Av Shunt Mabi Xx

7/25/2019 Av Shunt Mabi Xx

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A-V SHUNT FOR

HEMODIALYSIS

HEROE SOEBROTO, DR., SPB, SPBTKV(K)THORACIC, CARDIAC, & VASCULAR SURGERYDIVISION/DEPARTMENT OF SURGERY

SOETOMO GENERAL HOSPITAL FACULTY OF MEDICINEAIRLANGGA UNIVERSITY SURABAYA20!


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INTRODUCTION

Vascular access for hemodialysis :

- central vein cannulation double lumcatheter

- device implantation Port-a-Cath

- surgical AV Shunt (Brescia-Cimino

AV Shunt : surgical procedure to create aanastomosis bet!een an artery and a vefor hemodialysis access


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INTRODUCTION

"heoretical Basis

AV Shunt !or# e$ectively forhemodialysis because they:

%ave high volume &o! rates

'se native blood vessels !hich !hencompared to synthetic graftsare lessli#ely to develop stenosesand fail)
https://en.wikipedia.org/wiki/Volume_flow_ratehttps://en.wikipedia.org/wiki/Stenosishttps://en.wikipedia.org/wiki/Stenosishttps://en.wikipedia.org/wiki/Volume_flow_rate


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ANATOMY


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ANATOMY


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GENERAL PRINCIPL

OFAV SHUNT


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GENERAL PRINCIPLES

*) "he arm vessels is more preferable ratherthan the leg vessels) +on-dominant arm

,rst)

) Access site should be placed as distally sthat pro.imal sites !ill be available forsubse/uent procedures)

0) 1nade/uate or atherosclerotic arteriesshould be avoided and a long section ofpatent vein is re/uired to accommodatemultiple cannulation site)


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GENERAL PRINCIPLES

2) "he chosen site should allo! for ease of access focannulation and should be positioned so that paticomfort is assured during hemodialysis)

3) "echnical precision and gentle tissue handling ismandatory)

4) A temporary access procedure such as :

5ight internal 6ugular Subclavian or femoral catheter

7.ternal shunt

Peritoneal catheter

are re/uired during the time that AV shunt needeto mature)


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GENERALPRINCIPLES

8) Anticoagulation is not routinely needed durinsurgery e.cept for graft thrombectomy andrevision procedures or patients !ho do nothave the usual hypocoagulable state ofchronic renal failure)

9) Prophylactic antibiotics are used for all casesinvolving insertion of prosthetic material)

) 1deal vascular access for hemodialysis ;1 5ule of 4s :

- access &o! rate ? 4@@ mmin

- access depth 4 mm belo! s#in


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PATIENTS PREPARATION

Dlomerular ,ltration rate (DE5 0@mmin*)80m must be educated for

any renal replacement therapy includingdouble lumen catheter AV Shunt orrenal transplantation

"he vessels of arm !hich !ill be used foAV Shunt should be preserved byavoidance of:V"#$%#'"I#*+"#- '*##*$#I#+*-$+" #$$# $#"-


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PATIENTS PREPARATION

Anamnesis :

- history of disease such as diabetesmellitus hypertension stro#e

- history of intravenous line use

Physical e.amination :

1 vein /uality consistency siFe (minG mm infection

1 artery patent palmar arch Allentest


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VASCULAR ULTRASONOGRAPHY

Preoperative vasc!ar !traso"#:

- 1n addition to clinical assessment improves AVE outcome

in terms of patency- 1mproves maturation and use of AVE for dialysis

I"traoperative e$a%i"atio"&

- Con,rm pre-op studies

- Assess the impact of ,stula &o! on the artery in&o!- Assess the &o! in the ,stula vein

Eva!atio" o' VA&

- Heasurement of access &o!

-


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PROCEDURE CHOICES IN VASCULAR ACCESS SURGERY

Eirst choice:5adiocephalic direct AV ,stula

Brescia-Cimino (!rist

Snu$-bo. (base of the thumb

Second choice:Eorearm AV graft bridge ,stula

Straight : radial artery largest

super,cial vein of the cubital fossa oop : brachial artery largest

super,cial vein of the cubital fossaBrachioa.illary graft'pper arm AV ,stula (brachial basilic


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PROCEDURE CHOICES

"hird choice:Eorearm AV graft to brachial vein

Straight : radiobrachial oop : brachiobrachial

Eourth choice:Eemorosaphenous graftEemorofemoral graft

=thers:A.illoa.illary graft1lliac-femoral graftHiscellaneous


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SURGICAL TECHNIQUES

() Si#e to si#e a"asto%osis&

"echnically is the easiest

anastomosis %ighest ,stula &o!

*) E"# to si#e +arter, to vei"&

HinimiFe turbulence and distal steal Slightly lo!er ,stula &o!

"!isting of the artery duringconstruction


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SURGICAL TECHNIUES

.) E"# to si#e +vei" to arter,&


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S'5D1CA "7C%+1>'7S


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COMPLICATIONS


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COMPLICATIONS

Fai!re& "he most fre/uent complication early

failure 5eported incidence: up to 8J Hay be a result of :

"hrombosis: (more in


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COMPLICATIONS

"hrombosis is suspected by clinicaevaluation further assessment can bemade by :

Angiogram

'ltrasonography

Surgical thrombectomy is done byma#ing a small venotomy and using afogarty balloon catheter to remove thethrombus


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COMPLICATIONS

A"er,s%&

Pseudoaneurysm formation may occuat puncture sites follo!ing dialysis

"he incidence in autogenous ,stula prosthetic grafts

"rue aneurysm are much rare bu

have also been reported in fe!occasions in the vein distal to theanastomosis

"reated !ith resection and either

7nd to end anastomosis

Placement of short segment graft


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COMPLICATIONS

I"'ectio"&

1nfection of autogenous ,stula are rarecompared to prosthetic graft

Signs K symptoms :

Eever

7rythema

"enderness

And complications (such as thrombosi

and aneurysm "he most common infecting organism

S*%34'''- *"-

Hanaged by systemic antibiotics drainageand revision as necessary) Prosthetic grafmust be completely e.cised)


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COMPLICATIONS

Isc0e%ic c0a"1es& Steal symptoms may occur in around 2J o

patients !ith autogenous ,stula"he incidence is higher in :


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COMPLICATIONS

Ve"os 0,perte"sio"&

"he hand distal to the ,stula becomes!ollen and uncomfortable !iththic#ening of the s#in andhyperpigmentation

Venous hypertension may be avoided by

forming an end to end anastomosis =r to ligate the enlarged venou

tributaries causing the hypertension othe distal digits so preserving the ,stula


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COMPLICATIONS

Car#iovasc!ar co%p!icatio"&

%igh output cardiac failure is a rarecomplication !hich may occurparticularly in patients displaying acombination of lo! hematocritcardiomyopathy from diabetes and

the presence of high &o! ,stula"reatment usually involves sacri,cingthe ,stula


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CARE AFTER A-V SHUNTSURGERY

;eep the arm raised on a pillo! to reduce s!ellin

"he dressing should remain intact and dry at all t

As soon as post operative pain has subsided se.ercises


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NOTES

"he use of regional anesthesia may lead to dilaboth the peripheral veins and in&o! arteries maturation

+o bene,t of intraoperative anticoagulation in Patients in 7S5< are li#ely have defects in he

mechanism increase bleeding

Stapled anastomosis is as good as sutured anasto

ength of the anastomosis irrelevant to the ris# related hand ischemia


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REFERENCES

*) Loo ; 5o!e V) @*2) %emodialysis Access:


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"%A+; ='

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Av Shunt Mabi Xx