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A-V SHUNT FOR

HEMODIALYSIS

HEROE SOEBROTO, DR., SPB, SPBTKV(K)


THORACIC, CARDIAC, & VASCULAR SURGERY
DIVISION/DEPARTMENT OF SURGERY
SOETOMO GENERAL HOSPITAL FACULTY OF MEDICINE
AIRLANGGA UNIVERSITY SURABAYA
2015

INTRODUCTION

Vascular access for hemodialysis :


- central vein cannulation double lumen
catheter
- device implantation Port-a-Cath
- surgical AV Shunt (Brescia-Cimino)
AV Shunt : surgical procedure to create an
anastomosis between an artery and a vein
for hemodialysis access

INTRODUCTION

Theoretical Basis
AV Shunt work effectively for
hemodialysis because they:
Have high volume flow rates
Use native blood vessels, which, when
compared to synthetic grafts, are less
likely to develop stenoses and fail.

ANATOMY

ANATOMY

GENERAL PRINCIPLES
OF
AV SHUNT

GENERAL PRINCIPLES

1. The arm vessels is more preferable rather


than the leg vessels. Non-dominant arm
first.
2. Access site should be placed as distally , so
that proximal sites will be available for
subsequent procedures.
3.

Inadequate or atherosclerotic arteries


should be avoided, and a long section of
patent vein is required to accommodate
multiple cannulation site.

GENERAL PRINCIPLES

4.

The chosen site should allow for ease of access for


cannulation and should be positioned so that patient
comfort is assured during hemodialysis.

5.

Technical precision and gentle tissue handling is


mandatory.

6.

A temporary access procedure, such as :


Right internal jugular
Subclavian or femoral catheter
External shunt
Peritoneal catheter
are required during the time that AV shunt needed
to mature.

GENERAL
PRINCIPLES
7.

Anticoagulation is not routinely needed during


surgery, except for graft thrombectomy and
revision procedures, or patients who do not
have the usual hypocoagulable state of
chronic renal failure.

8.

Prophylactic antibiotics are used for all cases


involving insertion of prosthetic material.

9.

Ideal vascular access for hemodialysis


KDOQI
Rule of 6s :
- access flow rate = 600 mL/min
- access depth < 6 mm below skin

PATIENTS PREPARATION
Glomerular filtration rate (GFR) < 30
mL/min/1.73m2 must be educated for
any renal replacement therapy including
double lumen catheter, AV Shunt, or
renal transplantation
The vessels of arm which will be used for
AV Shunt should be preserved by
avoidance of:
Venipuncture
Intravenous cannulation
Invasive monitoring lines

PATIENTS PREPARATION
Anamnesis :
- history of disease such as diabetes
mellitus, hypertension, stroke
- history of intravenous line use
Physical examination :
- vein quality, consistency, size (min
2 mm), infection
- artery patent palmar arch Allen
test

VASCULAR ULTRASONOGRAPHY
Preoperative vascular ultrasound:
- In addition to clinical assessment improves AVF outcomes
in terms of patency
- Improves maturation and use of AVF for dialysis
Intraoperative examination:
- Confirm pre-op studies
- Assess the impact of fistula flow on the artery inflow
- Assess the flow in the fistula vein
Evaluation of VA:
- Measurement of access flow
- Detection of complications (stenosis, steal, thrombosis)

PROCEDURE CHOICES IN VASCULAR ACCESS SURGERY

First choice:
Radiocephalic direct AV fistula
Brescia-Cimino (wrist)
Snuff-box (base of the thumb)
Second choice:
Forearm AV graft bridge fistula
Straight : radial artery largest
superficial vein of the cubital fossa
Loop : brachial artery largest
superficial vein of the cubital fossa
Brachioaxillary graft
Upper arm AV fistula (brachial basilic)

PROCEDURE CHOICES

Third choice:
Forearm AV graft to brachial vein
Straight : radiobrachial
Loop : brachiobrachial
Fourth choice:
Femorosaphenous graft
Femorofemoral graft
Others:
Axilloaxillary graft
Illiac-femoral graft
Miscellaneous

SURGICAL TECHNIQUES

1. Side to side anastomosis:


Technically is the easiest
anastomosis
Highest fistula flow
2. End to side (artery to vein):
Minimize turbulence and distal steal
Slightly lower fistula flow
Twisting of the artery during
construction

SURGICAL TECHNIQUES

3. End to side (vein to artery):


Decrease turbulence
Highest venous flow
Minimal venous hypertension
More difficult than side to side
4. End to end:
Least arterial steal and venous
hypertension
Lowest flow of the four configurations

SURGICAL TECHNIQUES

COMPLICATIONS

COMPLICATIONS

Failure:
The most frequent complication early
failure
Reported incidence: up to 27%
May be a result of :
Thrombosis: (more in)
DM
erythropoietin
Failure to mature and achieve an
adequate flow rate to maintain dialysis:
Technical problems in constructing the
anastomosis
A sclerotic vein segment in the forearm
because of previous venesection
Inadequate venous size
Calcification of the arterial wall

COMPLICATIONS

Thrombosis is suspected by clinical


evaluation further assessment can be
made by :
Angiogram
Ultrasonography
Surgical thrombectomy is done by
making a small venotomy and using a
fogarty balloon catheter to remove the
thrombus

COMPLICATIONS

Aneurysm:
Pseudoaneurysm formation may occur
at puncture sites following dialysis
The incidence in autogenous fistula <
prosthetic grafts
True aneurysm are much rare but
have also been reported in few
occasions in the vein distal to the
anastomosis
Treated with resection and either
End to end anastomosis
Placement of short segment graft

COMPLICATIONS

Infection:
Infection of autogenous fistula are rare
compared to prosthetic graft
Signs & symptoms :
Fever
Erythema
Tenderness
And complications (such as thrombosis
and aneurysm )
The most common infecting organism:
Staphylococcus aureus
Managed by systemic antibiotics, drainage
and revision as necessary. Prosthetic graft
must be completely excised.

COMPLICATIONS

Ischemic changes:
Steal symptoms may occur in around 4% of
patients with autogenous fistula
The incidence is higher in :
Diabetic patients
Atherosclerotic patients
Antecubital fistulas
The symptoms may only manifested during
dialysis and as such may be managed by
observation and by using low flow rate
Gangrene may occur requiring amputation
To avoid the problem of retrograde flow
through the palmar arch in wrist fistula :
- ligation of the radial artery distal to the
anastomosis
- end to end anastomosis

COMPLICATIONS

Venous hypertension:
The hand distal to the fistula become
swollen
and
uncomfortable
with
thickening
of
the
skin
and
hyperpigmentation
Venous hypertension may be avoided by
forming an end to end anastomosis
Or to ligate the enlarged venous
tributaries causing the hypertension of
the distal digits, so preserving the fistula

COMPLICATIONS

Cardiovascular complication:
High output cardiac failure is a rare
complication
which
may
occurs
particularly in patients displaying a
combination
of
low
hematocrit,
cardiomyopathy from diabetes and
the presence of high flow fistula
Treatment usually involves sacrificing
the fistula

CARE AFTER A-V SHUNT


SURGERY
Keep the arm raised on a pillow to reduce swelling.
The dressing should remain intact and dry at all times.
As soon as post operative pain has subsided, start arm
exercises
Do not allow blood pressure, blood taking or intravenous
administration on the arm which the AV Shunt is made.
Check for thrill

NOTES
The use of regional anesthesia may lead to dilatation of
both the peripheral veins and inflow arteries increase
maturation
No benefit of intraoperative anticoagulation in patency.
Patients in ESRD are likely have defects in hemostatic
mechanism increase bleeding
Stapled anastomosis is as good as sutured anastomosis
Length of the anastomosis irrelevant to the risk of access
related hand ischemia

REFERENCES
1. Woo K, Rowe VL. 2014. Hemodialysis Access: Dialysis Catheter.
Rutherfords Vascular Surgery 8th Edition. Philadelphia: Elsevier.
page 1099 1107
2. Levin et al. 2006. National Kidney Foundation. KDOQI Clinical
Practice Guidelines and Recommendations for 2006 Updates:
Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and
Vascular Access. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1)

THANK YOU