-brachial and brachial-median antecubital AV accesses. The published experience with the
brachial-brachial conguration is somewhat limited and
contradictory.94-96 However, it is another autogenous option
for patients with a large brachial vein or paired brachial
veins. These veins are often intimately attached to the
brachial artery and have multiple communicating branches
that can complicate the dissection. The brachial-brachial
autogenous access can be constructed in two stages, as outlined previously for the brachial-basilic conguration, and
the same advantages apply. The brachialmedian antecubital
access (i.e., Gracz) can be an attractive option in patients
with CKD whose veins are somewhat diminutive and in
whom dialysis is not imminent.97 The cephalic or basilic
veins, which have diminutive outow, may ultimately dilate
enough to be suitable for cannulation.
Prosthetic Arteriovenous Access. The increased emphasis
on autogenous access by the KDOQI guidelines and the other
national initiatives has gradually decreased the number of
prosthetic AV accesses, although they play a signicant role
and may be a better access choice for some patients, as
not always an option, Jennings et al72 reporting that it

accounted for less than 10% of their access congurations.
Rooijens et al,73 who performed a meta-analysis of autogenous radial-cephalic access, reported an initial failure rate
of 15% with a primary patency rate of 65% at 1 year,
concluding that the conguration was associated with moderate rates of both failure and success. In another report,
Rooijens et al74 performed a randomized trial of autogenous
radial-cephalic and prosthetic AV accesses in patients with
compromised vessels and concluded that the patency rates
were poor in this setting, although there was no benet
for prosthetic access.
The success rates for the autogenous radial-cephalic AV
access are lower than those reported for brachial arterybased
procedures75-77 and are likely lower for women, diabetics, and
older patients, with the combination of these three risk
factors particularly bleak.31,32,37,38 The poor success rates in
these cohorts of patients likely reects the presence of forearm
arterial occlusive disease and the inability of the forearm
vessels to dilate in response to the AV communication
sufcient to increase ow and sustain effective dialysis.
Indeed, this nding is consistent with the observations that
radial arteries of size below a certain threshold (diameter
<1.5 mm to 2.0 mm) are less likely to be successful.44-46
The outcomes for the autogenous radial-cephalic AV access
constructed at the wrist or the anatomic snuffbox are likely
comparable.78,79 The anastomosis for the autogenous radialcephalic AV access is traditionally congured in an end
(vein)-to-side (artery) conguration to reduce the likelihood
of venous hypertension in the hand from retrograde venous
ow (i.e., side-to-side conguration).
1091
1092
outlined previously. Historically, the radial-antecubital (i.e.,

median antecubital, basilic, cephalic) conguration was used
in the forearm, but this has been largely replaced by the
brachial-antecubital conguration because of the larger size
of the brachial artery. In our practice, we rarely construct a
forearm prosthetic access because it is not usually an option
(i.e., no suitable outow veins at the antecubital fossa) after
we have exhausted the various autogenous options in the
forearm and upper arm. The upper arm prosthetic AV access
can be congured in a brachial-axillary conguration with
use of a segment of the brachial artery in the axilla or immediately proximal to the antecubital fossa. Although the
patency rates for the two congurations are likely comparable, the incidence of access-related ischemia may be lower for
accesses based off the more proximal artery near the axilla.
Despite the manufacturers claims, the patency rates for the
various prosthetic (e.g., polytetrauoroethylene [PTFE],
heparin-bonded PTFE) and nonautogenous biologic materials (e.g., bovine mesenteric vein, bovine carotid artery) are
likely comparable. The prosthetic grafts that the manufacturers claim can be cannulated immediately after implantation
afford some advantage in terms of reducing the need and/or
duration of dialysis catheters. However, it has been our anecdotal impression that patients are not very willing to have
their new accesses cannulated early because of the residual
discomfort from the surgical procedure itself.
Additional Imaging
The access conguration chosen on the basis of the noninvasive imaging may be conrmed with additional imaging.
We have traditionally used catheter-based venography and
arteriography, although they have partially been replaced by
computed tomography (CT)based alternatives. Notably, the
techniques for the CT venogram and arteriogram are somewhat different, and specic protocols should be developed
with the radiology team to ensure that the vessels of interest
are adequately imaged. The potential indications for arteriography are the presence of peripheral arterial occlusive
disease, diabetes, complex access procedures, multiple
failed access procedures, abnormal noninvasive studies, and
prior episodes of access-related hand ischemia. The potential
indications for venography include arm edema, multiple
venous collaterals, pacemakers, multiple central venous
catheters, multiple prior access procedures, and complex
reconstructions.
We have reported a 40% incidence of some type of abnormality on catheter-based arteriography and venography
during the prospective validation of our access algorithm,
with the ndings affecting the operative plan in up to half
the cases.53 Our ndings are likely not particularly surprising,
given the presence of forearm arterial occlusive disease in
the diabetic population and the high incidence of central
vein problems reported with central venous catheters, PICC
lines, and pacemakers. Iodinated contrast agents are nephrotoxic and relatively contraindicated in patients with CKD,
although the associated risk can be reduced with a combination of hydration, acetylcysteine, and sodium bicarbonate.
Unfortunately, gadolinium, an alternative contrast agent, is

contraindicated in patients with CKD or ESRD because of
the risk of nephrogenic systemic brosis. Similarly, the use
of carbon dioxide in the upper extremity is contraindicated
because of its potential to enter the cerebral circulation.
Strategies to Reduce Complications

As for most surgical procedures, the incidence of postoperative complications after AV access procedures may be reduced
by the appropriate preoperative plan. The combination of
the artery and vein should be carefully selected to optimize
maturation and patency. The course of the target vein is
marked on the skin in the noninvasive vascular laboratory
during the preoperative evaluation in an attempt to minimize
intraoperative dissection and potentially reduce the incidence of wound complications. Autogenous access should
be used preferentially for patients with recurrent infections.
Notably, several studies have reported that patients with
human immunodeciency virus (HIV) have an increased
rate of infectious complications with prosthetic access.98-100
Obese patients have a higher risk of wound complications,
particularly with the extensive incision required for a transposed brachial-basilic autogenous access. Options for obese
patients include a forearm prosthetic access, a two-stage
brachial-basilic autogenous access (avoiding the transposition until the access is mature), and the use of subcutaneous
lipectomy to essentially remove the overlying fat as an alternative to transposition.101 Patients with a history of accessrelated hand ischemia and those deemed to be at high risk
(i.e., advanced age, female gender, peripheral arterial occlusive disease, diabetics, large conduits, multiple prior access
procedures) should likely have an arteriogram to exclude an
arterial inow stenosis. Siting the arterial anastomosis proximal on the arterial tree (i.e., proximal vs. distal brachial
artery) may reduce the incidence of hand ischemia as a
preemptive variant of the remedial treatment referred to as
proximalization of the arterial inow (PAI).102 In particularly worrisome cases, we have obtained a lower extremity
vein survey during the preoperative evaluation to identify a
potential conduit for a distal revascularization and interval
ligation (DRIL) procedure.103 Lastly, we have avoided placing
permanent AV accesses in patients with ipsilateral central
vein stenosis or occlusion, which we consider a relative contraindication. Notably, the central vein stenoses/occlusion
secondary to pacemaker wires seem to be particularly problematic and fairly refractory to the usual endovascular
interventions.104,105
Operative Technique
The generic operative technique for hemodialysis access is
identical to that for all vascular surgical procedures, but
several points merit further comment. First, the choice of
anesthesia is based primarily on surgeon and patient preference, the various local, regional, and general approaches all
being acceptable. There is some suggestion that regional
anesthesia may lead to dilatation of both the peripheral veins
Autogenous Radial-Cephalic Arteriovenous Access

A 3-cm incision is made in the distal forearm midway between
the radial artery and the cephalic vein (Fig. 73-6). Small skin
aps are created, and the cephalic vein and radial artery are
dissected free. A sufcient length of vein (approximately

3 cm) should be mobilized to facilitate its transposition onto
the artery. The vein is transected, gently distended with
saline, and then spatulated to enlarge the anastomosis. The
artery is occluded with two small microvascular clamps, and
a 7- to 8-mm arteriotomy is created with use of a scalpel and
ne arteriotomy scissors. The end-to-side anastomosis is performed using a running 6-0 monolament vascular suture.
A thrill should be detected in the outow vein upon completion of the AV anastomosis, although it is not always
found after a radial-cephalic AV access, presumably owing to
spasm in the artery and vein. The anastomosis and the perfusion to the hand (i.e., ulnar artery, palmar arch, digital artery)
should be interrogated with continuous wave Doppler ultrasonography. A continuous Doppler signal throughout systole
and diastole should be detected in the outow vein. A pulsatile or arterial signal in the vein suggests an outow obstruction and mandates further investigation with a stulagram
or duplex ultrasound or revision of the anastomosis. These
concerns are relevant for all of the access congurations
detailed here.
Autogenous Radial-Basilic Arteriovenous Access

A 3-cm incision is made directly over the radial artery, immediately proximal to the wrist. The basilic vein is exposed with
an incision from the antecubital fossa to the wrist, and this
step can be facilitated with the preoperative vein marking.
The vein is transected at the wrist and then distended with
saline. The vein is tunneled across the volar aspect of the
forearm to the radial artery incision in a gentle, curved course
with use of a vascular clamp or graft-tunneling device. The
vein should be tunneled immediately deep to the dermis,
particularly in patients with considerable subcutaneous fat.
The remaining portions of the procedure, with the obvious
exception of the basilic vein closure, are identical to those
already described for radial-cephalic access.
Autogenous Brachial-Cephalic
Arteriovenous Access
End to end
anastomosis
Figure 73-6 Radial-cephalic autogenous arteriovenous access. (From

Englesbe MJ, et al: Upper extremity arteriovenous hemodialysis access. In
Zelenock GB, et al, editors: Mastery of vascular and endovascular surgery,
Philadelphia, 2005, Lippincott Williams & Wilkins.)
A transverse incision is made across through the antecubital

crease over the brachial artery and cephalic vein (or median
antecubital vein) (Fig. 73-7). Care should be exercised during
the incision to prevent inadvertent injury of the veins because
they course very supercially. The cephalic vein (or median
antecubital vein) is dissected free for sufcient length to
facilitate transposing it onto the brachial artery, and this step
may require creation of superior and inferior skin aps. The
deep vein branches in the forearm join together to form
the median antecubital vein, which ultimately drains into the
cephalic and basilic veins. It can be helpful to preserve part
of these branches to help create a generous hood for the
anastomosis, although the proximal remnant should be
suture-ligated because it can retract, causing troublesome
bleeding if the tie falls off. The brachial artery is exposed by
incision of the overlying bicipital aponeurosis, and a sufcient length is dissected free for the anastomosis and occluding clamps. The vein is distended with saline and spatulated.
and inow arteries, thereby facilitating autogenous access

creation and improving their maturation rate.106-108 Second,
the use of intraoperative ultrasound may improve the identication of suitable peripheral veins for autogenous access.109
Third, the use of intraoperative anticoagulation and the specic dosage regimen are also somewhat surgeon dependent.
Patients with ESRD have an increased risk of bleeding as a
result of defects in hemostatic mechanisms secondary to
uremia and other coagulation abnormalities and likely have
some inherent protection from intraoperative thrombosis. A
randomized trial examining the role of heparin anticoagulation at the time of access construction demonstrated no
benet in terms of patency but increased bleeding.110 In our
practice, we routinely use a standard dose of heparin (i.e.,
5000 units) that is smaller than the one used for most other
open, arterial revascularizations (i.e., 100 units/kg). Fourth,
a small randomized trial has demonstrated that stapled anastomoses are comparable or superior to the traditional sutured
anastomoses, although the stapling technique has not been
widely adopted.111 Fifth, the length of the AV anastomosis is
likely irrelevant in terms of the risk of development of accessrelated hand ischemia; accordingly, the length of the anastomosis should be adequate to ensure early patency. Notably,
the ow through a large AV stula is independent of the
extent of the anastomotic length once the length exceeds
75% of the arterial diameter.112 This fact underscores the
futility of trying to reduce the size of the anastomosis because
shortening the anastomotic length of a 3-mm brachial artery
to less than 2.25 mm (i.e., <75% diameter) would likely result
in early thrombosis.
1093
1094
Cephalic
vein
Brachial
artery
End to end
anastomosis
Figure 73-7 Brachial-cephalic autogenous arteriovenous access.

(From Englesbe MJ, et al: Upper extremity arteriovenous hemodialysis
access. In Zelenock GB, et al, editors: Mastery of vascular and endovascular
surgery, Philadelphia, 2005, Lippincott Williams & Wilkins.)
A 7- to 10-mm incision is created in the artery with a scalpel

and the arteriotomy scissors, and the anastomosis constructed
with use of a 6-0 monolament vascular suture. Occasionally,
the proximal cephalic vein may be compressed by the adjacent soft tissue or tethered by a lateral branch. This problem
can usually be corrected by more distal dissection on the
outow vein (i.e., proximal on the vein), to release the soft
tissue compressing the vein as it transitions lateral to medial
on the arm and/or to ligate the branch responsible for the
tethering effect.
anastomosis. A tunnel is created along the course marked on

the skin with use of a semicircular, hollow tunneling device.
The tunneler is passed deep to the subcutaneous tissue
near the antecubital fossa and the axilla, but immediately
below the dermis throughout the region that will actually be
used for cannulation. A sharp-tipped or pointed-tipped tunneler is particularly helpful because it facilitates passing of the
device in the desired plane. The anastomosis is performed as
described previously for brachial-cephalic access. A closedsuction drain is placed in the bed of the basilic vein harvest
and brought out through a separate stab wound on the distal
upper arm near the antecubital fossa. Care should be exercised during the wound closure to prevent compressing or
kinking the basilic vein that constitutes the access.
Two-Stage Procedure. In the two-stage brachial-basilic procedure, a more limited incision is created in the proximal
upper arm, and both the basilic vein and the brachial artery
are dissected free. The anastomosis is completed as outlined
previously, and the wounds are closed. The second-stage procedure is performed when/if the vein dilates sufciently for
cannulation; we have generally used 6 mm as the threshold
vein diameter as dened by the KDOQI rule of 6s.6 A
continuous incision or a series of skip incisions is made over
the course of the vein during the second stage, and the vein
is dissected free. It has been our anecdotal impression that
the vein tends to elongate in addition to dilate during the
Autogenous Brachial-Basilic Arteriovenous Access

Single-Stage Procedure. An incision is made over the course
of the basilic vein in the proximal upper arm, immediately
above the antecubital fossa (Fig. 73-8). A limited incision is
created initially in an attempt to limit the extent of dissection and skin aps, because the vein can course quite deep
relative to the skin and preoperative marking does not always
correspond to its true location. The basilic vein courses adjacent to the medial antecubital cutaneous nerve in the upper
arm, and the nerve can serve as a landmark for the vein. The
skin incision and the dissection are extended proximally to
the axilla and distally to at least the antecubital crease. The
incision can be performed as a single, continuous one or a
series of shorter skip incisions in attempt to reduce postoperative wound complications. Either the median antecubital
or the forearm basilic vein can be used as part of the vein for
the access, provided that it is sufcient in terms of caliber and
quality. The basilic vein should be dissected throughout its
course, with ligation of small branches and oversewing of
larger, broad-based branches with a 5-0 monolament vascular suture. The distended vein is then gently draped over the
upper arm in an arc, and the future course of the transposed
vein is marked on the skin. The brachial artery is dissected
free in the distal upper arm at the site of the planned
Axillary
vein
Basilic
vein
Brachial
artery
End to end
anastomosis
Figure 73-8 Brachial-basilic autogenous arteriovenous access. (From

Prosthetic Forearm Loop Arteriovenous Access

An incision is made across the antecubital fossa, and the
brachial artery and median antecubital vein are dissected free
as described for autogenous brachial-cephalic autogenous
access (Fig. 73-9). Notably, the median antecubital, basilic,
cephalic, or deep veins can be used for the venous anastomosis, with the choice usually based on the size and quality of
the respective veins. Alternatively, the incision can be positioned 1 to 2 cm distal to the antecubital crease, and small
skin aps can be elevated to expose the vessels. The proposed
course of the prosthetic access is drawn on the forearm skin,
and the graft is draped over it to conrm that there is sufcient length. A small counter-incision is made over the proposed course of the graft at approximately the 6 oclock
position with the antecubital crease being 12 oclock. A
hollow tunneler is passed through the subcutaneous plane
along the proposed access course, with an attempt to make
the tunnel somewhat deeper (or the skin/subcutaneous tissue
thicker) near the antecubital incision and counter-incision.
A 6-mm expanded PTFE grafts is a passed through the tunnel
and then distended with saline to conrm that the graft
follows a continuous, unobstructed course. The arterial and
venous anastomoses are completed in sequence with a 5-0 or
6-0 expanded PTFE vascular suture.
Prosthetic Upper Arteriovenous Access

A prosthetic brachial-axillary AV access is commonly congured as gentle curve or a loop conguration with use of the
brachial artery immediately proximal to the antecubital fossa
or near the axilla, respectively (Fig. 73-10). Both congurations are acceptable, although the loop conguration with
Median
antecubital
vein
Brachial
artery
6 mm
PTFE graft
Separate
incision
Figure 73-9 Prosthetic forearm arteriovenous access. (From

Englesbe MJ, et al: Upper extremity arteriovenous hemodialysis access.
In Zelenock GB, et al, editors: Mastery of vascular and endovascular
surgery, Philadelphia, 2005, Lippincott Williams & Wilkins.)
the anastomosis near the axilla affords a potential advantage

for patients at risk of access-related hand ischemia, because
the anastomosis is more proximal on the arterial tree. The
brachial artery immediately proximal to the antecubital
crease can be exposed by means of a longitudinal incision
over the vessel, similar to that described for the two-stage
brachial-basilic autogenous access. The brachial artery and
axillary vein can be exposed in the axilla with a longitudinal
incision over the course of the vessels that is somewhat distal
on the arm relative to the true axilla. The vessels in the axilla
can be exposed by simple creation of small skin ap and
retraction of the skin with a hand-held retractor. This affords
the advantage of keeping the skin incision out of the axillary
crease and may reduce the incidence of wound complications.
The conuence of the basilic and brachial veins in the axilla
is somewhat variable. Accordingly, the largest identiable
vein in the axilla is used for the venous outow. A separate
counter-incision is required at the 6 oclock position to pass
the graft for the looped conguration, which can be performed like the forearm loop already described. The prosthetic graft should be tunneled in such a fashion that it
courses laterally on the upper arm, thereby making it ultimately more comfortable for the patient when he or she
positions the arm in the chair during dialysis. The arterial
and venous anastomoses are completed in sequence as outlined previously. A partial occluding clamp (e.g., baby
initial maturation period, thereby increasing the available

length that can be elevated or transposed.
The management of the basilic vein that composes the AV
access outow is dictated by the available length and the
body habitus of the patient. In the most ideal setting (i.e.,
sufcient length of vein, thin patient), the anastomosis can
be dissembled and the vein can be tunneled in a curvilinear
path over the course of the upper arm as outlined for the
single-stage procedure. If the vein length is somewhat limited
and there is a signicant amount of subcutaneous tissue, the
vein can be simply elevated and the subcutaneous tissue reapproximated deep to the vein. The medial antecubital cutaneous nerve overlies the basilic vein and must be addressed if
the vein will be simply elevated. The options include transecting the nerve or transecting/re-anastomosing the access
(i.e., arteriovenous or venovenous). Simply elevating the
basilic vein is somewhat suboptimal for two reasons. First, the
mature access courses very medially on the upper arm and
can be difcult and/or awkward to cannulate during dialysis.
Second, the vein sits immediately below the skin so it would
be vulnerable if the wound were to break down (and expose
the access). A subcutaneous pocket can be created in this
situation by elevation of skin aps, thereby avoiding having
the vein course immediately below the skin, although this
option is predicated on there being a sufcient length of vein.
1095
1096
Postoperative Care
The patient is seen in the outpatient clinic within 2 weeks

after the procedure and then at monthly intervals thereafter
until the access is suitable for cannulation. Patients with
standard prosthetic AV accesses are cleared for cannulation
at 4 to 6 weeks postoperatively, after the associated edema
and pain have resolved, although the early cannulation
prosthetic accesses can be used earlier as previously mentioned. A diagram outlining the access conguration, direction of blood ow, and date of access creation is given to the
patient, and a copy sent to the patients dialysis unit.
Patients with autogenous accesses are assessed on monthly
basis with physical examination and duplex ultrasound, as
necessary. The vein that composes the autogenous access
must be sufciently dilated and the wall arterialized to
sustain the trauma associated with repeated cannulations. As
noted previously, we have adopted the KDOQI rule of 6s
to determine whether the access is suitable for cannulation
and, accordingly, use 6 mm as the diameter criterion. Ultrasound is quite helpful to determine the vein diameter,
although we have not found the ultrasound-based ow measurements to be reliable or reproducible. Furthermore, it is
impossible to assess the integrity of the outow vein wall prior
to cannulation. We are very conservative about releasing
autogenous accesses for cannulation and have established a
relationship with patients and nephrologists such that the
accesses are not cannulated until released from our clinic. It
is important to remember that the ultimate goal is long-term
access patency, and a short delay on the front end is likely
irrelevant. In our practice, the maturation period for autogenous access is somewhere between 3 and 4 months, and this
time is consistent with the median time for rst cannulation
(98 days) in the United States reported by Rayner et al.18
Notably, these researchers reported that access cannulation
within 14 days of construction was associated with a greater
than twofold increase in access failure. Lee et al113 further
emphasized the consequences of a bad stick with a signicant hematoma, reporting that it was associated with numerous interventional procedures and 3 months of catheter
dependence.
General
Strategies to Facilitate Maturation
Patients undergoing autogenous brachial-basilic AV access

procedures and those with signicant comorbidities are often
admitted to our hospital overnight for observation, whereas
the other upper extremity accesses are routinely created in
outpatient procedures. The patient is placed on a telemetry
bed with continuous pulse oximetry. The patients electrolytes are checked and the patient is dialyzed as necessary. The
patients wound and hand function are monitored closely,
given the risk of access-related hand ischemia. The closedsuction drains from the autogenous brachial-basilic access are
usually removed on the postoperative day provided that the
drainage is minimal. All patients discharged from the recovery room (i.e., outpatient procedures) are contacted the day
after the procedure to make sure that they are recovering
satisfactorily, and, specically, that their hands are not
ischemic.
Autogenous accesses that fail to mature sufciently for cannulation are evaluated further to identify the underlying,
potentially correctable, problem. In our practice, we usually
obtain a duplex ultrasound examination at one of the early,
monthly postoperative follow-up visits, with the timing dictated by the clinical progression of the access and the patients
status, delaying further investigation somewhat in patients
with CKD and no immediate need for dialysis. Remedial
imaging and intervention are dictated by the presumed
underlying cause of the failure to mature, with the common
problems including focal stenosis in the outow vein, diffuse
stenosis in the outow vein, inadequate arterial inow, central
vein stenosis/occlusion, accessory veins, and inaccessibility
due to the access depth relative to the skin (i.e., obesity). A
stulogram with central vein runoff is usually obtained for
patients with presumed problems in the outow or central
Axillary
vein
6 mm
PTFE
graft
Brachial
artery
End to end
anastomosis
Figure 73-10 Prosthetic upper arm arteriovenous access. (From

Satinsky) can be helpful for the venous anastomosis and

facilitates occlusion of a longer length of vein without circumferential dissection.
veins, with the direction of the cannulation (i.e., retrograde

or antegrade) dictated by the presumed anatomic location
problem (e.g., peri-anastomotic, cephalic arch). A standard
arteriogram with a femoral cannulation is obtained in patients
with presumed arterial inow problems, thereby facilitating
visualization of the whole access circuit from the aortic arch
inow to the central vein return. Admittedly, arterial inow
problems are somewhat rare as a cause of early autogenous
access failure in our practice, given our preoperative noninvasive arterial imaging protocol. As with most other vascular
surgical problems, the endovascular approach has largely
replaced open surgical repair, with the latter reserved for
diffuse stenoses or refractory lesions.
Multiple reports have shown that remedial treatment can
improve access maturation and patency rates.114-116 Berman
and Gentile115 reported that secondary or remedial procedures resulted in a 10% improvement in achieving or maintaining a functional autogenous access. Not surprisingly, Lee
et al117 reported that autogenous accesses that mature without
intervention have a better long-term patency and require
fewer future interventions.
Access Elevation. Access revision with elevation has proved

to be remarkably successful and represents a variation of the
two-stage brachial-basilic technique. Bronder et al43 reported
their 7-year experience with 295 consecutive cases, concluding that elevation can salvage most autogenous accesses
deemed too deep for cannulation and that the long-term
patency rates were satisfactory. Their approach involved
making an incision over the course of the vein and then
simply supercializing it by reapproximating the underlying
subcutaneous tissue. Others have reported using suction
lipectomy to remove the overlying subcutaneous tissue,
thereby essentially elevating the autogenous access closer
to the level of the skin.101,120
Accessory Branch Ligation. The role of ligation of accessory
veins or branches to facilitate maturation remains unclear.
The KDOQI guidelines state that maturation may be
enhanced by the selective obliteration of major venous side
branches in the absence of downstream stenosis, although
the supporting evidence provided is somewhat weak.6 The
ligation or obliteration of the accessory veins can be accomplished in a variety of ways, including ligation through a small
stab wound, percutaneous ligation,121 and coil embolization.
Central Vein Stenoses. The treatment of asymptomatic or

minimally symptomatic central vein stenoses also remains
somewhat controversial.122,123 Notably, Levit et al122 reported
that the treatment of asymptomatic stenoses greater than 50%
were associated with a more rapid progression of stenosis and
an escalation of the lesion, as compared with no treatment.
Medical Treatment. The role of medical management to
improve autogenous access maturation and patency for both
autogenous and prosthetic accesses remains unresolved.124
Several small studies have demonstrated a benet for the
various antiplatelet agents,125-127 but the results on aggregate
are equivocal. Notably, the DAC reported that clopidogrel
and dipyridamole/aspirin improved the primary patency rates
for autogenous and prosthetic accesses, respectively, without
an increase in the rate of bleeding complications, although
there was no improvement in the stula maturation or cumulative patency rates.17,19 Similarly, warfarin may have a modest
effect on access patency but is clearly associated with an
increased risk of bleeding complications that must be weighed
against any potential patency benet.128,129
Outcomes and Complications

Many of the postoperative complications after permanent
hemodialysis access are generic to vascular surgical procedures and include both local (thrombosis, infection, wound)
and systemic (myocardial ischemia, dysrhythmias, cerebral
vascular accident) concerns. The perioperative predictors
and management of these complications are well known to
most vascular surgeons. The KDOQI panel has dened Clinical Outcome Goals that include a thrombosis rate of 0.25
episodes/patient-year and life expectancy of more than 3
years for autogenous accesses and a thrombosis rate of 0.5
episodes/patient-year and a life expectancy of more than 2
years for prosthetic accesses, as cited previously.6 Furthermore, the panel states that the infectious complication rates
should not exceed 1% and 10% over the functional life of
an autogenous and prosthetic access, respectively. Indeed,
the superior patency rates have been used as justication for
the preferential use of autogenous accesses as detailed previously (see Fig. 73-3). There are a variety of access-related
complications, including access-related hand ischemia,
venous hypertension, and neuropathy, which are addressed
in subsequent chapters (see Chapters 76 and 77). Although
the magnitude of most access procedures is relatively small
in comparison with the other commonly performed open
vascular operations, the perioperative complication rates are
signicant, underscoring the magnitude of the patients
underlying comorbidities. Indeed, our perioperative mortality
rate for access-related procedures is approximately 3%, and
our complication rate was 20% in our prospectively validated
algorithm, with roughly half of the complications attributed
to wound complications and the balance due to access-related
hand ischemia.53 Fortunately, the majority of the wound
complications are self-limited and do not usually result in
loss of the access.
Balloon Angioplasty Maturation. Balloon angioplasty maturation (BAM) likely represents the most aggressive treatment
algorithm to facilitate access maturation.118,119 In the technique outline by De Marco Garcia et al,118 angioplasty was
performed on the vein selected for the autogenous access
through its spatulated end prior to the construction of the
stula, and then remedial angioplasty procedures were performed at 2, 4, and 6 weeks postoperatively with sequentially
larger balloons. The investigators reported that 85% of the
veins were ultimately used for dialysis and that the 12-month
secondary patency rates were also approximately 85%.
1097
1098
Follow-up and Surveillance

The role of surveillance with remediation for permanent
hemodialysis AV accesses remains unresolved. Routine surveillance seems justied, given the natural history and costs
(both nancial and patient-related) associated with access
failure and is predicated on the assumptions that the various
screening tools can identify a signicant stenosis, that these
failing accesses are destined to fail in the near future, that
remedial intervention can prolong patency, and that the outcomes after remediation for the failing access are superior
to those after a thrombosed access. Unfortunately, not all of
these assumptions are correct. The KDOQI expert panel recommends an organized monitoring/surveillance approach
with regular assessment of clinical parameters of the AV
Access and HD (hemodialysis) adequacy, one the basis of
the panels position that prospective surveillance of stulae
and grafts for hemodynamically signicant stenosis, when
combined with correction of the anatomic stenosis, may
improve patency rates and may decrease the incidence of
thrombosis.6 Despite the recommendations, the underlying
data supporting access surveillance are somewhat limited.
Several randomized trials have failed to demonstrate a benet
for prosthetic AV access surveillance,130-135 and a systematic
review by Casey et al136 that constituted part of the Society
for Vascular Surgery Clinical Practice Guidelines concluded
that very low quality evidence yielding imprecise results
suggests a potentially benecial effect of AV access surveillance followed by intervention to restore patency.
Despite the equivocal benet of surveillance, several care
delivery systems have been identied to improve access outcomes, including a dedicated/experienced surgeon,20,137 interventional nephrologists,138 a nurse practitioner,139 a medical
director,140 a multidisciplinary team,141,142 a coordinated
ESRD network,143 clinical pathways,144,145 access centers,146,147
and a quality improvement program.148
STRATEGIES TO MAINTAIN ACCESS

It is important to emphasize that maintaining hemodialysis
access is a lifelong challenge for patients with ESRD that
requires committed providers and long-term plans. The
emphasis on autogenous AV access is appropriate because of
the reported longer-term patency rates and reduced complications, although the major focus should be on establishing a
functional access while minimizing the use of dialysis catheters. Strategies should be employed prospectively to preserve
all potential access options, including avoidance of PICC
lines, subclavian vein catheters, and harvest of arm veins.
Each access should be preserved as long as possible, within
reason, and the subsequent conguration identied with each
remedial treatment for a failing or thrombosed access. Patients
should be engaged to participate in their own care, and the
alternative strategies for renal replacement therapy should be
discussed.
SELECTED KEY REFERENCES

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A thoughtful analysis of the role of prosthetic accesses in the Fistula First and
Kidney Disease Outcomes Quality Initiative era.
Dember LM, Beck GJ, Allon M, Delmez JA, Dixon BS, Greenberg A,
Himmelfarb J, Vazquez MA, Gassman JJ, Greene T, Radeva MK, Braden
GL, Ikizler TA, Rocco MV, Davidson IJ, Kaufman JS, Meyers CM, Kusek
JW, Feldman HI; Dialysis Access Consortium Study Group: Effect of
clopidogrel on early failure of arteriovenous stulas for hemodialysis: a
randomized controlled trial. JAMA 299:21642171, 2008.
The results from the Dialysis Access Consortium, the randomized, prospective
trial that reported the autogenous access maturation rate was only 40%.
Fistula First Breakthrough Initiative. http//www.stularst.org.
The website contains all the current information about the Fistula First initiative
that has helped implement the Kidney Disease Outcomes Quality Initiative targets
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Huber TS, Carter JW, Carter RL, Seeger JM: Patency of autogenous and
polytetrauoroethylene upper extremity arteriovenous hemodialysis
accesses: a systematic review. J Vasc Surg 38:10051011, 2003.
A meta-analysis of clinical trials examining the patency of upper extremity
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Huber TS, Ozaki CK, Flynn TC, Lee WA, Berceli SA, Hirneise CM, Carlton
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National Kidney Foundation: KDOQI Clinical Practice Guidelines and
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Sidawy AN; Society for Vascular Surgery: Arteriovenous hemodialysis
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The Societys guidelines provide an evidence-based analysis of the national
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The Society for Vascular Surgerys reporting standards provide appropriate denitions and a standard nomenclature for the range of access procedures.
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renal disease in the United States, Bethesda, MD, 2012, National Institutes
of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Available at http//www.usrds.org adr.aspx.
The USRDS report contains an encyclopedic amount of information about
patients with end-stage renal disease and access care across the country.
The reference list can be found on the companion Expert Consult website
at www.expertconsult.com.
CHAPTER 73 Hemodialysis Access: General Considerations 1098.e1
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1098.e2 SECTION 13 Hemodialysis Access

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76. Dixon BS, et al: Hemodialysis vascular access survival: upper-arm
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81. Son HJ, et al: Evaluation of the efcacy of the forearm basilic vein
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82. Salgado OJ, et al: Ulnar-basilic stula: indications, surgical aspects,
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83. Cavatorta F, et al: Ulno-basilic arteriovenous stulae: indications and
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84. Bourquelot P, et al: Placement of wrist ulnar-basilic autogenous arteriovenous access for hemodialysis in adults and children using microsurgery. J Vasc Surg 53:12981302, 2011.
85. Capurro F, et al: The middle arm arteriovenous stula is an additional
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86. Bonforte G, et al: The middle-arm stula as a valuable surgical approach
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87. Jennings WC: Creating arteriovenous stulas in 132 consecutive
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88. Gefen JY, et al: The transposed forearm loop arteriovenous stula: a
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89. Keuter XH, et al: A randomized multicenter study of the outcome of
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90. Lazarides MK, et al: Transposed brachial-basilic arteriovenous stulas
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91. El Mallah S: Staged basilic vein transposition for dialysis angioaccess.
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92. Syed FA, et al: Comparison of outcomes of one-stage basilic vein
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93. Reynolds TS, et al: A comparison between one- and two-stage brachiobasilic arteriovenous stulas. J Vasc Surg 53:16321638, 2011.
94. Greenberg JI, et al: The brachial artery-brachial vein stula: expanding
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95. Torina PJ, et al: Brachial vein transposition arteriovenous stula: is it
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96. Lioupis C, et al: Autogenous brachial-brachial stula for vein access:
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J Vasc Endovasc Surg 38:770776, 2009.
97. Bender MH, et al: The Gracz arteriovenous stula evaluated: results of
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98. Curi MA, et al: Hemodialysis access: inuence of the human immunodeciency virus on patency and infection rates. J Vasc Surg 29:608616,
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CHAPTER 73 Hemodialysis Access: General Considerations 1098.e3

124. Matsumoto H, et al: Early use of brachial-basilic arteriovenous stula.
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125. Fiskerstrand CE, et al: Double-blind randomized trial of the effect of
ticlopidine in arteriovenous stulas for hemodialysis. Artif Organs
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126. Harter HR, et al: Prevention of thrombosis in patients on hemodialysis
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127. Grontoft KC, et al: Thromboprophylactic effect of ticlopidine in arteriovenous stulas for haemodialysis. Scand J Urol Nephrol 19:5557,
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128. OShea SI, et al: Hypercoagulable states and antithrombotic strategies
in recurrent vascular access site thrombosis. J Vasc Surg 38:541548,
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129. Elliott MJ, et al: Warfarin anticoagulation in hemodialysis patients:
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130. Dember LM, et al: Randomized controlled trial of prophylactic repair
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131. Lumsden AB, et al: Prophylactic balloon angioplasty fails to prolong
the patency of expanded polytetrauoroethylene arteriovenous grafts:
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132. Moist LM, et al: Regular monitoring of access ow compared with
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Nephrol 14:26452653, 2003.
133. Ram SJ, et al: A randomized controlled trial of blood ow and stenosis
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134. Malik J, et al: Regular ultrasonographic screening signicantly prolongs
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135. Robbin ML, et al: Randomized comparison of ultrasound surveillance
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136. Casey ET, et al: Surveillance of arteriovenous hemodialysis access: a
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137. He C, et al: Impact of the surgeon on the prevalence of arteriovenous
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138. Vachharajani TJ, et al: Dialysis vascular access management by interventional nephrology programs at University Medical Centers in the
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139. Lee W, et al: Effectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysisa single-centre
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140. Lacson E, Jr, et al: Intensity of care and better outcomes among hemodialysis patients: a role for the Medical Director. Semin Dial 25:299
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141. Allon M, et al: A multidisciplinary approach to hemodialysis access:
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142. Kalman PG, et al: A practical approach to vascular access for hemodialysis and predictors of success. J Vasc Surg 30:727733, 1999.
143. Nguyen VD, et al: Successful multidisciplinary interventions for arterio-venous stula creation by the Pacic Northwest Renal Network 16
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144. Becker BN, et al: Care pathway reduces hospitalizations and cost for
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145. Lopez-Vargas PA, et al: Barriers to timely arteriovenous stula creation:
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146. Jackson J, et al: How a dedicated vascular access center can promote
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147. Mishler R, et al: Dedicated outpatient vascular access center decreases
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148. van LM, et al: Implementation of a vascular access quality programme
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99. Brock JS, et al: The inuence of human immunodeciency virus infection and intravenous drug abuse on complications of hemodialysis
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100. Gorski TF, et al: Complications of hemodialysis access in HIV-positive
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101. Barnard KJ, et al: Accessible autogenous vascular access for hemodialysis in obese individuals using lipectomy. Am J Surg 200:798802, 2010.
102. Zanow J, et al: Proximalization of the arterial inow: a new technique
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103. Huber TS, et al: Midterm outcome after the distal revascularization
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104. Cavatorta F, et al: Subclavian vein stenosis: a potentially serious complication in chronic hemodialysis patients with permanent cardiac
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106. Reynolds TS, et al: Pre-operative regional block anesthesia enhances
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107. Sahin L, et al: Ultrasound-guided infraclavicular brachial plexus block
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108. Elsharawy MA, et al: Does regional anesthesia inuence early outcome
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118. De Marco Garcia LP, et al: Primary balloon angioplasty plus balloon
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119. Samett EJ, et al: Augmented balloon-assisted maturation (aBAM) for
nonmaturing dialysis arteriovenous stula. J Vasc Access 12:912, 2011.
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122. Levit RD, et al: Asymptomatic central venous stenosis in hemodialysis
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123. Renaud CJ, et al: Comparative outcomes of treated symptomatic versus
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27:16311638, 2012.
CHAPTER 74
Hemodialysis Access:
Dialysis Catheters
KAREN WOO / VINCENT L. ROWE
Central venous catheters for hemodialysis are categorized

by their intended duration as either acute or chronic.
Chronic hemodialysis catheters are placed in a tunneled
fashion and have a subcutaneous cuff at the skin exit site
for tissue ingrowth. Acute catheters do not have a cuff and
are placed percutaneously without a tunnel. As a result,
acute catheters are at higher risk for infectious complications
and can easily become dislodged. Thus, acute catheters
should be placed only in hospitalized patients and used for
a short time.1
This chapter focuses on tunneled hemodialysis catheters
and their management, but the potential complications
related to placement of acute hemodialysis catheters mirror
those of tunneled hemodialysis catheters. Because of the
short duration of use of acute catheters, long-term complications are less frequent but infectious complications are more
common.
INDICATIONS
The tunneled hemodialysis catheter serves a valuable role in
the treatment of patients with end-stage renal disease and has
distinct advantages over autogenous (arteriovenous stula
[AVF]) and prosthetic (arteriovenous graft [AVG]) arteriovenous hemodialysis access. The benets of tunneled hemodialysis catheters include immediate use for hemodialysis,
uncomplicated and needle-free connection to the dialysis
circuit, elimination of cannulation site complications, and
simple insertion technique that can be performed by many
different interventional specialists.2
The most common indication for placement of a tunneled
hemodialysis catheter is for urgent hemodialysis while the
patient is waiting for an AVF to be created or to mature.
Hemodialysis through a mature AVF represents the most
optimal form of hemodialysis access, and ideally patients
should be referred for placement of permanent access long
before the need for hemodialysis. In this way, patients have
an adequate amount of time for AVF maturation, and the
requirement for a tunneled hemodialysis catheter is eliminated altogether. Unfortunately, demise of renal function is
not a linear estimation. At the same time, care before endstage renal disease is often inadequate, resulting in late referral to a nephrologist and to an access surgeon.
Other indications include patients in whom an AVF or

AVG is not anatomically feasible or who are not operative
candidates because of advanced comorbidities. Temporary
hemoaccess is also indicated after revision of a permanent
hemodialysis access for management of a complication (e.g.,
access revision for pseudoaneurysm formation or infection),
after placement of a peritoneal dialysis catheter, and for a
chronic ambulatory peritoneal dialysis patient requiring
abdominal or inguinal surgery.
TYPES OF CATHETERS
The feasibility of using a felt cuffed catheter for prolonged
hemodialysis was rst described in 1988.3 The authors documented a median catheter survival of 8 weeks for a tunneled
hemodialysis catheter placed in the subclavian vein. Since
this initial report, catheter design and preferred anatomic
position for placement have evolved. Early cuffed catheters
were straight in conguration and stiff. These have been
largely supplanted by precurved exible catheters with various
tip designs.
Design Characteristics
Catheter designs aim to achieve one main goal: adequate
dialysis clearance at a relatively high ow rate. Currently used
hemodialysis machines maintain ow rates of 300 to 350 mL/
min through indwelling catheters to provide reasonable
clearance times for the patients.4 To support the high-ow
demand, some manufacturers have increased the catheter
lumen size up to 16F. In addition, the phenomenon of recirculation must be minimized to ensure adequate clearance.
The arterial lumen of the catheter is the outow to the
dialysis machine from the patient; the venous lumen is
dened as the inow from the machine back to the patient.
Access recirculation is the reentry of dialyzed blood from the
venous lumen directly into the arterial lumen, thus bypassing
the systemic circulation and leading to inefcient dialysis.5
Design Categories
Numerous manufacturer modications exist in an effort to
satisfy the requirements of high ow rates and minimal
1099
1100
recirculation. The modications fall into four general

categories.
Split Tip. Split-tip catheters have a double-lumen, singlebody conguration in the midbody but separate into two
distinct distal tips, each with side holes in all directions
(Fig. 74-1A).
Step Tip. The staggered-tip or step-tip catheter is a doublelumen, single-body catheter with the venous limb extending
at least 2.5 cm beyond the inow tip (Fig. 74-1B).
Dual Catheter. The dual catheter design consists of two
completely separate catheters that can be inserted in two
different locations (Fig. 74-1C).
Symmetric Tip. The Tal Palindrome (Covidien, Manseld,
Mass) is the only catheter that has a symmetric tip design
with equal length of arterial and venous limbs and biased
spiral ports. The design of the ports allows inow to
occur through the most proximal portion of the port and
outow to occur as a jet directed away from the catheter tip
(Fig. 74-2).6
Shape and Material

Because of the complication of catheter-associated central
vein stenosis, the anatomic preference for catheter placement
migrated cephalad from the subclavian veins to the internal
jugular veins.1 During the same time, straight catheter designs
evolved to adopt a premade curve to avoid kinking of the
catheter at the vein entry site in the neck. The material
composition of the tunneled hemodialysis catheter also
affects ow rates. Silicone rubber and Silastic catheters are
softer and more pliable, increasing patient comfort when the
A
B
Figure 74-1 Three types of tunneled hemodialysis catheters: split-tip

catheter (A), staggered-tip or step-tip catheter (B), and dual catheter
(C). (From Richard HM, 3rd, et al: A randomized, prospective evaluation
of the Tesio, Ash split, and Opti-ow hemodialysis catheters. J Vasc Interv
Radiol 12:431-435, 2001.)
Figure 74-2
Tal Palindrome catheter. (Courtesy Covidien.)
catheter is inserted into the internal jugular vein and tunneled over the clavicle. Newer polyurethane catheters have
a stiffer construct and higher tensile strength and thereby
allow thinner walled catheters with smaller outer diameters.
Numerous reviews directly compare performance of individual tunneled hemodialysis catheters with specic outcome
variables of ow rate, recirculation time, and patency. Unfortunately, despite isolated benecial characteristics of a particular catheter, no universal signicant benet has been
demonstrated by one catheter over the competitors.2,4,5,7
PREOPERATIVE EVALUATION
History and Physical Examination
As with any clinical assessment, the proper preoperative
evaluation of a patient begins with a detailed history and
physical examination. Specic inquiries should include
details such as prior long-term central line placement, prior
AVF or AVG placement, prior tunneled hemodialysis catheter infections, history of a coagulation disorder, and history
of a pacemaker. Physical examination of the neck and chest
is critical in the evaluation of the hemodialysis patient. Evidence of a previously placed tunneled hemodialysis catheter,
previous permanent accesses, upper extremity or facial edema,
and ipsilateral venous distention with visible venous collaterals should alert the clinician to the possibility of central
veno-occlusive disease.
Numerous specialists have acquired the skill set to properly place a tunneled hemodialysis catheter. However, there
is a signicant advantage in terms of continuity of care when
the same practitioner places the tunneled hemodialysis catheter and the permanent access or when a team approach
coordinates these procedures. There are a nite number of
access sites available for both tunneled catheter and permanent access placement. Therefore, a comprehensive plan that
embraces all forms of hemodialysis access may provide
maximum benet of each crucial access site.
CHAPTER 74 Hemodialysis Access: Dialysis Catheters
Central Venous Imaging

Color-Flow Venous Duplex Imaging
Similar to the screening of hemodialysis patients for permanent dialysis access, noninvasive color-ow duplex imaging
is the rst-line method of preoperative imaging for the tunneled hemodialysis catheter. Patency of internal jugular veins
and axillary veins is easily identied with compression of the
vein. However, as imaging moves toward the central chest,
the air interface with the lung tissue as well as obstructing
bone structures makes central vein imaging virtually impossible, limiting color-ow venous duplex imaging mainly to
the vein entry site.
Magnetic Resonance Venography
Computed Tomographic Venography

Computed tomographic venography (CTV) is similar to
MRV in being able to image multiple vessels in the chest in
one setting. However, CTV does have the advantages of
being readily available in most medical centers, fast acquisition times, and fewer deleterious contrast agent concerns. In
medical centers dedicated to use of this imaging modality for
the evaluation of hemodialysis patients, anecdotal evidence
points to an acceptable level of accuracy for the evaluation
of central venous disease. A small study of 18 patients was
performed to compare CTV and digital subtraction venography for the diagnosis of benign thoracic central venous
obstruction. The results of the study demonstrated that CTV
ndings correlated closely with those of digital subtraction
venography.9
Catheter-Based Contrast Venography

Catheter-based contrast venography remains the gold standard for diagnosis of central vein stenosis or occlusion.
Contrast venography has the distinct advantage of allowing
the clinician to initiate endovascular treatment if a signicant stenosis is detected at the time of venography. In
addition, it is often possible to perform catheter-based
venography with a much smaller volume of contrast material than what is required for CTV, reducing the risk of
nephrotoxicity.
CATHETER INSERTION
Site Selection
Numerous venous access sites exist for insertion of a tunneled
hemodialysis catheter. However, the right internal jugular
vein is the preferred access site because it has the best patency,
presumably owing to less kinking. In a prospective evaluation, factors affecting long-term survival of tunneled hemodialysis catheters were analyzed in a cohort of 812 catheters
in 492 patients.2 Factors that were associated with immediate
failure of the tunneled hemodialysis catheter were malposition and kinking. A tunneled hemodialysis catheter placed
in the right internal jugular vein demonstrated signicantly
longer survival compared with one placed in the left internal
jugular vein. Tunneled hemodialysis catheters placed in the
femoral vein had the worst long-term survival. The subclavian vein should be avoided if possible to prevent catheterinduced subclavian stenosis, which would negatively affect
the future placement of ipsilateral permanent access.2,4
A tunneled hemodialysis catheter from the right internal
jugular vein should be 17 to 19 cm in length; catheters from
the left are slightly longer. When femoral access is used, long
catheters (24 to 31 cm) should be placed so that the tip
can reach into the inferior vena cava to produce the best
ow rates.
Technique
Tunneled hemodialysis catheter insertion should be performed in a procedure room under uoroscopic guidance.
Bedside placement is discouraged because of the need for
proper sterility, the possibility of additional endovascular
procedures (such as venography and venoplasty), and the
requirement for uoroscopy. The procedure is usually performed under local anesthesia with conscious sedation.
Patients who have had numerous prior catheters have an
increased risk of central venous stenoses or occlusions that
may increase the complexity of the procedure. In such
cases, general anesthesia is preferred. Preoperative antibiotic
prophylaxis directed at gram-positive bacterial strains is
administered before skin incision in each case. The skin
is then prepared with isopropyl alcohol and chlorhexidine
solutions.
Ultrasound evaluation with a sterile covered transducer
conrms access vein patency. The site of vein cannulation
should be 3 to 4 cm cephalad to the clavicle. Real-time ultrasound guidance is used to access the vein. The puncture is
performed with a micropuncture 21-gauge needle, 0.018-inch
guide wire, and 5F coaxial catheter (Fig. 74-3). After successful vein cannulation with the micropuncture needle, the introducer and 0.018-inch wire are removed and exchanged for
a 0.035-inch wire. In preparation for the large-bore hemodialysis catheter, a 1-cm skin incision is made surrounding the
wire entry site (Fig. 74-4, short arrow). Fluoroscopic imaging
should be used during all wire maneuvers to conrm wire
position.
Contrast-enhanced magnetic resonance venography (MRV)

is a noninvasive modality for imaging of the central veins.
Three-dimensional gadolinium-enhanced MRV has been
evaluated in the assessment of central venous steno-occlusive
disease specically in hemodialysis patients. In a series of 14
patients, three-dimensional gadolinium-enhanced MRV had
a 93% sensitivity in identifying central vein occlusions and
stenoses greater than 50% when it was directly compared
with digital subtraction angiography.8 Despite the accuracy of
MRV, gadolinium must be administered with caution in
patients with a glomerular ltration rate of less than 30 mL/
min because of the risk of gadolinium-induced nephrogenic
systemic brosis. Although nephrogenic systemic brosis is
rare even in this patient population, the condition has not
been described in patients with normal renal function.
1101
1102
Figure 74-3 Ultrasound-guided puncture of the internal jugular vein

with a micropuncture needle.
Because of the large size and stiff nature of most tunneled

hemodialysis catheters, a moderate amount of forward pressure may need to be applied during insertion. It is highly
advisable to have the guide wire traverse the right atrium of
the heart and to rest in the inferior vena cava. This is especially true for left-sided placement of a tunneled hemodialysis
catheter. Because of the tortuous path from the left internal
jugular to the heart, it is possible for the dilator to push the
midportion of the guide wire, creating a loop that could
penetrate the side wall of the central vein. The incidence of
this can be reduced by use of a stiffer wire than the one provided in the insertion kit as well as by direct uoroscopic
visualization of smooth passage of all dilators and sheaths
over the wire.
Antegrade Placement
A small incision is made on the anterior chest where the
tunneled hemodialysis catheter is to exit the subcutaneous
tunnel (Fig. 74-4, long arrow). The exit site of the tunneled
hemodialysis catheter should be inferior and lateral to the
vein entry site in location. The exit site should also be positioned such that the felt cuff on the catheter shaft is 1 cm
Figure 74-4 Placement of the tunneled hemodialysis catheter alongside the anticipated catheter course to determine where to position
the exit site. Internal jugular vein puncture site (short arrow); upper
chest catheter exit site (long arrow).
Figure 74-5 Tunneling of the catheter subcutaneously from the

chest incision to the neck incision anterior to the clavicle.
proximal to the exit site. Placement of the tunneled hemodialysis catheter alongside the anticipated catheter course is
useful in determining where the exit site should be positioned. The tunneled hemodialysis catheter is then attached
to the tunneling device and passed subcutaneously from the
chest incision up through the vein entry site incision in the
neck, traversing anterior to the clavicle en route (Fig. 74-5).
The track of the wire is sequentially dilated, and the nal
introducer and peel-away sheath unit is inserted until the
sheath is hubbed at the skin (Fig. 74-6). The introducer
and wire are removed, and the tunneled hemodialysis catheter is inserted through the peel-away sheath (Fig. 74-7).
Once the tunneled hemodialysis catheter is fully inserted, the
peel-away sheath is withdrawn.
Each lumen of the catheter is aspirated and ushed with
dilute heparin (100 units of heparin sulfate per milliliter of
normal saline). Both of these actions should be easily accomplished without resistance. If resistance is encountered, the
tunneled hemodialysis catheter should be examined under
uoroscopy to rule out a kink in the path of the catheter
or malpositioning of the tip. Ideally, the most distal tip of
the catheter should be in the distal superior vena cava/
proximal right atrium border. This preferred position corresponds to the shadow of the right mainstem bronchus
(Fig. 74-8).
The chest wall and vein entry site incisions are closed
with absorbable sutures, and the tunneled hemodialysis
Figure 74-6
Dilatation of the track of the wire.
1103
Unconventional Catheter Sites
Figure 74-7 Insertion of the tunneled hemodialysis catheter through

the peel-away sheath.
catheter is secured to the chest wall with nonabsorbable

sutures. Each lumen of the tunneled hemodialysis catheter
is lled with the manufacturer-indicated volume of concentrated heparinized saline (1000 units/mL) to protect against
intracatheter thrombosis.
Retrograde Placement
PERIOPERATIVE CARE AND COMPLICATIONS

The perioperative management of patients after placement
of a tunneled hemodialysis catheter centers on the evaluation
for and treatment of potential acute complications. These
complications involve needle or catheter injuries to the
pleura, lung, vascular or nerve structures in the neck, thoracic
inlet, mediastinum, and heart. The keys to successful management of these complications are awareness, prompt recognition, and expeditious treatment. In a compilation of data
from 1794 central venous cannulations in critically ill
patients, there were a total of 127 complications for an overall
rate of 7.1%.14 Failure to place the central line and arterial
puncture were the most common mechanical complications,
followed by pneumothorax.
Pneumothorax
Figure 74-8 Chest radiograph demonstrating proper position of the
tip of the tunneled hemodialysis catheter (arrow) at the level of the
right mainstem bronchus.
An end-expiratory upright chest radiograph should be performed after placement of a tunneled hemodialysis catheter
More recently, some manufacturers have developed tunneled

hemodialysis catheters that can be placed in a reversetunneled or retrograde fashion. These tunneled hemodialysis catheters do not have the ports attached initially. The
catheter is inserted into the vein before tunneling in the same
fashion as the standard tunneled hemodialysis catheter. The
catheter is then tunneled from the neck incision to the chest
incision, and the ports are attached after tunneling. The
advantage of this type of insertion is that it allows precise
positioning of the catheter tip.
Patients who have been hemodialysis dependent for an

extended time often have exhausted conventional sites for
vascular access placement. In a 1996 report, 5% of dialysis
patients withdrew from dialysis secondary to lack of sites
for dialysis access.10 This statistic is likely to have increased
with the expanding dialysis population, the increased life
expectancy on dialysis, and the relatively stable number of
kidney transplants performed annually. Patients who have
exhausted conventional sites for vascular access may require
placement of tunneled hemodialysis catheters in unconventional sites, such as the transhepatic and translumbar routes
(see Chapter 75).
Translumbar catheters are generally placed with the
patient in the prone position by percutaneous puncture of the
inferior vena cava above the right iliac crest. The catheter is
tunneled through a right lateral abdominal exit site. For
transhepatic catheters, percutaneous access to the right or
middle hepatic vein is obtained through the eighth intercostal space in the midaxillary line under uoroscopic guidance.
The catheter is then tunneled to a lateral anterior chest wall
exit site. The tip of the catheter is positioned in the right
atrium in both approaches.
The reported mean total catheter service lifespan of transhepatic and translumbar catheters in the literature ranges
from 70 days to 450 days.11,12 Also, unique to this type of
access is the high rate of subsequent interventions for maintenance of adequate hemodialysis access. Two of the largest
published series reported that more than 60% of their patients
required at least one catheter exchange. Catheter migration
and catheter thrombosis are the two most commonly reported
reasons for catheter exchange.11-13 Translumbar catheter
exchanges may be more difcult than exchanges through the
transhepatic approach because of retroperitoneal brosis that
develops along the track.11
1104
to conrm tip placement and to exclude a pneumothorax.15

Bilateral attempts at venous catheterization should not be
made until pneumothorax has been ruled out on the initial
side by chest radiography to avoid the potential disaster of
bilateral pneumothorax. If acute, severe symptoms and signs
of pneumothorax develop, a tube thoracostomy should be
performed immediately and the patient should be given
oxygen by mask. In the setting of tension pneumothorax,
decompression of the pleural space by use of an intravenous
catheter can be lifesaving. The needle should be placed in
the second intercostal space in the midclavicular line. More
frequently, the air leak is relatively small, and the pneumothorax develops during a period of several hours. In such
cases, there is time to conrm the diagnosis and to determine
its size with a chest radiograph.
When a small pneumothorax is encountered (<20%) and
there are no symptoms or signs of respiratory compromise,
decrease in peripheral oxygen saturation, or hemodynamic
impairment, a watchful waiting approach with repeated
chest radiographs is appropriate.16 If symptoms develop or
there is an increase in the size of the pneumothorax on subsequent chest radiographs, tube thoracostomy should be performed. If the pneumothorax is initially noted to be large
(>20%), tube thoracostomy should be performed regardless
of whether symptoms are present. A mobile thoracic vent
device (e.g., Heimlich valve) is an alternative to thoracostomy that is signicantly more comfortable for the patient. If
the central venous catheter is well positioned and functioning appropriately, it can be left in place.
Hemothorax
Placement of tunneled hemodialysis catheters may be complicated by the development of a hemothorax when the back
wall of either a vein or artery and the parietal pleura are
perforated by an advancing needle tip, dilator, or sheath.17
The subclavian vein or artery, the innominate vein, or even
the superior vena cava may be involved. The lack of effective
tamponade combined with negative respiratory pressure may
result in a large blood loss through a small puncture. Clinically, patients may develop respiratory compromise accompanied by dullness to percussion and decreased breath sounds
on the affected side. A decreased hematocrit and evidence of
uid in the pleural cavity on the chest radiograph strongly
support the diagnosis. Drainage of the pleural space with a
tube thoracostomy is generally adequate therapy and should
be performed for signicant hemothorax to prevent entrapment of the lung. Rarely, bleeding must be controlled surgically or, if possible, percutaneously with the use of covered
stents.
Subcutaneous Hematoma
Subcutaneous hematoma can occur when vessels in the cervical and clavicular area are lacerated. Prolonged compression
(15 minutes or more), with or without catheter removal,
usually controls the bleeding unless there is a major vascular
injury.18 Elevation of the patients upper body to decrease

venous pressure is also helpful. If direct pressure with catheter
removal is inadequate to control the bleeding, surgical intervention or covered stent placement may be necessary.
Wire Embolism
Wire embolism occurs when control of the wire is lost during
the procedure or the guide wire is sheared off by the access
needle as it is withdrawn. If resistance to wire removal is
encountered, uoroscopic imaging should be used, and
removal of the wire and needle together as a unit may be
required. Fortunately, most foreign bodies, including segments of guide wires, can usually be removed in the angiography suite with use of a wire snare retrieval system.19
Cardiac Arrhythmia
Cardiac complications related to central venous catheterization are rare. Arrhythmia during placement of a tunneled
hemodialysis catheter is associated with the guide wires irritating the myocardium. Patients who have a history of a
cardiac arrhythmia or those with altered plasma electrolytes
are at a higher risk. The problem can be minimized by use of
guide wires that have distance markings and uoroscopy to
visualize the location of the tip of guide wires and catheters.
If cardiac arrhythmias develop after the placement of a tunneled hemodialysis catheter, the catheter position should be
checked uoroscopically or with a chest radiograph and the
catheter tip should be withdrawn if the tip is near or traversing the tricuspid valve. Rarely, patients will have arrhythmias
that require chemical or electrical cardioversion. In a series
of 300 patients who underwent central venous catheterization, the incidence of cardioversion for a procedure-associated
arrhythmia was 0.9%.20
Cardiac Perforation
The soft, exible hemodialysis catheters that are currently
used are unlikely to perforate the heart. More common causes
of cardiac perforation are guide wires, dilators, and rigid introducers. Cardiac perforation may result in acute pericardial
tamponade from bleeding or uid infusion into the pericardial
space. Signs and symptoms of pericardial tamponade can
develop rapidly and include shock and cyanosis with marked
cervical venous distention. Tachycardia and mufed heart
sounds are generally present, and a large globular cardiac
silhouette may be present on a chest radiograph. Any intraluminal catheter devices should be removed and pericardiocentesis or a pericardial window created. If the tamponade
recurs after pericardiocentesis or creation of a window, median
sternotomy with formal cardiac repair may be necessary.
Thoracic Duct Laceration

Percutaneous catheterization of the superior vena cava
through the left internal jugular or the subclavian approach
carries a small risk of thoracic duct laceration. Cirrhotic

patients are more prone to the development of this complication. If a lymphatic leak becomes apparent, the catheter
should be removed and a pressure dressing should be applied.
Nearly all such leaks resolve spontaneously.
Nerve Injuries
Catheter Misplacement
In a prospective study of 1619 patients, the incidence of
catheter tip malposition, dened as extrathoracic or ventricular positioning, was 3.3%.24 The use of uoroscopy during
catheter placement should eliminate the occurrence of catheter tip malposition. If there is a question as to the location
of the tip of the catheter during placement, contrast material
can be injected through the catheter under uoroscopic guidance to help dene the anatomy.
Venous
If the catheter tip is left in the subclavian, axillary, jugular,
or hepatic vein, the catheter tip or pressure generated during
hemodialysis frequently causes intimal injury, which leads to
thrombosis of the vein.25 Stiff catheters or introducers left
abutting the wall of the superior vena cava or more peripheral
veins can also erode through the vessel wall and produce a
hemomediastinum or hydromediastinum.
Arterial
Catheters may be inadvertently placed into the subclavian or
carotid artery without the practitioners recognizing the
problem. This is more common in a hypotensive or poorly
oxygenated patient who may not have return of bright red,
pressurized blood when an artery is punctured. As tunneled
hemodialysis catheters are generally placed on an elective
basis, arterial placement is rare. If there is a question of arterial placement, the pressure can be transduced through the
catheter to see if the waveform is arterial or venous. A sample
from the catheter can also be sent for a blood gas analysis to
determine if the values are consistent with an arterial or

venous blood gas. If the injury is recognized in a timely
fashion (<4 hours), most of the catheters placed in the carotid
artery can be simply removed and pressure applied for a prolonged time (15-20 minutes).26 If the injury is recognized
later, the catheter should be removed in the operating room
with open repair of the artery because the incidence of track
formation and accumulation of thrombus on the catheter is
increased.26 Injuries to the subclavian artery are more difcult
to compress because of the lack of bone structures to compress
against and should be monitored closely for evidence of
hemothorax. Open or endovascular repair of the artery may
be required.27
LONG-TERM CARE AND COMPLICATIONS

The long-term management of tunneled hemodialysis catheters is primarily performed by the staff at the dialysis
center where the patient receives dialysis. The National
Kidney Foundation Kidney Dialysis Outcomes and Quality
Initiative (NKF KDOQI) guidelines provide recommendations for the routine care of tunneled hemodialysis catheters,
which include cleaning with 2% chlorhexidine and redressing the exit site at each dialysis treatment, masks for the
provider and the patient when the catheter lumina or exit
sites are exposed, and use of aseptic technique when the
catheter is manipulated.1 Patients with tunneled hemodialysis catheters usually do not come to the attention of
the vascular surgeon unless a late complication of the
catheter develops.
Air Embolism
Air embolism is a rare but potentially lethal complication of
central venous catheterization that can be either an acute or
a late complication.17 In its late form, air embolism generally
occurs when air enters the catheter either before attachment
of the tubing or when the tubing becomes disconnected.28,29
Air embolization can also occur through cracks in the catheter or its hub as well as through the catheter track after the
removal of a central venous catheter.30 Patients should be
instructed that in the event the catheter becomes disconnected or uncapped, a critical complication could result.
Patients should be instructed to cap the open catheter with
a thumb or nger and to call for help immediately. An occlusive dressing should be placed over the skin puncture site
when the catheter is removed to allow adequate sealing of
the track.
If sudden cardiorespiratory collapse develops in a patient
with a tunneled hemodialysis catheter, air embolism must be
strongly considered. Further embolization must be prevented
by capping or clamping of the catheter while the patient is
simultaneously placed in the Trendelenburg and left lateral
decubitus position (Durant maneuver).31 This position displaces air away from the pulmonic valve, which relieves the
right ventricular outow obstruction. The catheter can be
advanced into the heart to aspirate the air.32
The brachial plexus is the nerve structure that is most vulnerable during percutaneous catheterization by virtue of its large
size and proximity to the subclavian vein and artery.21,22
Acute upper extremity pain referred along a neural anatomic
pathway suggests impingement on the brachial plexus and
necessitates immediate withdrawal of needles or catheters.
Permanent injury is rare. The vagus, recurrent laryngeal, and
phrenic nerves are also in proximity to the internal jugular
vein. However, these are small nerves and are infrequently
injured. The development of hoarseness after catheter placement suggests injury to the vagus or recurrent laryngeal nerve.
Phrenic nerve injuries are generally asymptomatic and are
incidentally identied on radiographic examination when an
elevated hemidiaphragm is seen.23 The development of
Horners syndrome has also been reported by inadvertent
trauma to the stellate ganglion during percutaneous cannulation of the internal jugular vein.
1105
1106
Catheter Embolism
Fractures can develop in the material of chronically indwelling catheters. This usually occurs at sites of stress, such as the
thoracic inlet.33,34 Fractures can result in breaking off and
embolization of the distal aspect of the catheter. Catheter
embolism is diagnosed when an incomplete catheter is
removed from a patient. The retained catheter segment can
typically be removed in the angiography suite with use of a
wire snare retrieval system.35
Catheter Occlusion
Catheter occlusion occurs in 30% to 40% of patients with
tunneled hemodialysis catheters.36 Occlusion of the catheter
generally is a consequence of the development of a brin
sleeve or plug at the catheter tip. The ability to infuse uid
into the catheter but the inability to withdraw blood often
indicates impending occlusion.
Prevention
A randomized controlled trial of the use of low-dose warfarin
to prevent catheter thrombosis demonstrated lack of efcacy.37 Another randomized trial was performed with three
arms: aspirin 325 mg/day, warfarin titrated to an international normalized ratio of 2 to 3, and control group. This
study found that whereas both aspirin and warfarin were
equally effective at increasing catheter patency, there was a
signicant increase in the risk of gastrointestinal bleeding in
both treatment groups.38 As such, use of antiplatelet agents
or systemic anticoagulation is not recommended to prevent
thrombosis. However, a randomized trial of patients assigned
to a catheter-locking regimen of heparin (5000 units/mL)
three times a week or recombinant tissue plasminogen activator (1 mg in each lumen) substituted for heparin one session
a week did demonstrate a twofold decrease in the risk of
catheter malfunction in patients treated with recombinant
tissue plasminogen activator once a week with no increase in
the risk of bleeding.39
Treatment
Local infusion of brinolytic agents has been used in the
salvage of occluded central venous catheters.40,41 Currently,
alteplase is the only brinolytic agent that is approved for
treatment of occluded central venous catheters. Most commonly, 2 mg of brinolytic agent in 2 mL of solution is
injected and allowed to dwell in the catheter for 2 to 3 hours.
The catheter is then irrigated and ushed, with removal of
any residual clot. This process can be repeated until patency
is restored. However, use of this technique may result in only
a limited number of additional dialysis sessions before the
treatment must be repeated. A study of 570 catheters during
a 2.5-year period demonstrated a median of ve to seven
additional dialysis sessions after each treatment.42 Guide
wires should never be passed through catheters in an effort
to relieve an obstruction because of the risk of dislodging part
or all of the occlusion and causing an embolic event.
Because of the frequency of recurrent occlusion and

the difculty in delivery of a highly concentrated brinolytic agent to the brin sheath around the tip of the
catheter, techniques have been developed to mechanically
eliminate the brin sheath. These techniques generally
involve the insertion of a wire snare device through another
venous access site, such as the femoral vein, to strip the
brin sheath from the catheter and remove it. In a study
of 131 sheath stripping procedures on 100 catheters, the
technical success of the procedure was 95.6% and the
mean primary patency after the rst stripping was 89 days.43
An alternative technique is to remove the catheter over
a wire, then use an angioplasty balloon to rupture the
sheath, and nally replace the catheter over the wire. A
retrospective review of these two techniques compared with
simple catheter exchange demonstrated no difference in
patency.44
Central Venous Thrombosis

Catheter-related thrombus is present in approximately 30%
of all patients with central venous catheters.45 However, less
than half of these thrombi are clinically signicant.45 The
incidence of pulmonary embolus from catheter-related
thrombus ranges from 0% to 17%, although catheter-related
thrombus has rarely been reported to be the cause of death.45
The more clinically signicant implication of catheter-related
thrombosis is its association with infection. In a study of
patients with catheter-related Staphylococcus aureus bacteremia, 71% were found also to have central venous thrombus.46
Nevertheless, the routine use of low-dose warfarin prophylaxis is not recommended.47
Venous thrombosis should be suspected in patients with
tunneled hemodialysis catheters who present with arm, neck,
or facial swelling; prominent collateral venous patterns;
signs or symptoms of embolic complications; or unexplained
fever. Duplex scanning generally is diagnostic, although
venography is required on occasion for denitive diagnosis
and determination of the extent of thrombosis. Conventional therapy consists of anticoagulation and elevation of
the symptomatic arm. If possible, the catheter should be
removed. As patients with tunneled hemodialysis catheters
often do not have other sites available for access placement, anticoagulation therapy with the catheter left in
place can be considered.48
Central Venous Stenosis

Catheter-associated central vein stenosis develops as a result
of injury to the intima of the vein by the catheter.49 The
association between subclavian vein cannulation for hemodialysis access and subsequent subclavian vein stenosis is well
described.50,51 The incidence of subclavian vein stenosis after
placement of a tunneled hemodialysis catheter is signicantly
higher than that of internal jugular vein stenosis. In a study
comparing venography in 50 patients dialyzed through a subclavian vein catheter and 50 patients dialyzed through an
internal jugular vein catheter, 42% of patients in the subclavian group had a stenosis versus 10% in the jugular group.52
As such, cannulation of the subclavian vein for hemodialysis
access should be avoided if at all possible. Catheter-associated
central vein stenosis can also involve the brachiocephalic
vein as well as the superior vena cava.
Presentation
Central vein stenosis can be completely asymptomatic.
Often, an ipsilateral upper extremity access is created without
knowledge of a central vein stenosis, which results in the
rapid development of symptoms, the most common of which
is arm edema. Patients with brachiocephalic vein stenosis
can also present with facial edema. Other manifestations of
central vein stenosis are aneurysmal dilatation of the extremity veins and the ipsilateral AVF, thrombosis of the access,
inadequate dialysis, prolonged bleeding after use of the access,
and superior vena cava syndrome.49
Treatment
Catheter-Related Infection
There are three categories of catheter-related infection: exit
site infection, tunnel infection, and bacteremia.1 The NKF
KDOQI guidelines dene an exit site infection as inammation conned to the area surrounding the catheter exit site,
not extending superiorly beyond the cuff if the catheter is
tunneled, with exudate culture conrmed to be positive. A
tunnel infection is dened as the catheter tunnel superior to
the cuff is inamed, painful, and may have drainage through
the exit site that is culture positive. Finally, catheter-related
bacteremia is dened as blood cultures are positive for the
presence of bacteria with or without the accompanying
symptom of fever. The incidence of catheter-related bacteremia ranges from 0.6 to 6.5 episodes per 1000 catheter days.54
Bacteriology
The predominant organism isolated from infected lines is
gram-positive (52%-84%), with Staphylococcus aureus making
up 21% to 43%.54 Methicillin-resistant S. aureus is reported
in 12% to 38% of cases.54 Gram-negative bacilli, including
Pseudomonas species, Klebsiella pneumoniae, Escherichia coli,

and Enterobacter species, have also been isolated from infected
lines.55 Fungal infections, predominantly Candida species, are
associated with broad-spectrum antibiotic therapy and renal
impairment.56 Consequences of bacteremia include infective
endocarditis and metastatic abscesses, the incidence of which
increases when catheter salvage is attempted.54
Treatment
Ideally, the management of an infected hemodialysis catheter
includes removal of the catheter.54 Initial empirical antibiotic
therapy should include broad-spectrum coverage of potentially resistant strains of gram-positive organisms as well as
gram-negative organisms.57 This coverage should be adjusted
to a focused regimen when culture results become available.
Amphotericin B or caspofungin, which has a more favorable
toxicity prole, should be used if there is evidence of disseminated fungal infection or if patients demonstrate persistent
fungemia after catheter removal.47 Uncomplicated S. aureus
catheter-related bacteremia is generally treated with 4 to 6
weeks of antibiotic therapy; gram-negative bacilli or enterococcus bacteremia is usually treated with 7 to 14 days of
therapy. Bacteremia with Candida is usually treated with a
minimum of 14 days of antibiotic therapy. Complicated bacteremia with septic thrombophlebitis or endocarditis is
usually treated for 4 to 6 weeks and osteomyelitis for 6 to
8 weeks.57
Catheter exit site infections alone can usually be salvaged
with topical and systemic antibiotics without the need for
catheter replacement.57 Presence of a tunnel infection or
catheter-related bacteremia requires catheter removal with
delayed placement of a permanent access. The NKF KDOQI
Work Group recommends delay of placement of a new permanent access until culture results have been negative for
at least 48 hours after cessation of antibiotic therapy.1
Depending on the length of antibiotic therapy, this may
or may not be reasonable. Strategies for catheter salvage
include exchange over a wire and catheter salvage with or
without antibiotic lock. Whereas catheter salvage has been
described, it is associated with failure rates greater than
65%.54 As such, the safest course of action is most often to
remove the catheter.
SELECTED KEY REFERENCES

dOthee J, Tham JC, Sheiman RG: Restoration of patency in failing
tunneled hemodialysis catheters: a comparison of catheter exchange,
exchange and balloon disruption of the brin sheath, and femoral stripping. J Vasc Interv Radiol 17:10111015, 2006.
Description and comparison of the various techniques to address the brin
sheath that can develop around tunneled hemodialysis catheters and cause them
to fail.
Hemmelgarn BR, Moist LM, Lok CE, Tonelli M, Manns BJ, Holden RM,
LeBlanc M, Faris P, Barre P, Zhang J, Scott-Douglas N; Prevention of
Dialysis Catheter Lumen Occlusion with rt-PA versus Heparin Study
Group: Prevention of dialysis catheter malfunction with recombinant
tissue plasminogen activator. N Engl J Med 364:303312, 2011.
Comparison of the use of recombinant tissue plasminogen activator and heparin
as a catheter-locking solution in the prevention of catheter malfunction and
infection.
Elevation and compression of the upper extremity can occasionally be enough to relieve the edema associated with
central venous stenosis but is unlikely to be effective if there
is an access on the ipsilateral extremity. NKF KDOQI guidelines recommend percutaneous transluminal angioplasty with
or without stent placement as the preferred treatment for
central venous stenosis.1 In a small randomized study of percutaneous transluminal angioplasty and stent placement,
1-year primary patency in both groups was dismal at 12% and
11%, respectively.53 However, the secondary patency at 1 year
was 100% for percutaneous transluminal angioplasty and
78% for stenting. This marked difference in primary and
secondary patency underscores the fact that multiple procedures are usually needed to maintain patency after endovascular management of central venous stenoses.
1107
1108
Lok CE, Mokrzycki MH: Prevention and management of catheter-related

infection in hemodialysis patients. Kidney Int 79:587598, 2011.
Review of the epidemiology, pathogenesis, prevention, and management of
catheter-related bacteremia in hemodialysis patients.
Vascular Access 2006 Work Group: Clinical practice guidelines for vascular
access. Am J Kidney Dis 48:S176S273, 2006.
National Kidney Foundation Kidney Disease Outcomes Quality Initiative

evidence-based clinical practice guidelines for the management of vascular
access.
The reference list can be found on the companion Expert Consult website
at www.expertconsult.com.

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CHAPTER 73

nd-stage renal disease (ESRD) is a huge public health

END-STAGE RENAL DISEASE

2010 (i.e., rst dialysis session) using a catheter as the sole

Morbidity and Mortality

CHAPTER 73 Hemodialysis Access: General Considerations

terms of establishing and maintaining access for hemodialysis.

Number of patients (in thousands)

GUIDELINES AND NATIONAL INITIATIVES

Hemodialysis access care over the past 2 decades has been

National Kidney Foundation

Figure 73-1 The projected incidence and prevalence for patients

with catheter, revision, removal) and complication (i.e.,

RENAL REPLACEMENT THERAPY

Foremost among the initiatives and guidelines is the National

KIDNEY DISEASE OUTCOMES QUALITY INITIATIVE CLINICAL

SECTION 13 HEMODIALYSIS ACCESS

SECTION 13 Hemodialysis Access

Centers for Medicare and Medicaid Services

FISTULA FIRST BREAKTHROUGH INITIATIVE CHANGE CONCEPTS

United States Prevalent Vascular Access Rates

to implement these concepts, including multimedia resources

Society for Vascular Surgery

CHAPTER 73 Hemodialysis Access: General Considerations

CHOICE OF ARTERIOVENOUS ACCESS TYPE

rates for prosthetic access were 75% at 1 year in a multicenter,

Autogenous Access Maturation

SECTION 13 HEMODIALYSIS ACCESS

The requirements for an ideal AV access include a ow

access, and the role of access surveillance and monitoring.

SECTION 13 Hemodialysis Access

However, it was a well-designed randomized, controlled trial

Morbidity, Mortality, and Cost

Role of Prosthetic Arteriovenous Accesses

amenable to remedial therapies in the presence of a failing

Predicting Autogenous Access Outcome

CHAPTER 73 Hemodialysis Access: General Considerations

Obesity. Obesity has not been shown to be a consistent

(without atherosclerosis) can frequently yield successful,

SECTION 13 HEMODIALYSIS ACCESS

Diabetes. Diabetes has also been associated with failure of

SECTION 13 Hemodialysis Access

Low risk (2.0)

high-risk patients still had successful autogenous accesses.

ARTERIOVENOUS ACCESS CONSTRUCTION

Figure 73-4 The risk that the autogenous

situations. Despite some resistance to the national guidelines

Factors Inuencing Vascular Access

Factors that adversely

Young patient age

Reproduced from Cull DL. Role of prosthetic hemodialysis access following

CHAPTER 73 Hemodialysis Access: General Considerations

Patient presenting for access

Noninvasive arterial/venous imaging

Potential autogenous access

Invasive arterial/venous imaging

Construct prosthetic access

catheters, in accordance with the national guidelines. Lastly,

should be educated about the different renal replacement

Preservation of Autogenous Options

History and Physical Examination

SECTION 13 HEMODIALYSIS ACCESS

Figure 73-5 An algorithm for patients presenting for permanent