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HISTORY

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Shunt

Quinton, Dillard and Scribner’s vascular access, 1960 Two silastic tubes with tapered Teflon tip, implanted in radial artery and cephalic vein, connected outside the patients skin •

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When Should

Fistula Be Placed

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GUIDELINES 2000

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NKF/DOQI GUIDELINE 8 Timing of Access Placement
A. Patients with chronic kidney disease should be referred for surgery to attempt construction of a primary AV fistula when their :













creatinine clearance is <25 mL/min, serum creatinine level is >4 mg/dL, within 1 year of an anticipated need for dialysis. (Opinion)

B. A new primary fistula should be allowed to mature for at least 1 month, and ideally for 3 to 4 months, prior to cannulation. (Opinion) C. Dialysis AV grafts should be placed at least 3 to 6 weeks prior to an anticipated need for hemodialysis in patients who are not candidates for primary AV fistulae. (Opinion) D. Hemodialysis catheters should not be inserted until hemodialysis is needed. (Evidence/Opinion) *25 mL/min = 0.42 mL/s *4 mg/dl = 0.353 mmol/L

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Order of preference for

permanent vascular access

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NKF/DOQI GUIDELINE 3 1. 2. 3. 4. 5.

Wrist fistula (Evidence) Elbow fistula (Evidence/Opinion) PTFE graft (Evidence) OR Basilic vein transposition (Evidence) Permanent central lines “should be discouraged”

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Snuffbox AV Fistula

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Basilic Vein Transposition

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Brachiobasilic AVF with vein transposition (upper arm)

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Tunneled Cuffed Cathters

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NKF/DOQI GUIDELINE 4 Type and Location of Dialysis AV Graft Placement
If a primary AV fistula cannot be established, a synthetic AV graft is the next preferred type of vascular access (see Guideline 3: Selection of Permanent Vascular Access and Order of Preferences for Placement of AV Fistulae). (Evidence)
Polytetrafluoroethylene (PTFE) tubes are preferred over other synthetic materials. (Evidence/Opinion)
Grafts may be placed in straight, looped, or curved configurations. Designs that provide the most surface area for cannulation are preferred. (Opinion)
Location of graft placement is determined by each patient's unique anatomical restrictions, the surgeons's skill, and the anticipated duration of dialysis. (Opinion)

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AV Graft Placement Straight Forearm

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What alternative sites are available for hemodialysis access?

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LifeSite Hemodialysis Access System
A totally subcutaneous alternative to hemodialysis catheters
Two valve design allows for blood draw and return and maximum implant flexibility
Can be used immediately after implantation
Uncertain role for long term access

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When Should

Fistula Be Used

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NKF/DOQI GUIDELINE 9 Access Maturation A. A primary AV fistula is mature and suitable for use when the vein’s diameter is sufficient to allow successful cannulation, but not sooner than 1 month (and preferably 3 to 4 months after construction. (Opinion)

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NKF/DOQI GUIDELINE 9 B.

The following procedures may enhance maturation of AV fistulae: 1)

2)

Fistula hand-arm exercise (eg, squeezing a rubber ball with or without a lightly applied tourniquet) will increase blood flow and speed maturation of a new native AV fistula. (Opinion) Selective obliteration of major venous side branches will speed maturation of a slowly maturing AV fistula. (Opinion) 23

NKF/DOQI GUIDELINE 9 C.

PTFE dialysis AV grafts should not routinely be used until 14 days after placement. Cannulation of a new PTFE dialysis AV graft should not routinely be attempted, even 14 days or longer after placement, until swelling has gone down enough to allow palpation of the course of the graft. Ideally, 3 to 6 weeks should be allowed prior to cannulation of a new graft. (Opinion) 24

“Any Questions ??”

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