Akses Vaskular untuk Hemodialisa

dr. Dedi A Zaelani, SpB(K)V

RSPAD Gatot Soebroto Jakarta
TIMING

• NKF-KDOQI and the SVS guidelines permanent

dialysis access (creatinine clearance is < 25 mL/min.)
• GFR < 30 mL/min/1.73 m2 (CKD stage 4) placement
of a permanent dialysis access.
• Patients should have a functional permanent
access at the initiation of dialysis therapy.
TIMING

• At least 6 months before the anticipated start of

HD treatments.
• At least 3 to 6 weeks before the anticipated start
of HD therapy for Graft.
• At least 2 weeks before the anticipated start of
dialysis treatments for Peritoneal Dialisys
PREOPERATIVE EVALUATION
• History
• Physical examination
• USG upper-extremity arteries
and veins,
• Vascular mapping
• Central vein evaluation
(previous catheter or
pacemaker)
PATIENT HISTORY
History of previous CVC
Dominant arm
History of pacemaker use
History of severe CHF
History of arterial or venous peripheral catheter
History of diabetes melitus
History of anticoagulan therapy
History of previous arm, neck or chest surgery traum
all co-morbid conditions.
PHYSICAL EXAMINATION

1.Brachial, radial,
and ulnar arteries
should be
evaluated for
compressibility
and equality
bilaterally.
2.Doppler
evaluation when
indicated
PHYSICAL EXAMINATION

– An Allen test 
evaluate palmar
arch patency.
– Physical
examination of
venous system,
evaluation for
edema
 SELECTION AND PLACEMENT
OF HEMODIALYSIS ACCESS
• Optimize access
survival
• Minimize
complications
• Placed distally
• Upper extremities
when possible
• Considering first:
fistula placement
• Prosthetic grafts if not
possible
 SELECTION AND PLACEMENT
OF HEMODIALYSIS ACCESS
• Preferred: Fistulae
– A wrist (radiocephalic)
primary fistula.
– An elbow
(brachiocephalic) primary
fistula.
– A transposed brachial
basilic vein fistula: (B)
AVG of synthetic or biological material

– A forearm loop graft,

preferable to a straight
configuration.
– Upper-arm graft.
– Chest wall or “necklace”
prosthetic graft or lower-
extremity fistula or graft;
– All upper-arm sites
should be exhausted.
SELECTION AND PLACEMENT OF
HEMODIALYSIS ACCESS
• Avoid if possible: Long-
term catheters.
• Short-term catheters
should be used for acute
dialysis and for a limited
duration in hospitalized
patients. Noncuffed
femoral catheters should
be used in bed-bound
patients only.
• Long-term catheters or
dialysis port catheter
systems should be used in
conjunction with a plan for
permanent access.
SELECTION AND PLACEMENT OF
HEMODIALYSIS ACCESS
• Rapid flow rates are
preferred.
• choice based on
– local experience
– goals for use
– cost
• Long-term catheters should
not be placed on the same
side as a maturing AV
access, if possible.
• Avoiding femoral catheter
access in HD patients who
are current or future kidney
transplant candidates
Fistula
Advantages;
• Lower rate of
complications
• Lowest rate of thrombosis
• Fewest interventions
• Longer survival
• Costs lowest.
• Lower rates of infection
than graftspercutaneous
catheters and
subcutaneous port
systems
Wrist Fistula (Radiocephalic)
• The wrist fistula is the first choice of
access type because of the
following advantages:
– It is relatively simple to create.
– It preserves more proximal vessels
for future access placement.
– It has few complications.
Specifically, the incidence of
vascular steal is low, and in mature
fistulae, thrombosis and infection
rates are low.
• The only major disadvantage of the
wrist (radiocephalic) fistula is a lower
blood flow rate (BFR) compared with
other fistula types
Elbow Fistula (brachiocephalic)
• Second choice
• Advantages
– Higher blood flow
– Easier to cannulate
• Disadvantages
– more difficult to create
– Arm swelling
– Greater incidence
cephalic arch stenosis
Arterial Assessment
• clinical examination
• no pressure gradient between bilateral
extremities
• arterial diameter 2 mm
• patent palmar arch
• evaluated segmental pressures
• USG
Vein assesment
• Using venous duplex imaging
• diameter
• distensibility
• continuity
• minimal diameter 2 mm
ACCESS LOCATION SELECTION
• Goal of AV access procedures is to provide long-term
dialysis access with low risk of complications.
• General principles
– as far distally if possible
– superior patency rate
– lower complication rate
– autogenous AV first before prosthetic AV access
– upper extremity access first, with non- dominant arm
Screen Shot 2013-09-17 at 1.15.35 AM
POSTOPERATIVE FOLLOW-UP
• Should be mature 12 weeks postoperatively,
• prosthetic AV access 2 weeks postoperatively.
• If failing to mature, examined USG followed by
venography
• Secondary procedures :
– open surgical procedures
– vein patches
– interposition vein grafts
– vein transposition
– branch ligations
– vein superficialization
– endovascular
LONG-TERM FOLLOW-UP
• Routinely monitor
• USG Doppler
• Decreased by 25%
over 4 months should
be evaluated with
– usg
– fistulogram
• Short-term Dialysis
Catheters
–double-lumen, noncuffed,
nontunneled chateters that can
be placed at the bedside
without fluoroscopic guidance.
–should be placed in patients
who require acute dialysis
access
–should be used for less than 3
weeks’ duration.
–the internal jugular,
subclavian, or femoral vein
–to achieve the best flow rates,
the distal tip should be placed
in the superior vena cava just
above the atrial-caval junction.
• Long-term Dialysis
Catheters
– double-lumen, cuffed,
tunneled catheters that are
placed with fluoroscopic
guidance and are intended to
be used for weeks to months.
– right internal jugular vein with
the distal catheter tip in the
right atrium left internal
jugular and femoral
– Dialysis catheters should be
placed contralateral to the
side of any maturing or
planned permanent AV
access,
Terima Kasih