Dialysis access

KDOQI guidelines

  • Fistula first — catheter last coalition
    • fistula is the most durable access
  • Rule of 6s for AVF maturation:
    • >600 mL/min
    • <6 mm below skin surface
    • min diameter 6 mm
    • maturation 6 weeks minimum

Anatomic components

  • inflow artery
  • outflow vein
  • AVF juxta-anastomotic region- within 4 cm of the anastomosis
  • avg- arterial limb, apex, venous limb

Preoperative evaluation:

Ultrasound needed -

Arterial luminal diameter >=2 mm. Palmar arch complete. High origin of radial May cause delayed maturation.

Venous luminal diameter >=2.5 for avf, 4mm for avg. uninterrupted outflow needed. Paired brachial vein usually good for BC fistula interposition.

Transposition fistula after maturation

Loop Grady, C graft, necklace graft

central vein stenosis - only treat if symptomatic

steal syndrome - arterial flow only going into fistula.

Drill procedure

Miller Branding procedure.

Megafistula- >2L/min. 3/4 L per minute- high output cardiac fistula.

radial artery aneurysm - from access of the radial artery

angioplasty >50% stenosis

When to stent- flow limiting dissections or major vascular rupture. Suboptimal angioplasty or recurrence within 3 months. Pseudosneurysms.

Percutaneous fistula placement

Contributing Authors

BGG, Kevin Liu