History of vascular access for haemodialysis.

The history of vascular access is a history of vascular surgery as well as a history of dialysis therapy. This survey is a personal view on the history of vascular access without the ambition to cover every detail, but with an effort to mention the major steps in a fascinating panorama.     

Axillo-iliac conduit for haemodialysis vascular access.

OBJECTIVES: To describe a series of venous surgical procedures performed to maintain vascular access. METHODS: We report eight patients with end-stage renal failure (ESRF) who had complex renal access problems. Three patients had central venous occlusion and underwent veno-venous axillo-iliac bypass. In five further patients with a symptomatic central venous obstruction we performed axillo-iliac arterio-venous grafting (AVGs) in order to achieve haemodialysis access. All patients were assessed pre-operatively with duplex ultrasound and venogram of upper and lower limbs. The axillary artery or vein, and iliac vein were approached via infraclavicular and extra-peritoneal groin incisions, respectively. Non-externally-supported polytetrafluoroethylene (PTFE) was used as a conduit in all patients and anti-coagulation regimen were commenced post-operatively. RESULTS: Following venous diversion surgery, there was a dramatic improvement in the facial and limb swelling experienced by the patients. There was no significant peri-operative morbidity. The veno-venous graft is still patent at 14 months in patient one, at 10 months in patient two, and 5 months in patient three. In the second group, who had arterio-venous grafts, the mean follow-up was 13.2 (7-20) months with a secondary patency rate of 80% at 6 months. Four patients had patent, usable grafts at 12 months. In two cases, graft occlusion was treated with successful thrombectomy. CONCLUSION: Axillary-iliac veno-venous diversion can overcome the symptoms and complications of superior vena cava and innominate vein obstruction. Although, axillo-iliac arterio-venous graft fistulae formation was previously described it has not been widely used. We have found the procedure to have low morbidity and advocate its use in these complex cases.     

Ultrasound-guided cannulation of the femoral vein for acute haemodialysis access

Background. Central venous access is a mandatory part of patient management in many clinical settings and is usually achieved with a blind, external landmark-guided technique. The purpose of this study is to evaluate whether an ultrasound technique can improve on the external landmark method. Methods. We prospectively evaluated an ultrasound-guided method in 28 patients undergoing femoral vein cannulation for acute haemodialysis access and compared the results with 38 patients in whom an external landmark-guided technique was used. External landmark-guided technique was done by manual localization of the femoral artery in the femoral triangle inferior to the inguinal ligament with needle insertion medial to the artery. Ultrasound-guided cannulation was performed in the same location with the aid of an ultrasound device (Site-Rite, Dymac Corp., USA) with a 7.5 MHZ transducer covered by a sterile sheath. Results. Cannulation of the femoral vein was achieved in all patients (100%) using ultrasound and in 34 patients (89.5%) using the landmark-guided technique. The vein was entered on the first attempt in 92.9% of patients using ultrasound and in 55.3% using the landmark technique (P <0.05). Average access time (skin to vein) was similar but total procedure time was 41.1 ± 18.8 s by the ultrasound approach and 79.4 ± 61.7 s by the landmark approach (P <0.05). Using ultrasound, puncture of the femoral artery occurred in 7.1% of patients, and haematoma in 0%. Using external landmark technique, puncture of the femoral artery occurred in 15.8% of patients, and haematoma in 2.6%. Conclusions. Ultrasound-guided cannulation of the femoral vein reduces the time required for the procedure, reduces the number of passes needed to puncture the vein, and minimizes complications such as arterial puncture or haematoma.     

Arteriovenous grafts for vascular access in haemodialysis.

The outcome of 68 arteriovenous grafts placed in 46 patients requiring haemodialysis was studied over a period of 3.5 years. The biological grafts included autogenous saphenous vein, modified bovine carotid artery and human umbilical cord vein allograft, whereas the synthetic grafts comprised Sparks Dacron mandril, expanded reinforced polytetrafluoroethylene and knitted Dacron velour. These subcutaneous grafts were arranged as looped or straight configurations in the forearm or thigh. Of 59 grafts evaluated in patients with end-stage renal failure, only 48 per cent of the forearm grafts performed well, compared with 85 per cent of the thigh grafts. Although only 38 per cent of the looped grafts were successful, 78 per cent of the straight grafts functioned satisfactorily. Synthetic grafts suffered less serious complications than the commercial biological grafts.     

Human umbilical vein for vascular access in chronic hemodialysis

Since 1979 we have used human umbilical vein graft as the ultimate vascular access for hemodialysis in patients with chronic renal failure. In 24 patients 33 graft fistulas were performed. Several complications were encountered. Among these infection was the most serious, occurring in seven grafts. All these grafts were removed and never used for hemodialysis. Thrombosis occurred 25 times, and five grafts were lost because of this, whereas 20 grafts had successful thrombectomy and continued to function. Aneurysm formation occurred four times, two grafts were lost. Stenosis was seen in three cases, one graft was lost. In the material 26 grafts were used for hemodialysis and a median function time of 8.5 months was obtained. At the end of the observation period 10 grafts were open, eight were used for hemodialysis, two were not used because of successful transplantation. The umbilical vein graft is an acceptable alternative as vascular access where conventional methods of fistula formation have been exhausted.     

Video-assisted basilic vein transposition for haemodialysis vascular access: preliminary experience with a new technique.

BACKGROUND: The brachio-basilic vein arteriovenous (AV) fistula is increasingly used as a secondary method for haemodialysis vascular access. The conventional surgical technique of brachio-basilic vein AV fistula creation consists of a long incision with dissection of the basilic vein and transposition of it to a subcutaneous anterior position in the upper arm. The aim of this study was to investigate whether minimal invasive basilic vein dissection with an endoscopic technique is feasible. METHODS: In 12 patients, brachio-basilic vein AV fistulas were created by means of a video-assisted technique with semi-closed dissection and harvesting of the basilic vein with the use of an endoscope and standard endoscopic instruments. All patients underwent pre- and post-operative duplex ultrasound investigation. RESULTS: In all patients, a successful endoscopic dissection was possible without peri-operative complications. One patient suffered from post-operative thrombotic occlusion, which was successfully treated by thrombectomy. One patient developed a haematoma in the upper arm. No wound complications occurred and all AV fistulas could be used satisfactorily for dialysis treatment. CONCLUSIONS: Video-assisted basilic vein transposition is a feasible minimal invasive technique to create secondary vascular access for haemodialysis.     

Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: an ultrasonographic survey in uraemic patients

Background: Creation of a reliable haemoaccess is a critical problem for practicing nephrologists once haemodialysis has been considered. A double-lumen internal jugular-vein catheter is favoured in most cases requiring temporary haemoaccess. However, numerous complications, even lethal ones, may occur with the cannulating procedure. Using ultrasound, we attempted to describe the occult anatomical variations of vessels which may be responsible for complications. Methods: A 'SiteRite' ultrasonographic device was used to inspect the anatomical structure of the internal jugular veins (IJV) in 104 consecutive uraemic patients undergoing creation of internal jugular vein temporary angioaccess. Images of the vessels and demographic data of patients were recorded and analysed. Results: Anatomical variations of the right and left IJVs were found in 19 (18.3%) and 17 (16.4%) uraemic patients respectively. Unilateral IJV variations were discovered in nine patients (8.7%). A total of 27 patients (26.0%) had IJV anatomical variations that might contribute to difficulty in external landmark-guided IJV cannulation. Conclusions: The external anatomical landmarks for cannulating the IJV are not reliable in about one-quarter of uraemic patients. An ultrasound survey on the IJV anatomy is recommended for selecting proper puncture site and reducing risks of insertion complications for IJV dialysis catheters. Key words: jugular vein; anatomy; uraemia; haemodialysis catheter; vascular access; ultrasonography      

Depopulated bovine ureteric xenograft for complex haemodialysis vascular access.

OBJECTIVES: To assess performance of a de-cellularised bovine ureter vascular graft for haemodialysis in patients for whom conventional access was not possible. METHODS: The Syner Graft Vascular Graft Model 100 (SGVG 100) is a bovine ureter modified by a tissue-engineering depopulation technology and uniquely it is not chemically cross-linked. SGVG 100 was implanted in patients with a failed fistula or vascular access grafts. Graft patency was the primary outcome; secondary outcomes included adverse events and associated treatments. RESULTS: 25 SGVG 100 were implanted in 23 patients; mean age was 59+/-14 years. Mean follow-up was 370 days. The mean time to occlusion (19 events) was 215+/-141 days with patency re-established in 14 of 18 surgical interventions. Thirty angioplasties were performed on 14 SGVG 100 for luminal/anastomotic stenosis. Two grafts demonstrated areas of dilation; however, both grafts continue to be usable at last reported follow-up (930 and 602 days) with no further changes in graft size. Primary patency, assisted primary patency, secondary patency, and freedom from infection were 29, 45, 81, and 95% at 1 year, respectively. CONCLUSIONS: This report demonstrates SGVG 100 is a stable vascular access conduit, providing a suitable graft alternative when autologous vein is not available.     

A survey of vascular access for haemodialysis in The Netherlands

After nearly 30 years of access surgery for haemodialysis, a survey of vascular access in a large population seemed relevant in order to analyse the state of the art. On 1 January 1988, 2195 patients in 52 centres in The Netherlands (population 14,714,900) were on long-term haemodialysis and 588 on continuous ambulant peritoneal dialysis (CAPD) for renal insufficiency. A questionnaire was mailed out, to which there was 100% response. Of all the patients on long-term haemodialysis, 70% had a Cimino fistula, 22% a graft fistula, and 6% a more proximal arm fistula. The remaining 2% had a Scribner shunt. Of all the graft fistulae, the expanded polytetrafluoroethylene (ePTFE) graft was the one most used (58%), followed by the homologous vein graft (25%), the autologous vein graft (13%), and those made of other materials (4%). Preference for acute access was recorded; catheterisation of the subclavian vein was used almost exclusively in 17 centres, while in 24 centres it was chosen in more than 50% of the cases. The femoral vein was almost always the choice for acute access in 6 centres and it was selected in more than 50% of the cases in 17 centres. Another alternative, the Scribner shunt, was applied in selected cases in 22 of the 52 centres. Percutaneous transluminal angioplasty (PTA), as a method for treating stenoses in vessels used for vascular access, was applied routinely in 5 centres and occasionally in 19 centres.     

Trials and trade-offs in haemodialysis vascular access monitoring.

There are currently more than 300 000 patients receiving haemodialysisin the US and similar numbers are estimated in Europe. Despitethe recognition that vascular access is the ‘Achillesheel’ of the dialysis procedure, haemodialysis vascularaccess failure and related complications continue to be oneof the most difficult obstacles in the optimal care of dialysispatients. In the US, haemodialysis vascular access proceduresand complications account for more than 20% of hospitalizationsof haemodialysis patients and result in more than $1 billionper year of government paid expenditures [1]. Additional, oftenunrecognized costs stem from missed treatments, the placementand use of dialysis catheters and the significant     

Vascular access for haemodialysis with autogenous vein graft arteriovenous fistulas.

Nine autogenous vein grafts (AVG) have been used in nine patients to create arteriovenous fistulae for haemodialysis. All the patients lacked vessels for construction of a regular arteriovenous fistula. Three of the AVG failed during dialysis treatment 3, 10 and 14 months respectively following construction. Another AVG thrombosed but function was restored by thromboectomy. The same graft was later complicated by a false aneurysm and rupture but was then reconstructed with a vein patch. One AVG with a false aneurysm in the proximal anastomosis was repaired within six weeks.     

Vascular access for chronic haemodialysis in Lombardy

To evaluate the organisation of vascular access surgery, the techniques used to monitor surgical access and the central catheters, a survey was conducted amongst dialysis Units of Lombardy. A questionnaire was sent out to the 43 dialysis centres in Lombardy, 96% of which replied. In almost 90% of dialysis units nephrologists perform vascular access albeit in close cooperation with vascular surgeons for the more complex cases. First choice access is by distal arteriovenous fistula (AVF): 36% end-to-end, 31.7% side-to-end, and 19.5% side-to-side with distal ligature of the vein. As second choice proximal AVF is more widely used than AV grafts, which are implanted only when all native vessels and related surgical procedures are exhausted. Central venous catheters offer valid solutions not only as temporary access, but also as an alternative permanent one. In both cases the jugular vein is the most frequent site of insertion. Despite the documented incidence of related episodes of stenosis/obstruction, the subclavian vein is used as a temporary access in quite a high per-centage of cases. Only in selected cases are diagnostic procedures (mainly Venography and Doppler studies) performed prior to permanent access choice. Similarly vascular access is monitored mainly using a recirculation test albeit not routinely. In case of vascular access thrombosis, surgical revision is the most common approach.     

Repeated femoral vein puncturing for maintenance haemodialysis vascular access.

BACKGROUND: When access cannot be achieved using a native arteriovenous fistula or a synthetic prosthetic graft, central venous catheters are usually placed. This mode of access is short-lived, prone to infection, stenosis and thrombosis of central veins. To overcome access problems, we developed a new native vascular access ('femoral vein access') and devices. We report here on our experience with the availability, longevity, procedure and morbidity of haemodialysis (HD) using femoral vein access. METHODS: Repeated (three times a week) patient's native femoral vein puncturing has been used as the vascular access (femoral vein access) for maintenance HD in 30 patients (mean age +/- SD: 61.70 +/- 15.27 years old; 18 female/12 male). The femoral vein was punctured beneath the inguinal ligament (on a length ranging from 30 to 100 mm) after disinfection and local anaesthesia. Long (effective length 56 mm) 19- and 18-gauge needles with four side holes were used for the femoral vein puncture as an arterial site of the extracorporeal circuit of HD and shorter (effective length 40 mm) similar gauge needles for the subcutaneous vein puncture used as the return site. The needle is inserted blind into the femoral vein after the femoral artery has been located by palpation and the perception of a pulse. Patients returned home the same day. RESULTS: The mean duration of HD treatment using femoral vein repeated puncture was 4.99 +/- 3.42 years (up to 16.0 years). This represented a total experience of 23 369 femoral vein punctures. The mean blood flow achieved on dialysis was 165 +/- 20 ml/min. The average Kt/V was 1.74 +/- 0.48 per session. CONCLUSIONS: The femoral vein repeated puncture technique has substantial advantages over venous catheters. It does not require surgery, while permitting adequate blood flow. This method can be used as a long-term (over 10 years) blood access. Apart from a few local haematomas, no serious complications have been observed. Moreover, it does not carry a heavy financial burden.     

Short-term femoral vein catheterization: A safe alternative venous access?

Results of femoral vein catheterization were compared with those of subclavian and antecubital vein catheterization in 2,345 combat casualties during treatment of hypovolemic shock. Femoral vein catheterization was successful in 95.5 per cent of cases. Accidental arterial puncture occurred in 6.3 per cent, hematomas in 1.3 per cent, and infection in 1.4 per cent. Subclavian vein catheterization was successful in 92.4 per cent. Arterial puncture occurred in 0.4 per cent, hematomas in 0.3 per cent, infection in 1.1 per cent, pneumothorax in 1.4 per cent, and hydrothorax in 0.4 per cent. Antecubital vein catheterization was successful in 77.6 per cent, infection developed in 3.3 per cent, and phlebitis occurred in 5.6 per cent. No clinically detectable phlebitis occurred after either femoral or subclavian vein catheterization. The low morbidity of femoral vein catheterization in this series suggests that this approach be considered when short-term massive intravenous fluid administration is indicated in the treatment of circulatory collapse or cardiac arrest.