Mary Hammes

*University of Chicago United States* 

#### **1. Introduction**

16 Technical Problems in Patients on Hemodialysis

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The primary aim of this chapter is to understand the importance of placement and maintenance of arteriovenous fistula (AVF) in the patients with advanced renal failure prior to the need for dialysis. Vascular access complications contribute significantly to the morbidity and mortality associated with end-stage renal disease patients on hemodialysis. The major concern this publication will address is that with the recommendation for an increased number of AV fistulas, we are faced with the fact that many fistulas fail, with limited data to understand complications of AVF specifically stenosis and thrombosis. Attempts to understand underlying mechanisms of stenosis and thrombosis will aide in access design, treatment options, and hence improve morbidity and mortality.

The care and outcome of the patient with end-stage renal failure (ESRD) on chronic hemodialysis is dependent on their access. Although a variety of techniques have been developed for providing hemodialysis access, there have been no major advances in the past three decades. This contributes to the fact that hemodialysis access dysfunction is one of the most important causes of morbidity and mortality in the hemodialysis population. In addition, the expense of providing ESRD care in the US is a significant portion of the Medicare budget, totaling \$23.9 billion in 2007, of which a significant portion is spent on placement and maintenance of vascular access (USRDS, 2009).

The fistula provides the best outcome and can be placed with the least expense and complication rate when compared to a catheter or graft. Therefore, regional and network indicators promote the placement of AVF. Several recent initiatives have focused on vascular access and ways to improve outcomes. The National Foundation for Kidney-Dialysis Outcomes Quality Initiative (K-DQOL), End Stage Renal Disease Clinical Performance Measures (CPM) and Fistula First Initiative (FFI) have provided guidelines that mandate fistula access in patients on hemodialysis (Vasquez, 2009). FFI, developed to promote fistula placement, had an initial goal of 40% of prevalent patients with fistula access. This goal was achieved in 2005, with a goal of 66% set for 2009. Nationwide, however, there are only 54.4% of prevalent hemodialysis patients with fistula access as of November, 2009, with the number of fistula access placements falling for the first time in 2007 (USRDS, 2009).

New insights into the care and maintenance of fistula access will help to ensure duration of long term access patency. With national initiatives to place more fistulas, the number of fistulas has and will continue to increase. There are gaps in knowledge as to surveillance, maturation, cannulation techniques and mechanism and treatment of stenosis and thrombosis. The following chapter on fistula access for hemodialysis will help to fill these voids.

Hemodialysis Access: The Fistula 19

incision at the wrist (Fig 1). This access is easy to place and once mature and used for dialysis has a low complication rate. The classic Cimino fistula is constructed with a side-to side anastomosis but this design may lead to venous hypertension. Therefore an end-to-side anastomosis is commonly used. The most frequent clinical problem is that this access has a higher primary failure rate when compared to BCF or BBF (Miller, 1999). However, if a RCF matures, the 5 to 10 year cumulative patency rate is 53 and 45 percent respectively (Bonalumi, 1982, Rodriguez, 2000). Placement of a lower arm fistula is desirable as it

The BCF is a suitable second choice for access (Reubens, 1993). The cephalic vein in the upper arm is larger with increased flow as compared to the lower arm. The anastomosis for a BCF is usually in the antecubital fossa between the brachial artery and cephalic vein (Fig 2). The location of the BCF enables ease of cannulation with the benefit of a large surface area. The major complication with a BCF is the steal syndrome (see complications) as compared to RCF or BBF. In a retrospective review of 2,422 patients with vascular access, the BBF had a superior patency rate in diabetic pateints when compared to diabetic pateints who had a RCF (Papanikolaou, 2009). The authors even went so far as to argue that the BCF

Fig. 2. Brachial-cephalic fistula. Figure reprinted by permission from Macmillan Publishers

The BBF is the third choice for fistula placement (Dagher, 1976). Because the basilic vein is less accessible to venipuncture it tends to be better preserved and less involved with

may be the best access option for the older diabetic patient on hemodialysis.

preserves the upper arm for future use.

**2.2 Brachial-cephalic fistula** 

Ltd: Kidney International, 62, 2002

**2.3 Brachial-basilic fistula** 
