1. Vascular Access Formation Care
Pre/Post
Vascular Access Formation Care
ปิ่นแก้ว กล้ายประยงค์
สาขาวิชาโรคไต ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี

2. VASCULAR ACCESS for HEMODIALYSIS
Temporary Vascular Access
1. Noncuffed Catheter
2. Long-term Catheter
2.1 Tunneled cuffed catheter
2.2 Port catheter system
Permanent Vascular Access
1. Native AV Fistula
2. Synthetic AV Graft

3. K/DOQI Guidelines for Vascular access
• Published guidelines in 1997
Updated in 2000, 2006
• Creation of AVF’s in 50% of all incident
and 65% of prevalent patents.
• Less than 10% of chronic hemodialysis
patients should be maintained on catheters.
• 6 Headings
• 38 Guidelines

4. K/DOQI Guidelines I. Patient Evaluation Prior to Access
Placement Monitoring, Surveillance, and Diagnostic
testing
II. Selection and Placement Select Areas of Most
importance
III. Prevention of Complications: Infections
IV. Management of Complications: When to intervene
V. Management of Complications: Optimal
Approaches for Testing Complications
VI. Potential Quality of Care Standards.

5. Objectives Provide an overview purpose of the KDOQI guidelines 2006
Review pre-post operative methods to maximize
maturation of AV Fistula
Describe how to the access formation, and identify ways that the patients can be prepared

6. Vascular Access – KDOQI 2006
Fistula First Change Package
Clinical and organizational recommendations based on best practices for increasing AV fistula use and improving hemodialysis patient outcomes
- Lasts longer than other access types
- Has fewer infections than grafts or catheters
- Needs fewer follow-up procedures to keep it working, which means
fewer hospital visits
fistulafirst.org

7. Which is Closest to the Ideal Access?
+ = close to ideal, - = far from ideal
Lynch P. What is it? Where are we now? Where do we need to go? How are we going to achieve the fistula first goals?

8. Fistula First Change Package
1. Routine CQI review of
vascular access
2. Timely referral to
nephrologist
3. Early referral to surgeon
for “AVF only”
4. Surgeon selection
5. Full range of appropriate
surgical approaches
6. Secondary AVFs in AVG
patients
7. AVF evaluation/placement in catheter patients
8. Cannulation training
9. Monitoring and Maintenance
10. Continuing education
11. Outcomes feedback
fistulafirst.org

9. Vascular Access – KDOQI 2006 of Access
Routine CQI review of vascular access
Timely referral to nephrologist
CPG 1: Preparation & Evaluation for Permanent Access
- Patients with a GFR of < 30 ml/min/1.73m2
(CKD stage IV) should be educated on all modalities of
RRT including transplantation and placement of a
permanent dialysis access if necessary (A)

10. Kigney Transplantation
Counseling for RRT modalities
Kigney Transplantation
CAPD
Hemodialysis

11. Vein Preservation and Hemodialysis Fistula Protection
If the patient has CKD or is at risk for CKD, whether or not he/she is on dialysis:
DO use the dorsum of the hand for venipuncture and IV infusions
DO rotate venipuncture sites
DO use a manual blood pressure device
DO NOT use the cephalic veins of either arm for blood draws, IV fluid therapy, or drug infusions
DO NOT place a subclavian catheter or a PICC line (place an internal jugular line, instead)

12. Vascular Access – KDOQI 2006 of Access
Early referral to surgeon for “AVF only” evaluation and timely placement
- 6 months prior to initiation
Surgeon selection based on best outcomes, willingness, and ability to provide access services
Full range of appropriate surgical approaches to AVF evaluation and placement
fistulafirst.org

13. Vascular Access – KDOQI 2006 of Access
CPG 2. Selection and Placement Select Areas of Most
importance
Reducing Catheter Use -- Strategies
Role of vein imaging (mapping) in fostering the AV fistula initiative
Major Focus Areas
􀂃 Pre-op venous imaging/mapping for planning
AVF construction

14. AV Fistula Maturation Pre-Op Assessment
Vascular mapping
– Caliber
– Patency
– Phlebitic changes
– Neutralizes demographic
impact
Venogram
Access history
Physical exam
– Pulses
– Vein pattern

15. Pre-operative preparation
Patient :
Informed consent
Non-dominant arm
Reduction of non-maturing (FTM)
AVF via mapping /optimal vessel selection
Arterial requirements
Pressure differential < 20 mmHg between arms
Patient palmar arch has to be good
Allen test
Arterial lumen diameter ≥ 2.0 mm at point of anastomosis

16. Pre-operative preparation
Venous requirements
Luminal diameter ≥ 2.5 mm or greater at anastomosis point
Absence of obstruction, calcifications
Straight segment for cannulation
Within 1 cm of surface
Continuity with patent central veins
Doppler USG

17. Pre-operative preparation
Davis J, People like us: The NKF’s patient empowerment program, 14; 1: 2005

18. Chronic AV Access Algorithm CPG 2. Selection of Access
AV fistula :Preferred (B+)
A wrist: radiocephalic (forearm) primary fistula (A)
An elbow: brachiocephalic (upper arm) primary fistula (A)
A transposed: brachiobasilic vein fistula (upper arm) (B)
Primary failure –forearm > upper arm
AV graft acceptable: AVG of synthetic or biological material, such as: (B) : 3-6 wks prior to initiation
Forearm loop graft
Brachio-axillary AVG
Femoral loop AVG
Avoid if possible: Long-term catheters (B)

19. Vascular Access – KDOQI 2006 of Access
Secondary AVF placement in patients with AV graft
AVF placement in patients with catheters where indicated
Cannulation training for AV fistulas
Monitoring and maintenance to ensure adequate access function
fistulafirst.org

20. CPG 3. Cannulation & Access Care
AVF dysfunction/failure-to-mature:
- Early recognition of F-T-M AVF by evaluation
- Monitoring & Timely Intervention for late AVF failure
/aggressive Salvage
Maturation - Fistula hand-arm exercise (B)
If a fistula has not matured, a fistulogram or other
imaging study should be obtained to determine the cause of the problem (B+)

21. CPG 3. Access Care: Patient Education
Teach patients fistula exercise
Isometric exercise should help develop both enlarge the vein by increasing flow and build the muscle below to
make the vein more prominent
Have the patient use a light tourniquet or opposite hand to help engorge the veins with exercise
Have the patient exercise 4 times a day for 5-10 minutes a day or more

22. CPG 3. Access Care: Patient Education
Fistula hand arm exercise: before a fistula is placed and help the fistula mature after placement .

23. Pre-operative Teaching
About the surgery:
Will be done as a day or short stay surgery; non-dominant arm preferred
After the surgery:
Keep arm straight & raised on a pillow, even while sleeping
Monitor discomfort: If mild to moderate, take pain medication regularly
Follow-up appointments in 2 weeks

24. CPG 3. Access Care: Patient Education
Post-op care:
Keep dressing clean and dry
Rest and take medicine as prescribed
Notify the surgeon’s office or go to ER if dressing becomes satuated with blood or fluid
Monitor colour & warmth of fingers on fistula hand should be the same as other hand
Experience a rise in temperature, numbness of the hand,
or and increase in pain

25. CPG 3. Access Care: Patient Education
Post-op care:
Keep fingers moving, squeeze soft ball to encourage vein development
Check fistula every morning & evening for thrill (feel for buzzing sensation) & bruit (hold anastomosis site to the ear & listen for bruit)

26. Patient Education
Have the patient demonstrate the proper exercise procedure while at dialysis for review by the dialysis
staff
Ask the patient every treatment if they are still exercising daily
Examine the fistula weekly for signs of proper maturation

27. When is an AVF mature? Maturity Characteristics
􀁹Goes from soft and pliable to springy and firm
: adequate dilation
􀁹Diameter of vessel is increasing
(2mm →→ 4mm →→ 6mm)
􀁹Thrill is stronger
􀁹Bruit is continuous and low pitch
􀁹 No accessory veins detracting form the main conduit
Causes of Non-Development
􀁹 Location
􀁹 Diseased vessels
􀁹 Poor cardiac output
􀁹 Accessory veins
􀁹Juxta-anastomotic stenosis

28. AV Fistula Maturation Adequate flow
–Access flow 100 mL/min > dialysis flow rate
–International variation
USA –400 cc/min
Europe –300 cc/min
Japan –200 cc/min
Adequate wall thickening
Adequate location

29. Rule of 6s for the Fistula Maturation
Greater than 600mL / min flow
Greater than 6 mms in diameter
Less than 6mms below skin surface
AND all fistulae should be thoroughly examined no later than 6 weeks post op
Is there at least 6 cms of vein to cannulate?
(>6 cm long)

30. All Patient should be taught how to:
Compress a bleeding access
Wash skin over access with soap and water daily and before HD
Recognize s/s of infection: redness, warmth or pain in fistula arm, oozing or drainage
Select proper methods for exercising fistula arm with some resistance to venous flow
Palpate for thrill /pulse daily
Listen for bruit with ear opposite access if can’t palpate for any reason
Call your health care provider or dialysis center immediately
if you can't feel a thrill

31. All patients should know to:
Avoid heavy lifting
Avoid putting pressure on fistula
- Avoid sleeping on the access arm
- Avoid tight clothing on the access
- Do not wear restrictive jewelry wearing
occlusive closing over access
Stay active, but avoid contact sports
Save fistula arm for dialysis & let others know this No BP, blood work or IV Wear medical alert bracelet

32. All patients should know to:
Apply pressure for stop bleeding post dialysis: with 2 fingers
– Strong enough to prevent bleeding
– Not so strong as to occlude flow
Noticeable swelling or itching in fistula arm
Be aware of site rotation (unless buttonhole cannulation method is used)
Be aware of proper skin preparation and importance of staff wearing masks
Report and s/s of infection and absence of bruit /thrill to staff immediately

33. AV Fistula Immaturation
Causes of early fistula failure
– Inflow problem
• Pre-existing arterial anomalies – Anatomically small – Atherosclerosis
• Acquired
– Anastomotic stenosis
– Outflow problems
• Pre-existing venous anomalies – Anatomically small – Fibrosis
– Accessory veins (side branches)

34. Goals for Access Placement
Each center should establish a database
and CQI process to track the types of accesses
created and the complication rates for these accesses
The goals for incident hemodialysis access
placement should include:
- fistula >65%, catheters <10%.
- The primary access failure rates of hemodialysis
accesses (grafts and catheters)
: Forearm straight grafts < 15 %
: Forearm loop grafts < 10%
: Upper-arm grafts < 5 %

35. Conclusion Reported Barriers – No vascular access counseling
• Lack of pre-dialysis care / delayed nephrology referral
– No vascular access counseling
– Patients discharged from hospital with no plan for
permanent access
• Lack of timely surgical placement of permanent access
– Low rate of pre-dialysis access surgery despite referral
– Incomplete AVF maturity
• Patient refusal of permanent access surgery
– Fear of pain, cosmetic concerns

36. QUESTION