Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4031_Библиотеки_им_академика_М_И_Перельмана
.pdf
How to Prolong the Patency of VA
151
the option for PTA and stenting. As the goal of access management is to
maintain the access site for the longest period of time, we prefer surgical re-
pair prior to stent placement for any stenotic lesion that is surgically acces-
sible. This is an important patient safety issue in prolongation of access pa-
tency.
Summary
Prolonging the patency of an access circuit is a key element for patient safety. It
starts with optimal access planning utilizing DUS and surgical techniques that
minimize hemodynamic stress responsible for the development of MIH. Moni-
toring, surveillance and timely interventions play a key role in prolonging the
access patency. It is important that the access plan developed and communi-
cated to the patient gets reinforced by all personnel involved in patient care ac-
tivities.
Disclosure Statement
The authors have no conflicts of interest to declare.
References
1 US Renal Data System, USRDS 2013 Annual
Data report: Atlas of chronic kidney disease
and end stage renal disease in the United
States. Bethesda, National Institutes of
Health, National Institutes of Diabetes and
Digestive and Kidney Diseases, 2013, 2.1.1 p
217, 2.12.3 p 338.
2 Dixon BS, Beck GJ, Vazquez MA, et al: Effect
of dipyridamole and aspirin on hemodialysis
graft patency. N Engl J Med 2009;
360: 2191–
2201.
3 Dember LM, Beck GJ, Allon M, et al: Effect of
clopidogrel on early failure of arteriovenous
fistulas for hemodialysis: a randomized con-
trolled trial. JAMA 2008;
299: 2164–2171.
4 Anaya-Ayala JE, Bellows PFH, Ismail N, et al:
Surgical management of hemodialysis related
central venous occlusive disease: a treatment
algorithm. Ann Vasc Surg 2011;
25: 108–119.
5 Okada S, Shenoy S: Arteriovenous access for
hemodialysis: preoperative assessment and
planning. J Vasc Access 2014;
15(suppl 7):s1–
s5.
6 Lee T, Roy-Chaudhury P: Advances and new
frontiers in the pathophysiology of neointi-
mal hyperplasia and dialysis access stenosis.
Adv Chronic Kidney Dis 2009;
16: 329–338.
7 Yevzlin AS, Conley EL, Sanchez RJ, Young
HN, Becker BN: Vascular access outcomes
and medication use: a USRDS study. Semin
Dial 2006;
19: 535–539.
8 Lok CE, Moist L, Hemmelgarn BR, et al: Ef-
fect of fish oil supplementation on graft pa-
tency and cardiovascular events among pa-
tients with new synthetic arteriovenous
hemodialysis grafts. A randomized controlled
trial. JAMA 2012;
307: 1809–1816.
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 143–152 (DOI: 10.1159/000366122)
152
Glazer Saint Shenoy
9 Remuzzi A, Ene-lordache B: Novel para-
digms for dialysis vascular access: upstream
hemodynamics and vascular remodelling in
dialysis access stenosis. Clin J Am Soc
Nephrol 2013;
8: 2186–2193.
10 Bharat A, Jaenicke M, Shenoy S: A novel
technique of vascular anastomosis to prevent
juxta-anastomotic stenosis following arterio-
venous fistula creation. J Vasc Surg 2012;
55:
274–280.
11 Hoganson DM, Hinkel CJ, Chen X, Agarwal
RK, Shenoy S: Validation of computational
fluid dynamics-based analysis to evaluate he-
modynamic significance of access stenosis. J
Vasc Access 2014;15:409–414.
12 Asif A, Leon C, Orozco-Vargas LC, et al: Ac-
curacy of physical examination in the detec-
tion of arteriovenous fistula stenosis. Clin J
Am Soc Nephrol 2007;
2: 1191–1194
13 Robbin ML, Oser RF, Lee JY, et al: Random-
ized comparison of ultrasound surveillance
and clinical monitoring on arteriovenous
graft outcomes. Kidney Int 2006;
69: 7305.
14 Besarab A, Sullivan KL, Ross RP, Moritz MJ:
Utility of intra access pressure in detecting
and correcting venous outlet stenosis prior to
thrombosis. Kidney Int 1995;
47: 1364–1373.
15 Moist LM, Churchill DN, House AA, et al:
Regular monitoring of access flow compared
with monitoring of venous pressure fails to
improve graft survival. J Am Soc Nephrol
2003;
14: 2645.
16 Tessitore N, Bedogna V, Verlato G, et al: The
rise and fall of access blood flow surveillance
in arteriovenous fistulas. Semin Dial 2014;
27:
108–118.
17 NKF-KDOQI clinical practice guidelines and
clinical practice recommendations for vascu-
lar access, update 2006. Am J Kidney Dis
2006;
48(suppl 1):S177–S247.
18 Tessitore N, Bedogna V, Melili E, et al: In
search of optimal bedside screening program
for arteriovenous fistula stenosis. Clin J Am
Soc Nephrol 2011;
6: 819–826.
19 Wilson NA, Shenoy S: Managing ‘buttonhole’
complications. J Vasc Access 2014;
15(suppl
7):s91–s95.
20 Kim CY, Guevara CJ, Engstrom BI, et al:
Analysis of infection risk following covered
stent exclusion of pseudoaneurysms in pros-
thetic arteriovenous hemodialysis access
grafts. J Vasc Interv Radiol 2012;
23: 69–74.
21 Peden EK: Role of stent grafts for the treat-
ment of failing hemodialysis accesses. Semin
Vasc Surg 2011;
24: 119–127.
22 Falk A: Maintenance and salvage of arterio-
venous fistulas. J Vasc Interv Radiol 2006;
17:
807–813.
23 Cull DL, Washer JD, Carsten CG, et al: De-
scription and outcomes of a simple surgical
technique to treat thrombosed autogenous
accesses. J Vasc Surg 2012;
56: 861–865.
24 Georgladia GS, Lazarides MK, Lambidis CD,
et al: Use of short PTFE segments (<6 cm)
compares favorably with pure autologous
repair in failing or thrombosed native arte-
riovenous fistulas. J Vasc Surg 2005;
41: 76–81.
25 Chang C, Ko P, Hsu L, et al: Highly increased
cell proliferation activity in the restenotic he-
modialysis vascular access after percutaneous
transluminal angioplasty: implication in pre-
vention of restenosis. Am J Kidney Dis 2004;
43: 74–84.
26 Bittl JA: Catheter interventions for hemodi-
alysis fistulas and grafts. J Am Coll Cardiol
Intv 2010;
3: 1–11.
27 Hyun JH, Lee JH, Park SI: Hybrid surgery
versus percutaneous mechanical thrombec-
tomy for the thrombosed hemodialysis au-
togenous arteriovenous fistulas. J Korean
Surg Soc 2011;
81: 43–49.
28 Klimach SG, Norris JM: Surgical versus en-
dovascular management of thrombosed au-
togenous arteriovenous fistulae. Int J Surg
2014;
12: 237–240.
29 Tordoir JHM, Bode AS, Peppelenbosch N, et
al: Surgical or endovascular repair of throm-
bosed dialysis vascular access: is there any
evidence? J Vasc Surg 2009;
50: 953–956.
Surendra Shenoy, MD, PhD
Section of Abdominal Organ Transplantation, Department of Surgery
Barnes Jewish Hospital, Washington University School of Medicine
Campus Box 8109
660 South Euclid Blvd
Saint Louis, MO 63110 (USA)
E-Mail shenoysu
@ wustl.edu
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 143–152 (DOI: 10.1159/000366122)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Dealing with Complications of Vascular Access
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163
DOI: 10.1159/000365912
Abstract
A great variety of thrombotic and nonthrombotic events may complicate all types of vas-
cular access (VA) procedures. Thrombotic events are the most frequent complication,
caused by stenoses in various locations, representing a common problem for arteriove-
nous fistulas (AVFs) and arteriovenous grafts (AVGs). Monitoring AVF with physical ex-
amination by trained physicians represents an accurate method for diagnosis of mal-
function. AVF stenoses >50% in diameter should be treated either by surgical or endo-
vascular means when accompanied with access malfunction. Aneurysms and infections
represent the most frequent nonthrombotic VA complications. Access-related aneurysms
do not represent per se an indication for intervention; however, anastomotic aneurysms
and those with skin erosion should be repaired urgently to avoid rupture. Infections of
AVFs are extremely rare, while AVG could be complicated either with postoperative infec-
tions attributable to the initial procedure with an early onset and more frequently with
late infections caused by punctures, with an annual rate of 5%. Treatment options for AVG
infections comprise total or subtotal graft excision or partial excision of the involved seg-
ment only, the latter representing a VA salvage procedure but with a significantly higher
risk of recurrence.
© 2015 S. Karger AG, Basel
Recommendations to Improve Patient Safety
•
Check after creation of an arteriovenous fistula or arteriovenous graft
(AVG) for palpable thrill or a bruit: The presence of a strong pulse in the
draining vein without a thrill or bruit indicates a proximal venous stenosis.
Patients need an instruction when checking their vascular access (VA) dai-
ly for bruit and thrill.
Safety Issues in Surgical and Endovascular
Techniques to Rescue Failing or Failed
Arteriovenous Fistulas and Arteriovenous Grafts
Miltos Lazarides George Georgiadis Christos Argyriou
Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis , Greece
154
Lazarides Georgiadis Argyriou
•
Failed or failing VA needs revision by surgical or endovascular means de-
pending on the location of the lesion. Check thrombosed accesses after
thrombectomy for underlying stenotic lesions that have to be corrected.
•
Anastomotic aneurysms and those with skin erosion (mostly false aneu-
rysm of AVG) should be repaired urgently to avoid rupture and life-threat-
ening hemorrhage. Patients should be informed about this complication.
•
Aneurysms are often associated with proximal stenosis, and this should be
corrected simultaneously.
•
The best policy to prevent infection is to limit the implantation of synthetic
prostheses only to patients with no autogenous options.
Introduction
The failure of vascular access (VA) represents the major cause of morbidity for
those end-stage renal disease patients on hemodialysis, and access maintenance
is the most frequent cause of hospitalization for such patients [1] . The subse-
quent extended length of stay commonly encountered in older patients is also
related to further adverse events as hospital-acquired infections and fever, pro-
longed catheterization predisposing to central venous obstruction and delay in
access revision with increased associated costs. The VA maintenance cost in-
creases 5-fold for those patients with a failed autogenous access [2] .
A great variety of thrombotic and nonthrombotic events may complicate all
types of VA procedures and necessitate a wide spectrum of rescue operations.
Stenoses and Thrombosis in Arteriovenous Fistulas or Grafts
Thrombotic events represent the most frequent complication of all VA with an
incidence rate of 0.2/patient/year for arteriovenous fistula (AVF) and 0.8/pa-
tient/year for synthetic arteriovenous graft (AVG) [3] . Therefore, redo surgery
is the rule rather than exception in VA patients.
Stenosis is a common problem for AVFs and AVGs and represents the main
cause of dysfunction and thrombosis, and the choice of the best method for re-
pair depends on the location of the lesion. Access stenosis has been classified
based on its location as: juxta-anastomotic (type I), in the cannulable segment
(type II) and at the outflow into the deep venous system (type III) [4] ( fig.1 ).
There are two additional categories of stenoses not involving the access itself,
those of the central veins caused by longstanding catheters and those of the arte-
rial inflow [5] .
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163 (DOI: 10.1159/000365912)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Safety Issues in Techniques to Rescue Failing or Failed AVF/AVG
155
Juxta-anastomotic type I stenosis is the most frequent reason for access dys-
function, especially in the distal radiocephalic AVFs. With endovascular means,
in most cases the fibrotic perianastomotic tissue necessitates high-pressure or
cutting balloons and prolonged dilatation times, and therefore most authors
suggest surgical revision instead, with creation of a new anastomosis a few cen-
timeters proximally; however, in brachiocephalic AVF, a short polytetrafluor-
ethylene segment may be needed to bridge the greater distance between the ar-
tery and the vein [5, 6] .
Central vein
stenosis
Typ e I I I st eno sis
junctional
Feeding artery
stenosis
Typ e I I steno sis
outflow vein
Typ e I ste nosis
juxta-
anastomotic
V. cep hal ica
A. brachialis
V. basilica
A. ulnaris
V. cep hal ica
Fig. 1. Schematic representation of the main types of stenotic lesions complicating ac-
cesses.
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163 (DOI: 10.1159/000365912)
156
Lazarides Georgiadis Argyriou
Type II is a mid-vein cannulable segment stenosis and should be first treated
with PTA (percutaneous transluminal angioplasty) in autogenous accesses in
order to preserve the length of the needling site of the vein; however, in case of
failure an interposition graft should be inserted [4] . In this type of lesions, the
dialysis dose is usually not affected because the stenosis often falls between the
arterial and venous needles [5] .
Type I and II stenoses are not frequent in AV grafts, where type III stenosis
is the predominant type of stenosis causing access failure and should be treated
either by endovascular or open surgical means consisting of patch angioplasty
or jump graft repair depending of center’s experience and availability. Regarding
the endovascular methods of treatment, stent grafts have better patency rates in
comparison to PTA alone according to a recent randomized study [7] . Cephalic
arch stenosis is the equivalent of type III stenosis in AVF; PTA should be the first
choice as the use of stents may cause axillary vein obstruction, while surgical ce-
phalic vein transposition is an alternative option with equal patency but fewer
reinterventions [8] .
Stenoses of central veins principally induced by longstanding catheters can
become symptomatic as a result of increased flow when an ipsilateral AV fistula
is functioning distally to an obstruction. In case of complete venous outflow ob-
struction, venous hypertension with intractable upper arm painful edema occa-
sionally involving the breast and head may necessitate urgent intervention to
avoid tissue loss of the fingers. Access ligation and abandonment bring immedi-
ate relief of the complaints but requires a new access creation, which is not always
feasible. Surgical repair of the inflow obstruction is not recommended as first
choice because of the significant morbidity and mortality of such ‘exotic’ major
operations, in opposition, PTA is recommended as the treatment of choice, but
it is a matter of debate if primary stenting would be a better option [9] .
Arterial inflow stenoses represent atherosclerotic lesions proximal to the
anastomosis, and their clinical picture is usually characterized by delayed AVF
maturation. These lesions usually involving the radial artery are best treated
with PTA [10] .
All accesses should be evaluated immediately after their creation and then
routinely examined during their life span. After creation of an AVF or AVG,
there should be a palpable thrill or a bruit; the presence of a strong pulse in the
draining vein without a thrill or bruit indicates a proximal venous stenosis.
Monitoring AVF with physical examination by trained physicians represents an
accurate method for diagnosis of malfunction [11] .
AVF stenoses >50% in diameter should be treated either by surgical or endo-
vascular means when accompanied with low flow, difficulties in cannulation,
painful edema or prolonged bleeding at puncture sites [12] ( fig.2 ). None of the
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163 (DOI: 10.1159/000365912)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Safety Issues in Techniques to Rescue Failing or Failed AVF/AVG
157
currently available surveillance methods (periodic assessment using technical
devices) can reliably distinguish between stenosed VA destined to clot, and
those that will remain patent without intervention [13] . As a consequence, a per-
centage of unnecessary angioplasties are performed based on surveillance find-
ings only.
Thrombosis of AVF necessitates treatment as quickly as possible because de-
layed intervention allows the thrombus to propagate, and become fixed to the
vein wall with a local inflammation, making any thrombectomy attempt difficult
and predisposing to arterial wall damage with its risk of re-thrombosis. Throm-
bosed VA can be treated either by an open or endovascular intervention. Throm-
bectomy alone is generally insufficient unless the underlying stenotic lesion is
corrected.
Aneurysms
Aneurysms may complicate 2–10% of all types of VA [14] . These may be false
aneurysms (also called pseudoaneurysms from the Greek word pseudos: false)
and true aneurysms caused by degeneration and subsequent dilatation of the
Vascular
access
stenosis
Inflow
artery
stenosis
Typ e I I
Type III
PTA
Surgical
repair
Central
vein
stenosis
Typ e I
(periana-
stomotic)
Stenting/
stent graft
PTA
Failure
Surgical
repair
PTA/
stenting
Failure
Access
ligation
Surgical
repair
(exotic)
Proxima-
lization of
anastomosis
Fig. 2. Algorithm of the preferential treatment methods in failing accesses.
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163 (DOI: 10.1159/000365912)
158
Lazarides Georgiadis Argyriou
whole native vein wall. In contrast to AVF where true aneurysms are the most
frequent type, aneurysms in AVG occur mostly as false aneurysms and less fre-
quently as anastomotic aneurysms. The false aneurysms represent a chronic
blood extravasation through a circumscribed graft defect surrounded by throm-
bi encapsulated in a gradually developed fibrous false wall. The updated DOQI
guidelines differentiate between true and false aneurysms and suggest surgical
Table 1. Indications for surgical repair of aneurysms in AVG and AVF
AVGs AVFs
Size exceeding 2-fold the graft diameter
–
Rapid enlargement
–
Skin thinning or erosion
Rupture
Pain (throbbing)
Large or multiple aneurysms limiting the cannulable area
Signs of infection
–
Wall-adherent thrombus –
Anastomotic aneurysms
Cosmetic reasons ? ?
Fig. 3. Skin erosion about to rupture caused by a false aneurysm in a brachiocephalic AVF.
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163 (DOI: 10.1159/000365912)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Safety Issues in Techniques to Rescue Failing or Failed AVF/AVG
159
treatment of the enlarging false aneurysms and those exceeding twice the diam-
eter of the graft to prevent the risk of acute rupture. The indications for surgical
repair of aneurysms summarizing suggestions from guidelines and articles are
presented in table1 [15, 16] . Access-related aneurysms do not represent per se
an indication for surgery; however, anastomotic aneurysms and those with skin
erosion should be repaired urgently to avoid rupture and life-threatening hem-
orrhage ( fig.3 ).
Pseudoaneurysms can be managed either with conventional surgery or with
endovascular techniques; however, conventional surgery represents the current
standard treatment [17, 18] . Surgical correction includes resection of the in-
volved segment and new graft interposition in situ, or aneurysm ligation/exclu-
sion followed by a bypass graft adjacent to the old one via new route in cases of
suspected contamination of the sac [16] .
There are many recent series reporting results of stent graft repairs in AVG
but with small number of patients and limited follow-up; contraindications of
this method include overt graft infection, presence of skin erosion, need to cross
the elbow or axilla and lack of adequate landing zones [18, 19] . Aneurysms are
often associated with proximal stenosis and both lesions should be treated si-
multaneously [18] .
True aneurysms can be repaired with aneurysmorrhaphy ( fig.4 ), where the
excess sac of the aneurysm is resected, and a new autogenous access is recon-
structed by plicating the excess free wall [17] .
Infection
Infection of autogenous accesses is extremely rare, while AVG could be compli-
cated with two main types of infections: (1) postoperative infections attributable
to the initial access procedure with an early onset (<1 month) and an incidence
of 0.8%, representing only 6% of the total AVG infections and (2) late infections
caused by punctures, representing >50% of the total, with an annual rate of 5%
[20] . Bacteremias are 5 times more frequent in grafts than in AVF (3.1 vs. 0.6
bloodstream infections per 100 patient months) [21] . Staphylococcus species are
the most common culprits in over 70% of the cases [22] .
The difference between AVF and AVG is that infection in autogenous ac-
cesses can be treated successfully with antibiotics (and potential drainage) with
the exception of those infections involving the anastomosis because of the risk
of suture line bleeding and those complicated with septic emboli necessitating
access ligation.
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163 (DOI: 10.1159/000365912)
160
Lazarides Georgiadis Argyriou
a
b
c
Fig. 4. Details how to perform aneurysmorrhaphy to correct true AVF aneurysm: a Inci-
sion of overlapping skin with preparation of the aneurysm to control in- and outflow.
b Excision of the aneurysmatic vein wall. c Suture line using a tube graft as model to com-
plete a ‘new’ vein with a diameter of approximately 6 mm.
Widmer MK, Malik J (eds): Patient Safety in Dialysis Access.
Contrib Nephrol. Basel, Karger, 2015, vol 184, pp 153–163 (DOI: 10.1159/000365912)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Соседние файлы в папке Библиотека им академика М.И. Перельмана