Problematic Vascular Access Sites

The commonly used types of vascular access include native

arteriovenous (AV) fistulas, prosthetic AV grafts, and central venous

catheters (CVC). Complications of vascular access account for 20 % of

hospitalizations among patients on hemodialysis (HD) and can result in

loss of access, significant morbidity, and mortality. The limited number

of available sites makes the preservation of existing access sites

important. The longer a patient remains on HD, the greater the challenge

to find and maintain access sites. Every vascular access that is lost

brings the patient one step closer to a terminal access problem and

ultimate death. Problematic access prevents many patients on HD from

receiving optimal care. Low access flow rates limit dialysis delivery,

extend treatment times, and can result in underdialysis, which, in turn,

leads to increased morbidity and mortality.1 Several lessons have been

learnt recently in terms of the management of vascular access (see

Table 1).2 Despite these lessons, the proportion of patients on HD

who have had multiple access procedures, failed transplant(s), or who

have exhausted sites of conventional AV fistula or graft is increasing.

Consequently, an increasing proportion of such patients are requiring

more complex vascular access modalities for long-term HD. This article

provides an update on the management of patients with problematic

vascular access.

Ideal Vascular AccessAn ideal vascular access should exhibit a low primary failure rate, low

risk for infection or thrombosis, long survival, and trouble-free survival,

not requiring frequent or costly intervention to keep it functioning.

Apart from a high primary failure rate, native AV fistulas can loosely be

regarded as ideal. Once matured and functional, native AV fistulas have

superior longevity, fewer complications, lower mortality, and lower

costs compared with AV grafts.3 The ‘fistula first initiative’, while leading

to an increase in the prevalent dialysis population dialysing via AV

fistula, has also increased the number of patients with primary

non-function and who are using CVC. To achieve the ideal standard,

several actions are needed, including improved pre-dialysis care,

pre-dialysis vascular access surgery, and adequate fistula maturation.3

Even with these measures, not all patients on HD can achieve a native

AV fistula. The indications for prosthetic AV grafts include failed AV

fistula and/or exhausted superficial veins, lack of suitable vessels,

particularly in elderly patients and those with diabetes, vessels destroyed

by indiscriminate venipuncture, late referral for vascular access, and a

need for immediate cannulation with avoidance of a CVC.4,5 Several

factors contribute to the increasing use of CVC, including delayed referral

AbstractThe main problems affecting vascular access in patients are infection, thrombosis, steal syndrome, pseudoaneurysms, and central vein stenosis.

Complications of vascular access account for 20 % of hospitalizations among hemodialysis patients and can result in loss of access, significant

morbidity, and mortality. This article provides an update on the management of patients with problematic vascular access. The functioning native

arteriovenous (AV) fistula is the ideal access. To achieve the ideal standard, pre-dialysis care, pre-dialysis access surgery, adequate fistula

maturation, and successful fistula cannulation by dialysis staff must be improved. The risk for infection is highest with temporary catheters, high

with cuffed tunnelled catheters, medium with AV grafts, and lowest with native AV fistula. Percutaneous strategies are successful in declotting

thrombosed access in 67–95 % of patients. Complex access surgery may be required in patients with exhausted conventional access sites.

Vascular access management must be given more prominence to ensure trouble-free functional longevity through access monitoring, surveillance,

and early therapeutic intervention when necessary.

KeywordsAngioplasty, arteriovenous (AV) fistula, AV grafts, central venous catheter, hemodialysis, infection, primary failure, pseudoaneurysm, steal

syndrome, thrombosis, vascular access

Disclosure: The author has no conflicts of interest to declare.

Received: November 25, 2010 Accepted: January 16, 2011 Citation: US Nephrology, 2011;6(1):48–55

Correspondence: Jacob A Akoh, FRCSED, FRCS(Gen), Consultant General and Transplant Surgeon, Level 04, Derriford Hospital, Plymouth PL6 8DH, UK.

E: [email protected]

Managing Patients with Problematic Vascular Access Sites

Jacob A Akoh, FRCSED, FRCS(Gen)

Consultant General and Transplant Surgeon, Gastroenterology, Surgery and Renal Services Directorate,

Plymouth Hospitals NHS Trust, Derriford Hospital

48 © T O U C H B R I E F I N G S 2 0 1 1

Dialysis Vascular Access

Akoh_RL_US Nephrology 07/07/2011 17:47 Page 48

for access, acute presentation, delayed maturation of AV fistula, and the

primary failure of AV fistula.6,7 In addition to insertion complications,

the use of CVC is associated with higher morbidity, hospitalization rates,

and mortality in patients on HD.6,8–10

AV fistulas have advantages over AV grafts11 and CVC, but whether

they are associated independently with better survival is still unclear. The

Choices for healthy outcomes in caring for ESRD (CHOICE) study, which

included 1,084 accesses in 616 incident patients, reported an adjusted

relative hazard of death of 1.5 (95 % confidence interval [CI] 1–2.2) for

CVC and 1.2 (0.8–1.8) for AV grafts compared with AV fistula.12 The use of

venous catheters should be minimized to reduce the frequency of access

complications and to improve patient survival.

Problematic Vascular AccessInfectionInfection constitutes the most challenging and life-threatening

complication of vascular access and causes significant morbidity, loss

of access, and mortality.13–18 Infection (mainly owing to vascular access)

is the second leading cause of death after cardiovascular events in

patients on HD.6,8,10 Bacteremia is associated with subsequent death,

myocardial infarction, heart failure, peripheral vascular disease, and

stroke.19 Several studies demonstrate a hierarchy of infection risk

associated with vascular access type, with the highest associated with

temporary CVC, high with cuffed tunnelled CVC, medium with AV grafts,

and lowest risk with native AV fistula.10,20–25

Arteriovenous Graft InfectionInfection can present in the form of bacteremia, abscess around the

graft, septic emboli, and secondary hemorrhage. More recent reports

show variation in the incidence of AV graft infections, ranging from 3.5

to 17.3 %.13,26–29 AV graft infections are more probable in patients with

type 2 diabetes, insertion in the thigh, history of multiple infections,

surgical revisions, immunocompromized state, hypoalbuminemia,

obesity, and in thrombosed, abandoned AV grafts.13,28,30–32 Diagnosis is

confirmed by a positive culture from the access showing the same

organism found in blood.22 Treatment involves intravenous antibiotics

(two to four weeks) and some form of graft excision (total, in septic

patients or when the graft is bathed in pus; subtotal, when all of the graft

is removed except for an oversewn small cuff of prosthetic material on

an underlying patent vessel and partial [for localized abscess], when a

limited portion of the AV graft is removed and a new graft inserted

through adjacent sterile tissue).13,33,34 Early infection before the graft is

embedded into tissue should result in total graft excision. Total or

subtotal graft excision is more successful, but the main drawback is

the requirement for CVC.13 The need to excise an infected AV graft

is sometimes counterbalanced by the need to provide vascular access

for dialysis in a patient with limited or no other access options.

Central Venous Catheters InfectionCompared with AV fistulas, long-term dialysis with tunnelled cuffed

catheters is associated with a higher risk for death, a five- to ten-fold

increased risk for serious infection, increased hospitalization, and

an increased number of vascular access procedures.35,36 CVC accounts

for 66 % of vascular access-related bacteremias.22 Infection owing

to Staphylococcus aureus is significantly associated with metastatic

complications, such as osteomyelitis and infective endocarditis, and

also is an independent risk factor for recurrence of infection.37 In a study

involving 2,230 permanent silicone CVC implanted in 1,749 patients,

Lemaire and co–workers16 found an overall incidence of bacteremia of

0.51/1,000 catheter days, identifying a previous history of a bacteremia,

type 2 diabetes, a duration of catheter use of >90 days, and hypertension

as significant factors. Bacteremia is more probable in patients with nasal

carriage of S. aureus and catheter exit-site infections.

Diagnosis of CVC-related infection is confirmed by a positive blood

culture from the CVC and a peripheral vein with a four-fold quantitative

differential colony count or differential time to positivity.38 It is important

to draw blood before commencement of dialysis and, in the absence

of accessible peripheral veins, blood can be drawn from both

catheter lumens.39


U S N E P H R O L O G Y 49

Table 1: Lessons Learned in the Management of Vascular Access2

Subclavian Vein Catheterization Results In Central Vein Stenosis

Temporary non-cuffed central venous catheters are associated with

highest morbidity

Native arteriovenous fistulas produce best results

Stenosis owing to neointimal hyperplasia precedes access thrombosis in

most cases

Screening tests are useful in predicting vascular accesses at risk

Timely angioplasty prolongs access survival

Table 2: Management of Steal Syndrome

Intervention Comments

Percutaneous balloon angioplasty Arterial stenosis proximal to anastomosis

of inflow tract82 Day-case procedure

Intravascular coil insertion82 Embolization of efferent radial artery to

reduce flow into radiocephalic fistula

Minimally Invasive Limited Ligation Percutaneous approach/application of

Endoluminal-assisted Revision ligature around an inflated angioplasty

(MILLER procedure)83,84 balloon to create stenosis of a

defined size

Banding85–87 Risk for access thrombosis

Monitoring by measurement of access flow

and finger pressures

Insertion of vascular Aimed at reducing flow

clipping system Variable success

Placation procedure

Tapered graft insertion82

Flow reduction with Doppler Median diameter of access anastomosis

ultrasonography-guided surgery reduced to 4 mm88

DRIL procedure89–91 Ideal but complex procedure. Used for carefully selected patients. Excellent relief

of symptoms92–94

Revision Using Distal Artery Less complex than DRIL but produces

as Inflow (RUDI) good results95

Ligation of the distal limb of the Used in a radiocephalic fistula to

radial artery diminish retrograde flow78

Ligation of access77 Last resort, except in patients with

monomelic neuropathy82

New access required

DRIL = distal revascularization-interval ligation.


The options of treatment of CVC infection include antibiotics alone

(associated with a high risk for recurrence), exchange of CVC over a

guide wire and immediate removal of CVC in addition to insertion of

a temporary CVC until the infection is under control which is then

replaced with a tunnelled CVC (involves multiple procedures). Antibiotics

alone (CVC salvage) is associated with a high treatment-failure rate,

probably owing to the presence of biofilm. Bacterial incorporation into

this matrix of polysaccharide and protein shields them from systemic

antibiotics. Infection persists until the intra- and extraluminal biofilm is

removed.37 Antibiotic locks results in a high concentration of antibiotics

in the catheter lumen, which is able to penetrate the biofilm. The choice

of antibiotic depends on the local epidemiology, but either vancomycin

or ceftazidine is usually added to the lock solution.3 A dialysis catheter

should be removed when an infection involves a temporary HD catheter,

presence of systemic sepsis, bloodstream infection that continues

despite more than 72 hours of antimicrobial treatment, a tunnel infection

suppurative thrombophlebitis, or infection owing to S. aureus or

metastatic infection.39

ThrombosisThrombosis, the main cause of AV fistula and/or graft dysfunction and

failure, is usually the result of outflow tract obstruction.3,40,41 Although

stenosis is commonly thought to affect the access outflow tract,

inflow stenosis is not uncommon in dysfunctional HD accesses and

radiologic evaluation should also include the arterial inflow.42,43 Native AV

fistulas are associated with two major problems: initial failure to mature

(primary failure) and a later venous stenosis followed by thrombosis.40

Causative factors include a small artery (<1.5–2 mm), a small vein

(<2–2.5 mm), poor surgical technique, hemodynamic stressors, and a

predisposition to vasoconstriction and neointimal hyperplasia.40 In terms

of AV grafts, the etiologic factors include hemodynamic stress at the

graft–vein anastomosis, the type of graft material, and injury owing to

repeated needling. In predisposed AV access, thrombosis might be

heralded by dehydration, hypotension, compression during sleep, and

excessive pressure required to stop hemorrhage following dialysis.

DiagnosisAccess dysfunction can be identified by: physical examination pre-dialysis,

limb swelling, prolonged bleeding following needle withdrawal, dynamic

venous pressure >140 mmHg,44 re-circulation >15 %, transonic access

flow measurements, and colour Doppler ultrasound scan (CDUS) to

assess both access inflow and outflow.45

Pharmacologic ProphylaxisThe Dialysis access consortium (DAC) fistula trial involving 877 participants

showed that clopidogrel reduced the risk for native AV fistula thrombosis

by 37 %, but had no beneficial effect on fistula suitability for dialysis.

Sixty-one per cent of newly created fistulas failed to reach suitability for

dialysis.7,46 To reduce the risk for AV graft thrombosis, some clinicians have

used prophylactic warfarin or antiplatelet agents (e.g. aspirin, dipyridamole

or clopidogrel). However, warfarin does not appear to have any beneficial

effect in preventing thrombosis in patients on HD and could increase the

risk for bleeding.47–49 Antiplatelet drugs have a mixed effect on thrombosis

of AV grafts. Whereas dipyridamole is effective in reducing the rate of

thrombosis in patients with AV grafts, aspirin is associated with a high

risk for thrombosis.50 Aspirin has also been demonstrated to enhance

platelet-derived growth factor-induced vascular smooth-muscle-cell

proliferation and also exert a direct effect on the proliferation and the

mitogenesis of vascular smooth-muscle cells.2 Anticoagulation and

antiplatelet drugs are perhaps unnecessary in patients on HD who

receive heparin during dialysis treatment and have well-known intrinsic

platelet dysfunction.51 In a retrospective cohort study of 41,425 incident

patients on HD, Chan et al.51 showed that warfarin, aspirin, or clopidogrel

prescriptions are associated with higher mortality. Given the possibility

of confounding by indication, randomized trials are needed to determine

the risk and benefit of these medications.

Management of ThrombosisThe options for managing AV fistula or graft thrombosis include: surgical

thrombectomy performed soon after diagnosis52 and combined with

either patch angioplasty to widen the outflow vein or a jump graft to

bypass a long stenotic segment,53–55 pharmacologic thrombolysis with or

without angioplasty and/or stenting,53,54,56,57 and revision access surgery,

for example, refashioning of AV fistula in the case of a juxt-anastomotic

stenosis not responding to angioplasty. Two randomized trials comparing

surgery versus mechanical thrombolysis showed superior success rates

with surgery and revision (94 and 83 % compared with 67 and 72 % for

thrombolysis, respectively).52,53 Pharmacologic thrombolysis is performed

using either urokinase or recombinant tissue plasminogen activator

(rt-PA) and can be combined with angioplasty when necessary.54,58

Percutaneous strategies are successful in declotting access in 67–95 % of

cases52,57,59,60 and, when combined with prompt endovascular management

of subsequent thrombosis, significantly improves secondary patency

rates (62 and 47 % one- and two-years, respectively).61 Post-thrombolysis

angiography or CDUS is necessary to clarify anatomic stenosis and

enable targeted radiologic or surgical correction. The role of stenting of

the venous anastomoses following thrombectomy in extending access

life was studied by Maya and Allon.62 They compared 14 patients with

thrombosed AV grafts treated by thrombectomy and stenting with 34

sex-, age-, and date-matched controls treated by thrombectomy and

angioplasty alone. The secondary patency (time from thrombectomy to

permanent graft failure) was longer for the stent group (median survival

1,215 versus 46 days). The benefit of angioplasty alone is short lived

as stenosis appears to develop faster than de novo access stenosis.

This is probably because the vascular injury caused by the angioplasty

accelerates the underlying proliferative process.63 Use of expanding nitinol

stents placed at the venous anastomosis following graft thrombectomy

and angioplasty improves the outcome of recurrent graft stenosis

significantly and can rescue some AV grafts.64 Where the technology

is available, pharmacomechanical thrombolysis with or without

percutaneous transluminal angioplasty (PTA) and stenting is preferred

over surgical thrombectomy. Systemic complications are rare with rt-PA,

provided that patients who are at risk for bleeding are excluded.60 Local

bleeding is easily controlled by digital pressure and it is rarely necessary

to stop the thrombolysis infusion. Other new techniques to complement

angioplasty include application of vascular radiotherapy.65

Central Venous Catheters DysfunctionIf CVC dysfunction occurs soon after placement, then malposition,

migration, or kinking of the catheter is likely to be responsible. Late CVC

malfunction is usually the result of intra- or extraluminal thrombosis.


U S N E P H R O L O G Y50


This may present as low flow rates during dialysis or high negative

arterial pressures causing dialysis machine alarms. In severe cases,

there is inability to aspirate blood from the catheter lumens.

Blockage of CVC lumen is prevented by the instillation of a lock solution.

Using 30 % citrate solution or 4 % trisodium citrate has advantages

over heparin (5,000 units/ml), including a reduced risk for hemorrhage

and avoidance of heparin-induced thrombocytopenia.66,67 Low-dose

warfarin (1 mg/day) produces no difference in CVC thrombosis rates,

whereas therapeutic doses (International Normalized Ratio [INR]

1.8–2.5) in conjuction with ticlopidine produce a dramatic reduction in

thrombosis rates.68

Management involves a step-wise gradation of measures until either

catheter function is restored or the catheter is replaced. These options

include forceful aspiration and/or flushing, instillation of a thrombolytic

agent for CVC clearance—urokinase 5,000 units/ml or rt-PA 2 mg per

lumen over 30–60 minutes (successful in 65–95 % of cases),69–71

low- and high-dose streptokinase or urokinase infusion,70,72

improvement of catheter patency and blood flow rates through

disruption of fibrin sheaths by angioplasty and/or stripping,73,74 and

catheter exchange over a guidewire or a new CVC.

Steal Syndrome A less common, but challenging, complication of AV grafts and/or

AV fistulas is extremity ischemia caused by diversion of arterial flow

through the access site. It is thought that the presence of significant

peripheral vascular disease (particularly in the elderly and patients with

diabetes) and high fistula flow in addition to calcification of the arteries

does not allow the vessel to dilate and supply the extremity and the

fistula with more blood.75–77

Patients can present immediately following AV fistula or graft formation

with mild digital paresthesia or acute arterial insufficiency (i.e. cool, pale,

numb, or painful digits) or insidiously (months to years later) with finger

necrosis and/or permanent nerve damage. Steal syndrome, whether

acute or late onset (>30 days), is more common with AV grafts (4.2 %)

compared with AV fistulas (2.4 %), previous operations on the same

limb and use of a brachial instead of radial artery.77,78 Ischemia can affect

upper limb nerves predominantly or exclusively and result in ischemic

monomelic neuropathy.79 Some patients may present with dialysis

treatment-related ischemia, owing to a drop in blood pressure during

dialysis, which severely reduces the perfusion pressure in an already

compromised vascular bed.

Diagnosis of vascular steal is usually made on clinical grounds: manual

occlusion of the venous limb of the access resulting in immediate

relief of symptoms, supplemented by CDUS, which confirms severe flow

reversal; or by digital plethysmography revealing digital finger pressures

<50 mmHg, digital-brachial indices <0.47 associated with symptom

augmentation and reversal of pressures on manual compression, and

transcutaneous oxygen saturation measurements.80,81 In severe cases,

fistulography can confirm athero-occlusive disease amenable to

correction. Complete imaging of the arterial circulation by digital

substraction angiography (DSA), contrast enhanced-magnetic resonance

angiography (CE-MRA), or computed tomography (CT) angiography with

multidetector-row technology is the most important diagnostic tool and

helps in planning the treatment strategy.82,83

The challenge of treatment is to resolve distal ischemia while preserving

uninterrupted vascular access. The best way to avoid steal syndrome

is to construct a narrow caliber AV anastomosis after full assessment

of the vascular tree. Mild cases of steal syndrome can be observed,



Figure 1: Examples of Complex Vascular AccessProcedures Used in Patients with Exhausted Conventional Access Sites

Necklace graft

Axillo-axillarygraftFemoral arteryto right atriumbypass graft

‘Bikini’ graft

Right atrium

Brachial artery tocontralateral jugularvein bypass graft

Subclavian arteryto popliteal veinbypass graft

Modified with permission from Chemla et al., 2006.105

Table 3: General Principles for the ComprehensiveManagement of Patients with Vascular Access

Pre-dialysis care to ensure advice is given in terms of venipuncture sites and

early referral for access surgery

Comprehensive assessment including vessel mapping with detailed information

on both inflow and outflow tracts

Early creation of native AV fistula in the pre-dialysis phase

Improving maturation of native AV fistula, reducing stenosis and thrombosis of

AV fistula and grafts

Prevention, diagnosis, and appropriate treatment of vascular access infection

Judicious use of AV grafts

Avoidance of central venous catheters

Monitoring and surveillance of accesses to ensure early detection and

appropriate pre-emptive intervention before access thrombosis

Appropriate pharmacologic, radiologic, and surgical intervention

Encouragement of clinically oriented research into vascular access problems and

adoption of novel therapies into clinical practice

AV = arteriovenous.


but frequent follow-up is required. The options for treatment for more

severe forms include both percutaneous and surgical techniques

and are shown in Table 2.78,79,84–96 Percutaneous approaches have

the advantage of an inherent, clear demonstration of the anatomy

and clarification of the cause of distal ischemia. They are performed

as day-case procedures under local anesthesia and the effect of the

procedure can be monitored synchronously.

A new addition to the armamentarium is the Amplatzer Vascular Plug

Type II (AVP II), a self-expandable nitinol wire-mesh device that is a

promising tool for the management of problematic vascular access,

including steal syndrome and high-flow tributaries.97,98

PseudoaneurysmA large pseudoaneurysm causes turbulent flow in the AV fistula or

graft and can lead to thrombosis of the access. Pseodoaneurysms may

also become unsightly and painful. Pseudoaneurysms develop in

response to repeated needling in the same segment of the access and

can be avoided by careful rotation of needling sites. Traditionally, these

lesions were treated by surgical excision, refashioning using a

gastrointestinal anastomosis stapler,99 or abandonment of the fistula.

Ryan and co–workers100 successfully treated four patients with large

pseudoaneurysms by inserting a covered stent (Wallgraft, Boston

Scientific/Meditech, Newton, MA). The type of stent used allows needling

through the access segment containing the stent, which is especially

useful for short-length accesses.

Central Vein Stenosis and/or Venous HypertensionDespite minimizing the use of subclavian vein for CVC, central vein

stenosis (CVS) remains a relatively common problem. In some series,

approximately 50 % of patients with HD presenting with access

problems were discovered to have CVS.101 CVS leads to outflow

obstruction of AV fistula or grafts, severe venous hypertension, arm

swelling, and also compromises upper limb accesses. PTA and stenting

is successful in treating CVS and surgery is only required when PTA

fails. Axillary artery-to-right atrium bypass grafting in the presence of an

ipsilateral AV fistula has been described.102 More severe forms can be

managed by ligation of the AV graft or fistula or use of the Hemodialysis

Reliable Outflow (HeRO) device. This device consists of a 6 mm expanded

polytetrafluoroethylene graft attached to a 5 mm nitinol-reinforced

silicone outflow component designed to bypass venous stenoses and

enter the internal jugular vein directly. The HeRO device was studied in a

multicenter clinical trial demonstrating a statistically significant reduction

in bacteremia rates compared with a CVC.103 Selection of the appropriate

option should be based on perceived life expectancy, dialysis access

longevity and other comorbid factors.104

Patients with Exhausted Access SitesPatients with exhausted access sites are characterized either by failure of

all usual vascular access sites or are those in whom peritoneal dialysis is

not an option and transplantation is deemed not feasible.105 Several

factors interact to produce this state: longevity of dialysis, multiple and/or

failed access procedures, CVS, diabetes, peripheral vascular disease,

and morbid obesity. Patients with challenging vascular accesses dialyse

poorly, require prolonged and frequent hospitalization for access-related

morbidity and have high mortality that is not necessarily the result of

repeated vascular interventions but of their disease process instead.

Innovative approaches to the management of such patients include the

use of complex AV grafts: left axillary artery-to-right atrial shunt,102

saphenous vein loop-to-femoral artery AV fistula,106 cryopreserved

cadaveric femoral vein allograft,107 axillary loop,108,109 axillary artery-to-

contralateral axillary vein graft,110 and the use of an entirely subcutaneous

device (LifeSite Hemodialysis Access System) with reported advantages of

patient comfort and reduced catheter-related infection.111

Other complex vascular access procedures including a necklace (bypass

graft between the left subclavian artery and the right subclavian vein

or vice versa) are shown in Figure 1.105,108 Early results indicate good

short- to medium-term patency, but a significant morbidity associated

with use of these complex accesses. Awareness of the availability

of such complex procedures should prevent a knee-jerk selection of



Figure 2: Algorithm for Managing Vascular Access in the Hemodialysis Patient

Low clearance clinic(pre-dialysis)

AV fistula functioning

Primary failure

Exotic (complex)access

Not suitable forAV fistula

Not suitable forAV graft

Physical examinationand

vessel mapping(Doppler ultrasound±

venography)

Native AV fistula

AV graft:Upper limbLower limb

Tunnelled centralvenous catheter

Failed vascular access

New acute patient

Failing transplant

AV = arteriovenous.


CVC in patients with exhausted access sites. In selected patients,

insertion of cuffed tunneled femoral catheters may provide a safe and

effective access for long-term HD and obviate the need for complex

access procedures.18,112

Prevention StrategiesPrevention is better than cure and this is especially true in the

management of vascular access problems. The principles of a

comprehensive access management are presented in Table 3. Most

vascular access problems can be managed as day cases and efforts

must be made to avoid unnecessary hospitalizations.113

Comprehensive AssessmentRobust assessment, including a comprehensive review of previous

access procedures, full physical examination, and vessel mapping using

CDUS before access placement, is the best way to ensure that the

first access and/or subsequent accesses are appropriate (see Figure 2).

Vessel mapping should answer questions in terms of the condition of

the arterial tree and the venous circulation (i.e. size, depth, and flow

properties through the vein). Such assessment has been shown to

increase the use of native AV fistulas114–117 and lead to a higher

maturation rate (90 versus 68.5 %) and mean duration of patency

(14.7±16.8 versus 11.9±9.4 months) than those created without.118 In

addition, it has the potential to reduce the overall necessity for multiple

access procedures and, by unearthing problems such as CVS, enable

percutaneous intervention, which could help avoid early use of

secondary access procedures.

Local TherapyAnother strategy is the perivascular delivery of antiproliferative agents

to achieve high local drug levels while avoiding systemic toxicity. Two

studies in porcine AV graft models have shown promising results in

reducing neointimal hyperplasia and graft stenosis by local delivery

of paclitaxel.119,120

SurveillanceEarly access surveillance duplex scanning at six to eight weeks

post-operatively helps to identify AV fistula with potential problems early,

allowing either intervention to prevent primary failure or the creation of a

new access so as to limit use of CVC.116,121 Access surveillance coupled

with radiologic or surgical intervention has been known to prolong access

life.122–125 Cayco et al.126 introduced a vascular access surveillance protocol

(using dynamic venous pressure >140 mmHg, re-circulation >15 %,

limb swelling, and prolonged bleeding post-dialysis) to decide which

patients to refer for angiography with or without angioplasty; the

authors demonstrated a reduced thrombotic episode per graft year of

0.29 compared with 0.49 for a historical, controlled group in their center.

Additional benefits of this strategy are reduced hospitalization and

decreased use of CVC.127,128 However, a systemic review and meta-analysis

of 12 randomized controlled trials examining the effect of access

screening on thrombosis, access loss, and resource use found that

screening significantly decreased the risk for access thrombosis for AV

fistulas, but not the risk for fistula loss or resource use. In terms of

AV grafts, no decrease in the risk for thrombosis or access loss was

identified.129 Further research into ways of preventing or treating access

stenosis is therefore required.

Based on the observation that progression of stenosis is a precursor

to thrombosis, pre-emptive angioplasty has been recommended.130

The results of a prospective controlled trial to evaluate the effect of

prophylactic PTA of stenosis not associated with access dysfunction

offers strong support for access surveillance.128 Kaplan-Meier analysis of

the data showed that PTA improved AV fistula functional failure-free

survival rates (p=0.012) with a four-fold increase in median fistula survival

and a 2.87-times decrease in risk for failure.

Several imaging modalities are available for the evaluation of dysfunctional

HD access. Blood flow measurements using Doppler ultrasound did not

reduce the risk for thrombosis,129 but clinical assessment readily identified

problems leading to intervention.131 In a well-constructed, prospective

study, Doelman et al.45 compared CDUS and CE-MRA with DSA for the

detection of significant (≥50 %) stenosis in failing dialysis accesses (49 AV

fistula and 32 AV grafts). Their findings suggest that CDUS is the initial

imaging modality of choice but that CE-MRA should be considered before

angioplasty if DSA is inconclusive.45

ConclusionThis article highlights the need for vascular access management to

be given more prominence in the same manner as other major problems

that affect patients on HD. An integrated vascular access management

strategy encompassing evidence-based practice and a multidisciplinary

team that includes committed and trained vascular access surgeons and

interventionalists is required to ensure best quality of patient care. The

requirement for new ways of treating old problems affecting vascular

accesses is higher than ever. The dynamics of the dialysis population has

resulted in more elderly, long-term patients with multiple comorbidities

and multiple vascular access procedures, who are unsuitable for

peritoneal dialysis and transplantation. The drive to achieve native

fistula at all costs might increase the problem of primary failures and

paradoxically increase CVC use.

The two big players must continue to be native AV fistula and prosthetic

AV grafts. Apart from introducing novel techniques to improve these,

there is a need to optimize choice of access for individual patients. Once

that choice is made (and increasingly by the multidisciplinary team),

then efforts to ensure trouble-free functional longevity through access

monitoring and surveillance are required to ensure early therapeutic

intervention when necessary. n



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Problematic Vascular Access Sites