LUNCH SYMPOSIUM

PIT-IX

Hemodialysis Access in Indonesia :

Past, Present and Future
 The PAST
Direct access : - open cut down of radial artery
- direct puncture of radial-artery/ brachial artery
Permanent vascular access :
- Scribner external shunt (Quinton-Scribner) 1960
- Brescia-Cimino Shunt 1966
INDONESIA : - Jakarta 1970
- Surabaya 1973
Variant of vascular access : - anastomosis
- site : radial, brachial, femoral
Semi-permanent access : AV-fistula / CVC 1990s : subclavia, jugular
( up to now)
SURABAYA :
- 1973 : open cut down direct radial puncture (1973-1974)
- 1975 : 1st Brescia-Cimino shunt : radial end-to-end anastomosis
- 1989 : 1st subclavian A-V-Fistula
Surabaya, 1973
 Direct puncture of arm-artery and vein for vascular
access in emergency cases in limited facilities for
normal vascular access : is there a place to do that ?

USG-guided

EMERGENCY CASE ?
 Hemodialysis Vascular Access

Acute hemodialysis vascular access:

Acute dialysis catheters
Cuffed,tunneled dialysis catheters

Chronic hemodialysis vascular access:

native arteriovenous (AV) fistulas
synthetic grafts
 The PAST of vascular access

Scribner-fistula (Quinton-Scribner shunt)

Types of vascular access for hemodyalisis
Arteriovenous fistula
Arteriovenous graft
Central venous catheter

graft
Brescia-Cimino Fistula
 Native arteriovenous (AV) fistulas

Brescia-Cimino Fistula Snuff-box Fistula

 Acute Hemodialysis Catheters

Double-lumen, non-cuffed, non-tunneled hemodialysis

catheters have become the preferred method for
obtaining acute hemodialysis vascular access

An acute triple-lumen dialysis catheter has been

developed. The third lumen is available for blood
drawing and the intravenous administration of drugs
and fluid.

The maximum blood flow is usually blood pump speeds

of 300 mL/min, with an actual blood flow of 250 mL/min
or less.
 Acute Hemodialysis Catheters
Site of catheter Insertion
can be inserted into the jugular,
subclavian, and femoral veins

Routine use-life of catheters

The limits on use-life are caused by
infection internal jugular catheters are
suitable for 2 to 3 weeks of use
femoral catheters are usually used for a
single treatment (ambulatory patients) or
for 3 to 7 days in bed bound patients
Double lumen cuffed tunneled catheters

Are principally constructed of

silastic/silicone and other soft
flexible polymers, which are less
thrombogenic than polymers
used in acute catheters.

Require fluoroscopy for insertion

due to their larger size and to the
confirmation of tip location.

Many allow right atrial tip

location based on their soft
polymer construction
 Double lumen cuffed tunneled catheters

Allow faster blood flows than acute catheters, Usually

blood pump speeds of 400 mL/min
Actual blood flow rates are almost always lower than
those reported by the blood pump(20%-30%)

Compare to fistulas or arteriovenous grafts, most

patients require an increase in treatment time of
approximately 20 percent to achieve equivalent
urea removal.

Cuffed tunneled catheter survival

is highly variable, 74 percent 1-year and a 43
percent 2-year catheter survival
Variants of hemodialysis
VASCULAR ACCESS
 Brescia-Cimino
Radiocephalic Arteriovenous Fistula
Snuff-box Arteriovenous Fistula
Proximal Forearm Arteriovenous Fistula
Proximal Forearm Arteriovenous Fistula
Brachiocephalic Arteriovenous Fistula
Transposed Basilic Vein Arteriovenous Fistula
 Synthetic grafts

are constructed by anastomosing a synthetic

conduit, usually polytetrafluoroethylene
(PTFE, also known as Gortex), between an
artery and vein.
The 2006 K/DOQI work group recommends a
graft either of synthetic or biologic material
Forearm Loop Arteriovenous Graft
Upper Arm Arteriovenous Graft
Thigh Arteriovenous Graft
Comparison of Fistulas and Grafts

Primary failure
defined as an access that never provided
reliable hemodialysis.
In radiocephalic fistulas 24 to 35 %
brachiocephalic fistula 9 to 12 %
brachiobasilic fistulas 29 to 36 %
forearm grafts 0 to 13 %
upper arm grafts 0 to 3 %
 Comparison of Fistulas and
Grafts
Time to use

Grafts
Grafts can be cannulated for hemodialysis earlier than fistulas.
Grafts can usually be cannulated within weeks.
Some times within days of surgery
Fistulas
Cannulation before two weeks of age should be avoided.
Cannulation between two to four weeks may be attempted but only if
the fistula is considered mature.
Cannulation after four weeks of maturation may be safe, if the fistula is
mature.
Independent of the age of the fistula, clinical examination prior to
cannulation is very important, given that some fistulas require up to
six months to mature.
 FACTS of Hemodyalisis
vascular access
After decades of success in dialysis research and treatment,
the prompt availability of a well functioning vascular access
(VA) for dialysis remains a disturbing problem

VA complications account for 16-25% of hospital admissions

in hemodialysis (HD) patients

HD VA dysfunction is a major cause of morbidity and

hospitalization among the HD population

1. El Minshawy et al. The Journal of Vascular Access 2004; 5: 76-82)

2. Ravani P, et al. Am J Kidney Dis 2002; 40: 1264-76.
3. Dhingra RK et al ,. Kidney Int 2001; 60: 1443-51.
4. Roy-Chaudhury P, et al J Invasive Cardiol 2003; 15: A25-30.
 The puncture technique
The Buttonhole technique :
 The Buttonhole puncture
Buttonhole technique is a cannulation method where
an individual cannulates the AV Fistula in the exact
same spot, at the exact same angle and depth of
penetration every time.
A scar tissue tunnel track develops allowing the
eventual use of a buttonhole fistula needle (blunt, dull)
 35

Vascular Access Management Tools

Intraoperative Flowmeter Endovascular Flowmeter

Hemodialysis Monitor
 36

Vascular Access Blood Flow Monitoring

Reduces Access Morbidity and Costs

Patricia McCarley, Rebecca L. Wingard, Yu Shyr, William Pettus, Raymond M.

Hakim, and T. Alp Ikizler
Vanderbilt University Medical Center, Dialysis Clinics, Inc., Renal Care Group, Inc.

Kidney International, Vol. 60 (2001), pp. 1164-1172

 37

HD Monitor Parameters

Dialysis Adequacy
Delivered Blood Flow
Recirculation

Vascular Access Flow

Cardiac Output
 Guidelines for Monitoring
38

AV Grafts and Fistulas

Access flow < 600 ml/min, the patient
should be referred for fistulagram.

Access flow < 1000ml/min that has

decreased by > 25% over 4 months should
be referred for fistulagram.
 Europe 39

Objective monitoring of access function

should be performed regularly by
measuring access flow.

European best practice guidelines on hemodialysis Guideline 5.

Surveillance of Vascular Access. ERA/EDTA. Nephrol Dial Transplant, 2007;
22(Suppl 2): ii99. Transonic Reference # HD7450A
 Japan 40

Regular monitoring of shunt flow in

haemodialysis patients has become
extremely important.

Clinical Evaluation of New Non-Invasive Shunt Flow Measurement

Device. Satoshi YAMAGUCHI1, Noriko OKUMURA1, Izumi AMANO1
Department of Blood Purification, Tenri Hospital. 42nd Annual Meeting of
the Japanese Society for Artificial Organs; October 6, 2004
 Extremity edema:
Patients with extremity edema that persists beyond 2
weeks after graft placement should undergo an imaging
study (including dilute iodinated contrast) to evaluate
patency of the central veins.
The preferred treatment for central vein stenosis is PTA.
Stent placement should be considered in the following
situations:
Acute elastic recoil of the vein (>50% stenosis) after
angioplasty.

The stenosis recurs within a 3-month period.

Indicators of risk for graft rupture:

Any of the following changes in the integrity of

the overlying skin should be evaluated urgently:

Poor eschar formation. [B]

Evidence of spontaneous bleeding. [B]
Rapid expansion in the size of a
pseudoaneurysm. [B]
Severe degenerative changes in the graft
material. [B]
Indications for revision/repair:
AVGs with severe degenerative changes or
pseudoaneurysm formation should be repaired
in the following situations:
The number of cannulation sites are limited by
the presence of a large (or multiple)
pseudoaneurysm(s). [B]
The pseudoaneurysm threatens the viability of
the overlying skin. [B]
The pseudoaneurysm is symptomatic (pain,
throbbing). [B]
There is evidence of infection. [B]
Treatment of stenosis without thrombosis:

Stenoses that are associated with AVGs

should be treated with angioplasty or surgical
revision if the lesion causes a greater than
50% decrease in the luminal diameter and is
associated with the following
clinical/physiological abnormalities:
Abnormal physical findings. [B]
Decreasing intragraft blood flow (<600 mL/min). [B]
Elevated static pressure within the graft. [B]
Treatment of thrombosis and
associated stenosis:

Each institution should determine which

procedure, percutaneous thrombectomy with
angioplasty or surgical thrombectomy with
AVG revision, is preferable based upon
expediency and physician expertise at that
center.
 Signs of CVC Dysfunction: Assessment
Phase

Blood pump flow rates <300 mL/min

Arterial pressure increases (< -250 mm Hg)
Venous pressure increases (>250 mm Hg)
Conductance decreases (<1.2): the ratio of blood pump flow to the absolute value of
prepump pressure
URR progressively <65% or (Kt/V <1.2)
Unable to aspirate blood freely (late manifestation)
Frequent pressure alarms - not responsive to patient repositioning or catheter flushing

Trend analysis of changes in access flow is the best predictor of access patency and
risk for thrombosis

CVC; central venous catheter; URR, urea reduction ratio; Kt/V, (Kurea x Td)/Vurea, where Kurea is the effective (delivered)
dialyzer urea clearance in milliliters per minute integrated over the entire dialysis, Td is the time in minutes measured from
beginning to end of dialysis, and Vurea is the patient's volume of urea distribution in milliliters
 Causes of Early Catheter
Dysfunction
Mechanical
Kinks (angulation in tunnel)
Misplaced sutures
Catheter migration
Drug precipitation (some antibody locks or IV IgG)
Patient position
Catheter integrity
Holes
Cracks

IV IgG, intravenous Immunoglobulin G

 Available Thrombolytics
Streptokinase
Highly antigenic
Low fibrin affinity

Urokinase
Available for PE treatment
No longer manufactured (11/2004)

Reteplase
Used in treatment of AMI
Must be aliquoted and frozen

Ateplase, tPA
High fibrin specificity
FDA approved
Available in single dose vials
No antigenicity
 The FUTURE
Sutureless Hybrid Vascular Graft
Venous and arterial connectors of the InterGraft device.
 a | The allogeneic cells
are
seeded onto a scaffold.

b | The cells then

produce
Bioengineered vessels from allogeneic
matrix components.
cells

c | The scaffold is then

decellularized and

d | used as an
arteriovenous
Thank you

for your attention