Hemodialysis Vascular Access: A Transplant Surgeon’s Perspective

GAZI B. ZIBARI AND JOHN C. MCDONALD

The increasing burden of providing access to the circulatory system for hemodialysis patients in the United States is fueled by the increased number of patients who undergo this form of therapy. More than 300,000 patients were treated for end-stage renal disease (ESRD) in 1995.¹ Of these patients, only 15% were treated by renal transplantation, and at least 85 to 90% were treated by hemodialysis at some point during their lifetime.²^,³ As a result of the liberal use of hemodialysis, more older patients with multiple medical problems have been maintained on dialysis because most of these patients are not good candidates for renal transplantation or peritoneal dialysis (PD). Also, the prolonged waiting time for cadaveric renal transplantation has led to ever-increasing lengths of time that patients are undergoing hemodialysis. Therefore, surgeons and interventional radiologists are asked by nephrologists to create some form of vascular access for hemodialysis. In this chapter, acute and chronic renal failure is discussed briefly and, in addition, different forms of vascular access for HD will be discussed.

Historical Background

Kolff and Beck, in 1943, demonstrated the technical capability to perform hemodialysis using glass or metal tubes for intermittent cannulation of arteries and veins.⁴ Quinton et al⁵ described a permanent in-dwelling cannula in 1960. Brescia and Cimino,⁶ in 1966, introduced the concept of peripheral subcutaneous autogenous arteriovenous fistula. This type of fistula has proven to be most durable and easy to use, and it has a relatively low complication rate. Chinitz et al, in 1972, popularized bovine graft use, and in 1973 Volder used polytetrafluoroethylene (PTFE).⁷ These prosthetic materials are fraught with their own problems and complications. The vascular access for hemodialysis remains the “Achilles heel” of dialysis.

Renal Failure

Acute Renal Failure

Acute renal failure (ARF) involves a sudden decrease in the ability of the kidney to excrete nitrogenous wastes, resulting in azotemia. ARF may be prerenal, renal, or postrenal in origin. The etiology of ARF can be multifactorial and may include (1) intravascular volume depletion resulting from hemorrhagic shock, burns, and third-space sequestration; (2) reduced cardiac output resulting from cardiogenic shock, congestive heart failure (CHF), pericardial tamponade, and massive pulmonary embolism; (3) systemic vasodilation resulting from sepsis, anaphylaxis, and antihypertensive drugs; (4) systemic or renal vasoconstriction resulting from anesthetics, surgery, alpha-adrenergic agonists, or a high dose of dopamine and hepatorenal syndrome; (5) exogenous and endogenous toxin exposure resulting from antibiotic and myoglobin, respectively. ARF will require some form of temporary dialysis, such as continuous arteriovenous hemofiltration (CAVH) or continuous arteriovenous hemodialysis for unstable patients in the intensive care unit (ICU) versus hemodialysis via central doublelumen catheter placement for more stable patients.

Chronic Renal Failure

Chronic renal failure (CRF) occurs when renal function deteriorates and diminishes from underlying parenchymal renal disease. ESRD is present when there is so little remaining function that patients require some form of therapy such as dialysis or transplantation. The most common causes of CRF in adults are diabetic nephropathy, hypertension, nephrosclerosis, glomerulonephritis, hereditary renal disease, obstructive uropathy, and interstitial nephritis.¹^,² Three forms of therapeutic modalities are available to manage patients with ESRD: hemodialysis, PD, and renal transplantation. The overwhelming majority of these patients will require some form of hemodialysis at some point during their lifetime. The indications for dialysis in oliguric patients are uremic pericarditis, severe hyperkalemia, volume overload with CHF, severe refractory metabolic acidosis (pH < 7.2), and symptomatic uremia.

Hemodialysis Catheters and Vascular Access

Temporary and Permanent Percutaneous Hemodialysis Catheters

Urgent or emergency hemodialysis is best achieved by temporary percutaneous double-lumen catheter placement into the central venous system using the standard Seldinger technique. The sites more commonly used are internal jugular (IJ) veins, subclavian (SC) veins, and femoral veins. The IJ veins and SC veins are used for patients who require more frequent hemodialysis in whom the catheter can be left in place for 3 to 4 weeks. The femoral veins are used for patients with coagulopathy, for patients confined to bed, and for critical-care patients who require intermittent cannulation. These catheters can be inserted at the bedside or in the minorprocedure room. This technique will preserve more distal veins for permanent vascular access placement. Disadvantages of this type of catheter are complications of infection, venous stenosis, and thrombosis, and the catheter should not be left in place for longer than 4 weeks.

A more permanent type of percutaneous catheter, such as a Perm-Cath, can be placed in the IJ or SC veins by using the same technique as for temporary percutaneous catheter placement. Rarely, the interventional radiologist places a catheter in the inferior vena cava through a translumbar approach. Several alternative vascular access sites have been described in the literature, including the use of the gonadal vein, internal mammary vein, azygos vein, as well as the renal vein in patients with ESRD.⁸ This type of catheter is a large-bore, double-lumen soft Silastic catheter, and it has a Dacron cuff that remains subcutaneous to act as a barrier to infection. This catheter is best used for those patients who are not candidates for transplantation or peritoneal dialysis and for patients who have exhausted peripheral sites for vascular access.

Tunneled dialysis catheters also can be used for hemodialysis in ESRD patients waiting for their permanent vascular access to mature. We do not recommend leaving this type of catheter in place for long because of the increased incidence of central vein stenosis and thrombosis. To do so would compromise the use of more distal sites for chronic vascular access. Other well-recognized but rare (1%) complications of these types of percutaneous dialysis catheters include hemothorax, pneumothorax, air embolism, catheter dislodgment, vein, and arterial injuries. Catheter thrombosis and infection are not uncommon complications. If the catheter becomes infected, it must be removed. If the catheter becomes thrombosed, initial treatment can be either urokinase or streptokinase, and good success can be anticipated. An experienced surgeon can place the tunneled catheters in the operating room or in interventional radiology by using fluoroscopy, or an interventional radiologist and, more recently, an interventional nephrologist can perform this step. Regarding patency and complication, the best site for catheter placement is the fight IJ vein, followed by the left SC vein, the right SC vein, and, lastly, the left IJ vein. The inferior vena cava has been used rarely through the translumbar approach when the previously mentioned sites are not available. When we encounter any difficulty in percutaneous placement of a Perm-Cath, we expose the jugular veins operatively and insert the catheter under direct vision. Central vein stenosis can be managed using balloon angioplasty; if necessary, in selected patients, it is treated with stent placement.

Chronic Access for Hemodialysis

Before creating a vascular hemodialysis access in the upper extremity, an Allen test must be performed to ensure a patent palmar arch.⁹ If in doubt, Doppler ultrasound should be used to document palmar arch patency. Every attempt should be made to prolong the mean patency of each hemodialysis vascular access and to preserve other sites for future use. Premature hemodialysis access placement should be avoided because thrombosis is more likely to occur when the coagulation defects of azotemia are not present.² A creatinine level of 6 to 10 mg/dL should be present before an access is placed. Several general rules should be followed when planning a hemodialysis access placement, and the initial access site must be selected carefully.³^,¹⁰ The nondominant arm is preferable to a leg. The access should be placed as distal as possible. Thin skin and a slim fore- arm should be avoided when possible because of the high incidence of skin erosion and infection. Skin incisions should be placed away from the anastomotic site and the use of systemic heparin avoided while creating a primary access, and we recommend the use of prophylactic antibiotics when a synthetic graft is placed.

Arteriovenous Fistula

A general consensus exists that the use of the autogenous arteriovenous (AV) fistula for vascular access is associated with the longest period of graft patency and with relative freedom from thrombosis and infection complications (Table 17–1). The concept of the peripheral subcutaneous autogenous AV fistula was introduced by Brescia et al⁶ in 1966 and has proven to be relatively durable and easy to use, and it has a relatively low complication rate. Only 20 to 25% of patients with ESRD will be candidates for this type of fistula, however. The senior author reported his experience in 1978 and found the use of the native fistula to be possible in about 70% of his patients.¹² We reported our experience 10 years later in 1988, and it was possible to create native fistulae in only 49% of our patients, as shown in Figure 17–1. More recently (1997), we found it possible to create native fistulae in only 25% of a total of 408 access procedures we performed.¹³ The increased use of prosthetic material to achieve hemodialysis access is attributable to the increasing age of patients on dialysis, to the increasing length of time patients are on dialysis, and to the severity of underlying medical problems including peripheral vascular disease and diabetes. These prosthetic materials have their own set of problems and complications, with thrombosis the most common (Fig. 17–2). Silva et al¹⁴

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