How to prepare

vascular access
Hilman Ibrahim
Div. Of Vascular and Endovascular
FKUI/RSCM

What is Vascular Access (VA) ?

a way to get/reach the blood vessel
for
the insertion of a flexible thin;
- plastic tube
- catheter, into a blood vessel

Peripheral
venous catheter

Double lumen
catheter

Indication and
Contraindication
Indication
1.

Hemodialysis

2.

Chemotherapy

3.

Nutrition

4.

Fluid administration

5.

Drugs administration

6.

Blood transfusion

7.

Antiviral therapy

8.

Pain Emergency Case management

9.

Angiology

Relatif
contraindication
Coagulopathy
Allergy to the catheter
material
Mediastinal tumor
Skin infection at
implantation site

Vascular access can through

Intra arterial
Intra venous:
- perifer

a simple intravenous (i.v)

- central peripherally inserted central

catheter
central venous catheter (cvc)

Intra Arterial

Aortic Aneurysm
EVAR

Jugular vein

Subclavia vein

Brachial vein

Risks/Benefits of CVC
Placement
Indications for central
venous catheter (CVC)
Inadequate peripheral
vascular access
Need for frequent vascular
access
Hypertonic/hyperosmolar
infusions
Infusion of irritating or
vesicant drugs
Rapid absorption and
blood/tissue perfusion
Long-term IV therapy

Contraindications for placement of a CVC

Altered skin integrity

Anomalies of the central
vasculature
Cancer at the base of the neck
Cancer at the apex of the lung
Immunosuppression, septicemia
Problems with coagulation
Clavicle fracture
Hyperinflated lungs
Radiation to the insertion site
area
Superior vena cava syndrome
History of venous access device
complications
11

Timing V.A :
Emergency : life saving
i.V Catheter

Temporery

Permanent

: HD access

Double lumen Catheter HD

Blood stream over a period, either days

or weeks to years

The types of VA Catheters

a.standard intravenous (i.v) line
a.peripherally inserted central catheter (PICC)
a.non tunneled catheter with a cuf
a.port catheter or subcutaneous implantable port

Duration:
1.

IV Perifer less than week

2.

Non Tunnelled CVC 5 7 days

3.

Peripherally Inserted CVC (PICC) more than

weeks-month

4.

Skin tunnelled CVC more than 6 month

5.

Subcutanoues port cost effective more than 6

month Totally implantable

Non tunneled CVC

Skin tunneled
CVC

Subcutaneous port

Vena Cava Filter

How should VA prepare ?

Indication
Time :

Short term/day
Long term/weeks, month/years

USG Doppler :
Blood Clot (bt,ct)
X-ray (fluoroscopy)
C-Arm

Mapping/anatomy
Assess the vein

How is the procedure performed ?

Peripher (i.v line)
Central catether :

- jugular vein

- subclavia
- femoral
- brachial

Pre Operative
Operative
Post Operative

Patient
Anamnesis/History
- Comorbid/Underlying Disease
-DM
- Arterioscleorosis
- Heart Failure
- Trauma Puncture / CDL

Physical Examination
- Trauma Puncture vein
- Edema
- Countour of vein Cephalic to subclavia
- Countour arterial
- Allen test

USG Doppler
-

Countour Vein / Arterial

thrombus
plaque
flow

USG
DOPPLER

Internal jugular

Femoral vein

How do the result is

correctly ?
Chest xray (Evaluation)
Fluoroscopy
ECG
Function; using a needle/syringe injection
fluid through the catheter
C-Arm

Vascular Access
Match catheter size to patient size and anatomical site
Sites
Internal Jugular Vein
Femoral
Avoid subclavia vein if possible

Complications :
Infection
Heart failure
Distal ischemia
Aneurysm and pseudoaneurysm
Venous hypertension
Median nerve injury
Seroma formation

Complication of perypheral
Cannulation
Extravasation The
leakage of high
osmolarity solutions or
chemotherapy agents
can result in
significant tissue
destruction, and
significant
complications

Site Puncture

No Ideal Place VA

Venous Hypertension

Venous Hypertension

Port Implant

Catheter Rupture

Antibiotics can be used :

- as empiric
- after result of culture or resistance

Antibiotic lock: A high-concentration

solution of an antimicrobial substance
plus heparin/normal saline is instilled
into the catheter when it is not in use.
This method showed promising efects in
therapy of infections and prevention of
catheter colonization.
Bouza E, Burillo A, Munoz P. Catheter-related infections: diagnosis and
intravascular treatment. Clin Microbiol Infect 2002; 8(5): 265274.
Vescia S, Baumgartner AK, Jacobs VR, Kiechle-Bahat M, Rody A, Loibl S, Harbeck N.
Management of venous port systems in oncology: a review of current evidence. Annals
of Oncology 19: 915, 2008

Algoritma
Vescia S, Baumgartner AK, Jacobs VR, Kiechle-Bahat M, Rody A, Loibl S,
Harbeck N. Management of venous port systems in oncology: a review
of current evidence. Annals of Oncology 19: 915, 2008

Treatment of venous stenosis

Percutaneous angioplasty
Endovascular metallic stents
Surgical revision

Percutaneous angioplasty
Corrects over 80% of stenosis
in both native fistulas and synthetic grafts
in both venous and arterial outflow tracts

The 2006 K/DOQI guidelines recommend angioplasty if:

stenosis in fistula >50%
stenosis in graft >50% + (abnormal physical findings,
intragraft blood flow <600, or elevated static pressure)

 Success with angioplasty varies with the

size of the stenosis
Monitoring:
high recurrence rate (55 to 70% at 12 months)

Recurrent lesions: repeat angioplasty

Summary:
Reduced vascular morbidity
Preserves future access sites

Mr T,50 yo
central vein occlusion

Mr K, 33 y.o Central vein stenosis,

venoplasty

Post Plasty

Draining Vein Stenosis

Venoplasty

Vascular Access via

Arteriovenous Fistulas
The ideal vascular access
permits a flow rate that is adequate for the
dialysis prescription ( 300 ml/min),
can be used for extended periods,
and has a low complication rate.

The native AVF remains the gold standard

Ideal Catheter for Vascular

Access
Ideal Catheter Characteristics
Easy Insertion
Permits Adequate Blood Flow without
Vessel Damage
Minimal Technical Flaws
High Recirculation Rate
Kinking
Shorter and Larger Catheters
SIZE DOES MATTER
Lower Resistance
Improved Bloodflow

TREATMENT OF THROMBOSES
The 2006 K/DOQI guidelines
With grafts and associated stenosis:
Surgical thrombectomy
Thrombolysis
Mechanical disruption

With fistulas:
no recommend any approach to the removal of thromboses

Surgical thrombectomy
Outpatient procedure
quick
very low complication rate
initially success in 90%

However, failure to correct the underlying outflow

stenosis leads to rapid rethrombosis

Thrombolysis
Attempts to fistula thrombosis with urokinase and
streptokinase, originally yielded disappointing results
Dosing adjustments and technical advances:
improved the success rate
reduced the incidence of bleeding

Combines thrombolytic therapy with mechanical clot

disruption:
90% patency
50% patency in 1 year

K/DOQI goals for treatment

A success rate of 85%:
defined by the ability to use the graft at least once postprocedure

After percutaneous thrombectomy

40% patency at 3 months

After surgical thrombectomy

50% patency at 6 months
40% patency at 12 months

The Reality of Vascular

Access
There is no single access that meets even most of the
ideal criteria
Surgically created accesses, fistulae and PTFE grafts, do
however yield more reliable flows for adequacy with
much less risk of bacteremia
KDOQI (Kidney Disease Out Comes Quality Initiative)
guidelines make fistulae the access of choice

THANK
YOU