**2. Temporary hemodialysis vascular access**

Temporary hemodialysis access is required in patients scheduled to start hemodialysis treatment in several days to six months. It is mostly needed in patients with AKF of various etiology [3]. For that purpose, a hemodialysis catheter is introduced percutaneously into one of the large central veins (the internal jugular, subclavian or femoral veins) under local anesthesia. Catheters are made of different materials (polyurethane, silicon, and so on). Single-lumen catheters are used less often than double-lumen catheters of different lengths (usually 15 to 24 cm, rarely of other lengths – shorter are for pediatric use, and longer for permanent use) and 11.5-14 F in diameter. They are available in two configurations - straight and curved. A catheter is introduced after the puncture of an appropriate vein performed either in a "blinded" fashion or under ultrasound control [4]. Before the venipuncture, ultrasound should be used to visualize the relative anatomic position of the internal jugular vein and common carotid artery and determine the possible direction of puncture angle and depth in order to avoid the unwanted puncture of the common carotid artery (Figure 1).

After the catheter placement, a control chest x-ray is recommended to confirm the correct position of the catheter and exclude possible complications (Figure 2).

© 2012 Vujičić et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Source: Archive of the Department of Nephrology and Dialysis, University Hospital Rijeka

**Figure 1.** Ultrasonographic assesment in the B-mode of the internal jugular vein (V.J.I) and common carotid artery (A.C.C.).

Temporary vascular access for hemodialysis is sometimes indicated in patients with CKF stage 5, or end-stage kidney disease (ESKD), who are on regular dialysis, in cases of inadequate function of arteriovenous fistula (AV) or AV graft due to stenosis or thrombosis, and in new hemodialysis patients in whom AV fistula has not been created in a timely manner [5].

#### **3. Permanent hemodialysis vascular access**

Permanent vascular access is usually required in patients with CKF stage 4 because of permanent HD treatment [6]. For permanent vascular access, AV shunt (out of clinical use), AV fistula, AF graft or tunneled or non-tunneled hemodialysis catheters may be used. During the pre-dialysis preparation or pre-dialysis education program, the patients should be informed about possible ESKG treatment options, which include HD, peritoneal dialysis (PD), and kidney transplantation.

Source: Archive of the Department of Nephrology and Dialysis, University Hospital Rijeka

**Figure 2.** Chest radiogram showing correct position of the jugular cateter in the right atrium.

#### **3.1. Arteriovenous shunt**

454 Aneurysm

Source: Archive of the Department of Nephrology and Dialysis, University Hospital Rijeka

**3. Permanent hemodialysis vascular access** 

(PD), and kidney transplantation.

carotid artery (A.C.C.).

manner [5].

**Figure 1.** Ultrasonographic assesment in the B-mode of the internal jugular vein (V.J.I) and common

Temporary vascular access for hemodialysis is sometimes indicated in patients with CKF stage 5, or end-stage kidney disease (ESKD), who are on regular dialysis, in cases of inadequate function of arteriovenous fistula (AV) or AV graft due to stenosis or thrombosis, and in new hemodialysis patients in whom AV fistula has not been created in a timely

Permanent vascular access is usually required in patients with CKF stage 4 because of permanent HD treatment [6]. For permanent vascular access, AV shunt (out of clinical use), AV fistula, AF graft or tunneled or non-tunneled hemodialysis catheters may be used. During the pre-dialysis preparation or pre-dialysis education program, the patients should be informed about possible ESKG treatment options, which include HD, peritoneal dialysis External AV shunt belongs to history. It was used between 1960 and 1965, before the first AV fistula was created (Kenneth C. Apple), that is, radiocephalic (Brescia–Cimino 1966) (Figure 3).

#### **3.2. Arteriovenous fistula**

In patients on chronic hemodialysis, vascular access should be created in a timely fashion. Native AV fistula is the gold standard and the most frequently used type of vascular access in these patients [2]. After examining the patient in CKF stage 4 (GFR 30-15 mL/min/1.73 m²), a

Source: Archive of the Department of Nephrology and Dialysis, University Hospital Rijeka

#### **Figure 3.** Quinton-Scribner AV sunt

vascular surgeon makes an assessment of the patient's vascular system in order to plan for the AV fistula construction. In case of progressive kidney failure and/or diabetes mellitus, AV fistula should be created earlier [7]. Before choosing the type of vascular access, peripheral blood vessels (arteries and veins) should be evaluated by clinical examination and ultrasound. If diameters and walls of the blood vessels are satisfactory, AV fistula may be created. It is usually done on the non-dominant arm between the radial artery and cephalic vein as distally as possible. AV fistula is a surgically created subcutaneous anastomosis between an artery and a vein (Figure 4) and it matures by venous dilatation and arterialisation of the vein.

**Figure 4.** Typical arterivenous fistula (Brescia-Cimino)

Source: Archive of the Department of Nephrology and Dialysis, University Hospital Rijeka

vascular surgeon makes an assessment of the patient's vascular system in order to plan for the AV fistula construction. In case of progressive kidney failure and/or diabetes mellitus, AV fistula should be created earlier [7]. Before choosing the type of vascular access, peripheral blood vessels (arteries and veins) should be evaluated by clinical examination and ultrasound. If diameters and walls of the blood vessels are satisfactory, AV fistula may be created. It is usually done on the non-dominant arm between the radial artery and cephalic vein as distally as possible. AV fistula is a surgically created subcutaneous anastomosis between an artery and a vein (Figure 4) and it matures by venous dilatation

**Figure 3.** Quinton-Scribner AV sunt

and arterialisation of the vein.

The AV anastomosis redirects arterial blood flow into the vein, which then becomes dilated due to new hemodynamic conditions. Over time, the lumen of the vein widens, the venous blood flow increases, and the vein becomes suitable for puncture and hemodialysis usually after three to five weeks [8].

There two most common types of anastomosis. One is "side-to-side" (a standard anastomosis described by Brescia), where an artery and its neighboring vein are cut longitudinally and sewn or stapled together [9]. This type of anastomosis may lead to the venous hyperemia of the arm (Figure 5).

The other is "end-vein to side-artery" anastomosis, where the cephalic vein is completely severed, its distal part toward the hand is ligated, and the proximal part is sewn to the side of the relevant artery (Figure 6).

**Figure 5.** "Side to side" anastomosis of the AV fistula

**Figure 6.** "End to side" anastomosis of the AV fistula

If AV fistula cannot be created at the usual site, i.e., the wrist, it may be created proximally in the middle part of the forearm or cubital fossa. The fistula may also be created between the ulnar artery and the basilic vein.

#### **3.3. AV fistula complications**

#### *3.3.1. Thrombosis*

AV fistula thrombosis is characterized by a complete cessation of blood flow through the venous part of the AF fistula proximal to the AV anastomosis due to a thrombus, which may develop in any part of the vein (from the anastomosis to the confluence of the subclavian vein into the superior vena cava). Thrombosis may be diagnosed by a standard physical examination. The characteristic sign is the absence of the typical thrill of the fistula on palpation. In some cases, the thrombus in the vein may be palpable. Arterial pulsations may be noticed distal and the absence of blood flow in the empty vein proximal to the site of thrombosis. No AV fistula bruit can be heard with a stethoscope. The findings may be confirmed by ultrasound, i.e. the thrombus may be visualized and measured by B mode ultrasound, and the absence of the circulation proximal to the thrombosis site may be confirmed by Doppler [10].

Thrombosis is the most serious complication leading to the loss of function of the fistula. It is treated surgically by thrombectomy or via endovascular route.
