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Djony Edward, SpB.

(K) V
 Definition  VA for hemodyalisis
 Epidemiology and Opportunity  VA for chemotherapy
 Indication  VA for nutrition
 Contraindication  US guided insertion technique
 Anatomy
 Historical Development
 Site of intertion
Vascular Access
 Definition

 insertion of
catheter into the
vessel (artery or
vein) for certain
Epidemiology and Opportunity
Epidemiology Opportunity
 20 million patient’s  receive  The creation and maintenance of
vascular catheters per year functioning vascular access, along
with the associated complications,
 3 million central venous
constitute the most common cause
catheters/yr of morbidity, hospitalization, and
 2030: 2.24 million patients with cost in patients with end-stage renal
ESRD. disease
 Aging population with diabetes
increase  ESRD patient
 Annual cost in USA 1 billion US
Indication and
Indication Relatif contraindication
1. Hemodialysis ✺ Coagulopathy
2. Chemotherapy ✺ Allergy to the catheter material
3. Nutrition
4. Fluid administration ✺ Mediastinal tumor

5. Drugs administration ✺ Skin infection at implantation

6. Blood transfusion site
7. Antiviral therapy
8. Pain management
Anatomy and Surgical Landmark
Historical Development in VA
 <1970 catheter made from semirigid polyvinil chloride
 1973 Broviac barium impregnated silicon rubber cathether with
subcutaneous tunnelling for long term nutrition.
 Less thrombogenic
 Dacron Cuff  stimulate fibrosit growth in subcutaneous tissue 
prevent/barrier for bacterial invasion.
 1979 Hickman  modified Broviac catheter for chemotherapy.
 1980  developed totally implantable catheter system.
 First researched by Niederhuber (1982)
 CDL advance not only for hemodialysa but also for chemotherapy
 Current advancement: catheter more thin and port
material become smaller and can be inserted in
basilic and cephalic vein.
 Position guided by electromagnet unit, no need
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
 Lower Resistance
 Improved Bloodflow
Hemodialysis access
 K DOQI guideline:
 Native AV fistula is the preferred permanent HD
 Native AV fistula target  >50%
 CDL target  < 10%
 Risk of infection:
 CDL non tunnelled 8x more higher than native fistula
 CDL tunnelled 5x more higher than native fistula
 Mortality: CDL 1.31x more higher than native
 CDL insertion before AV fistula at ipsilateral
side increased risk of AV fistula failure.
Am Journal Kidney Disease 2004
DOPPS I (1997-99) and DOPPS II
Type of Hemodialysa Access
 Short term catheter
 Long term catheter
 Double port catheter
 Permanent
 Native AV fistula
 Graft AV fistula
Vascular Access with
 Immediate access.
 associated with higher risks.
 shorter than that of AVFs.
 Noncuffed catheters
 Cuffed catheters
 Short term: <3 weeks
 Patients who will require long-
term access should have a
tunneled catheter placed.
 allow so-called no-needle
dialysis with high flow rates
 eliminate the problem of
vascular steal
 placed in a subcutaneous tunnel
under fluoroscopic guidance
Vascular Access
 Match catheter size to patient size and anatomical site
 Sites
 femoral
 internal jugular
 avoid sub-clavian vein if possible
Vascular Access for hemodialysa:
Femoral Site
 Relatively larger vessel  Shorter femoral catheters
may allow for with increased %
 larger catheter recirculation
 higher flows  Poor performance in
 Ease of placement patients with
 No risk of pneumothorax ascites/increased abdominal
 Preserve potential future
vessels for chronic HD  Trauma to venous
anastamosis site for future
Vascular Access for hemodialysa:
Internal Jugular/Subclavian Vein Site
• Tip placement in right  SCV stenosis (SCV)
atrium decreases
recirculation  Superior vena cava syndrome
• Not affected by ascites  Risk of pneumothorax in
• Preserve potential vein patients with high PEEP
needed for transplant  Trauma to veins needed
potentially for future HD
Femoral versus Internal Jugular catheter
Type Number Qb (ml/min) Recirculation(%) 95% CI

Femoral 26 237.1 13.1* 7.6 to 18.6

> 20cm 19 233.3 8.5** 2.9 to 13.7

< 20cm 7 247.5 26.3** 17.1 to 35.5

Jugular 13 226.4 0.4* -0.1 to 1.0

* p<0.001
** p<0.007

Little et al: AJKD 36:1135-9, 2000

NEONATE Single-lumen 5 Fr (COOK) Femoral artery or vein
Dual-Lumen 7.0 French Femoral vein
3-6 KG Dual-Lumen 7.0 French Internal/External-Jugular,
(COOK/MEDCOMP) Subclavian or Femoral vein
Triple-Lumen 7.0 Fr Internal/External-Jugular,
(MEDCOMP) Subclavian or Femoral vein
6-30 KG Dual-Lumen 8.0 French Internal/External-Jugular,
(KENDALL, ARROW) Subclavian or Femoral vein
>15-KG Dual-Lumen 9.0 French Internal/External-Jugular,
(MEDCOMP) Subclavian or Femoral vein
>30 KG Dual-Lumen 10.0 French Internal/External-Jugular,
(ARROW, KENDALL) Subclavian or Femoral vein
>30 KG Triple-Lumen 12.5 French Internal/External-Jugular,
(ARROW, KENDALL) Subclavian or Femoral vein
Pediatric CRRT Vascular Access:
Performance = Blood Flow
 Minimum 30 to 50 ml/min to minimize access and
filter clotting
 Maximum rate of 400 ml/min/1.73m2 or
 10-12 ml/kg/min in neonates and infants
 4-6 ml/kg/min in children
 2-4 ml/kg/min in adolescents
Vascular Access via Arteriovenous
 The ideal vascular access
 permits a flow rate that is adequate for the dialysis
prescription (³ 300 ml/min),
 can be used for extended periods,
 and has a low complication rate.
 The native AVF remains the gold standard
Arteriovenous fistulas
 The standard by which all other fistulas are measured, is the
Brescia-Cimino fistula. (2 year patency: 55% to 89%)

•radial branch-cephalic direct access

(snuffbox fistula),
•autogenous ulnar-cephalic forearm
•autogenous brachial-cephalic upper
arm direct
•access (antecubital vein to the brachial
•autogenous brachial-basilic upper arm
transposition (basilic vein transposition).

These options should be exhausted before

nonautogenous material is used for dialysis access.
radiocephalic fistula radiocephalic fistula (Brescia-
(anatomic snuff-box) Cimino)
Vascular access via AVFs:
 brachiocephalic fistula  brachiobasilic fistula
Prosthetic Grafts for vascular access

 Upper arm grafts have a high flow rate and a low incidence
of thrombosis.
 higher incidence of ischemia in the hand
 higher rate of stenosis, secondery to endothelial
Pros and Cons of
Catheter as Access Types
 Pro  Contra
 No cannulation  high risk of bacteremia
 less flow volume (through
dialyzer ml/min)
 high potential for central
vessel occlusion
cannot shower/swim
Pros and Cons of
Fistula as Access Types
 Pro  Contra
 minor surgery  high initial failure rate
 little dysfunction attributable  flows initially not better
 very low risk of infection than catheter
 longest average patency of all  initially difficult to
access types cannulate
 seals and heals post
Pros and Cons of
PTFE Grafts as Access Types
 Pro  Contra
 moderately low risk of  more traumatic surgery
infection  edema/pain
 can be used in 2-3  life patency mean
weeks 18mths-2yrs
 low initial failure rate
 flows reliably high
 initially easier to
cannulate & monitor
The Reality of Vascular
 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
 DOQI guidelines make fistulae the access of choice
Attributes to facilitate
• Placed or transposed in an accessible body part
• Superficiality of graft or vein - easily palpated and
• tunneled in an even plane
• tunneled with gradual curves
• should provide reasonable amount of accessible surface
area to allow rotation of needle sites
Collaborative Care of
Vascular Access
 Surgeons have a role as vascular access advocates
 diagramming new accesses
 communicating specific access orders directly to the
 visiting the dialysis units to do patient & staff education
and to familiarize staff c surgeon’s point of view
 be readily accessible for consultation
Nutrition and
Chemotherapy VA
 Perypheral IV access: For Peripheral TPN, maximum

allowed osmolarity is 900 mosm/L.

 Central (total) Parenteral nutrition

 Chemotherapy infusion
Complication of perypheral
 Extravasation The
leakage of high osmolarity
solutions or chemotherapy
agents can result in
significant tissue
destruction, and
significant complications
Risks/Benefits of CVC Placement
 Indications for central  Contraindications for
venous catheter (CVC) placement of a CVC
 Inadequate peripheral  Altered skin integrity
vascular access  Anomalies of the central vasculature
 Cancer at the base of the neck
 Need for frequent vascular
 Cancer at the apex of the lung
 Immunosuppression, septicemia
 Hypertonic/hyperosmolar  Problems with coagulation
infusions  Clavicle fracture
 Infusion of irritating or  Hyperinflated lungs
vesicant drugs  Radiation to the insertion site area

 Rapid absorption and  Superior vena cava syndrome

 History of venous access device
blood/tissue perfusion
 Long-term IV therapy

Central Catheter Positioning
 Catheter tip should terminate in the superior vena cava
 Catheter tip must never rest within the right atrium
 Could traverse the sinoatrial (SA) node
 Dysrhythmia

 May become trapped in the tricuspid valve

 Permanent damage of the valve
 Requires valve replacement

 Proper positioning in the superior vena cava provides –

 Optimum dilution of infusates
 Large volume infusate administration
 Rapid administration when needed

Main types of Central Venous
Access Devices

 Centrally inserted catheters

 Peripherally inserted catheters
 Centrally implanted ports
 Peripherally inserted ports
1. Peripherally IV line  < 1 week
2. Non Tunnelled CVC  5 – 7 days
3. Peripherally Inserted CVC (PICC)  7 days until month
4. Skin tunnelled CVC  > 6 months
5. Subcutanoues port Totally implantable  > 6 months
Types of Cavafix
PICC Lines
 Single or multilumen
 Usual dwelling time: 1-12 weeks
 Made of silicone or
 Length from 33 to 60 cm
 Decreases the risk of air
embolism and prevents the need
for frequent venipuncture
 Preserves peripheral vasculature
 Appropriate for home IV therapy

PICC dressing
Totally implantable vascular access


 Jenis ini menjadi pilihan utama untuk kebutuhan akses

vaskuler permanen dalam jangka waktu lama.

 Implanted port terdiri dari portal body, septum, reservoir,

dan catheter.

 Cocok untuk pemakaian lebih jarang dalam jangka waktu

 Untuk bolus injeksi atau pengambilan darah pada
sistem ini digunakan jarum khusus: non coring
needle (Huber needle)

 Jarum khusus ini memiliki lubang di sisinya

 Non-coring needles memiliki alat didalamnya untuk

mencegah rebound needlestick injury.
3 generasi access ports:
 1st : 100% All metal Access ports
 Port-A-Cath (Smith Pharmacia)

 2nd : 100% Plastic Access ports

 Implantofix II
 Infusaid
 Bard MRI
 Infuse-A-Port (Pfizer)

 3rd : Combination Titanium-Plastic

 Celsite®
 Bard
 Port-A-Cath II (Smith/Sims )

Upper chest: Lower chest:

venous access peritoneal,
venous access
arterial or
spinal access
Ultrasound guided vascular

“In hospitals where US equipment

is available and physicians have
adequate training, the use of US
guidance should be routinely
considered for cases in which IJ
venous catheterization will be
McGee DC, Gould MK. Preventing Complications of Central Venous Catheterization. NEJM 2003;348:1123-33
Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein – a prospective comparison to the external landmark-guided
technique. Circulation 1993;87:1557-62
Ultrasound guided vascular
 Internal Jugular Vein  Femoral Vein

 Denys et al “randomized”  US technique slightly faster

patients to IJ  US more successful than
 US guided=928, landmark technique
 Landmark=302  90% vs 65%, p=0.058
 Overall success 100% vs 88.1%  Lower rate of arterial
 First attempt success 78% vs cannulation with US
38%  0% vs 20%, p=0.025
 Skin to vein time 9.8 (2-68) vs 44.5
(2-1000) sec

 Carotid puncture 1.7% vs 8.3%

Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Annals of Emergency Medicine
Ultrasound access techniques
 “Static”  “Dynamic”
 mapping technique  views needle entering vein
 freehand
 no sterile technique  needle guide
required for US  requires sterile technique
 Position patient as you will for  Place gel in palm of sterile glove
procedure  Place vascular probe in palm, avoid
 Look at vessels and confirm trapped air bubbles, and wrap free
landmark-predicted anatomy fingers out of way
 Mark location, note depths and  Sterile KY jelly for glove-skin
angles interface
 Remove ultrasound, prep patient  Two potential approaches:
without moving  Transverse
 Vein cannulated as usual  Longitudinal
Internal jugular
Femoral vein
thank you