1. The Dialysis Patient Access Kidney Transplantation Anne Lally, MD Surgical Director of Kidney Transplantation Hartford Hospital

2. Dialysis options for renal failure

3. Dialysis Access Catheters Catheters Fistulas Fistulas Grafts Grafts Peritoneal Dialysis Catheters Peritoneal Dialysis Catheters

4. Hemodialysis access options

5. Dialysis Catheters Temporary and Permanent

6. Tunneled Catheters Several sites can be used: Several sites can be used: Right / Left Internal jugular vein Right / Left Internal jugular vein Femoral vein Femoral vein Subclavian Vein ( higher central v. stenosis ) Subclavian Vein ( higher central v. stenosis ) Rarely the IVC is accessed through the translumbar Rarely the IVC is accessed through the translumbar or transhepatic approach or transhepatic approach

7. Perm Cath Right internal jugular vein preferred (more direct route to heart)

8. Perm Cath for Hemodialysis

16. Vascular Anatomy AVF and Forarm loop

17. Mature Wrist Arteriovenous Fistula

21. Vein Transpositions Additional Considerations Additional Considerations Cephalic and basilic veins not suitable on mapping, consider the brachial vein. Cephalic and basilic veins not suitable on mapping, consider the brachial vein. If brachial vein is suitable, do a two stage transposition because of the small size of the vein and the likelihood of injury. If brachial vein is suitable, do a two stage transposition because of the small size of the vein and the likelihood of injury. One stage basilic or cephalic vein transposition require an extended period of maturation. Plan ahead. One stage basilic or cephalic vein transposition require an extended period of maturation. Plan ahead.

22. Strategies to Increase Autogenous Fistulae Vein Transposition A-V Fistulae Vein Transposition A-V Fistulae Superficialize Superficialize Safe position for cannulation Safe position for cannulation Away from incision Away from incision

24. Mature Basilic vein

25. Transposition of basilic vein

28. Angioplasty, stent placement

29. Covered intravascular stent

30. Cryopreserved cadaver femoral vein Use in patients with multiple failed access Use in infected patients Must reverse because of valves Stenosis tend to be at the venous anastomosis in the cad vein

31. Cryopreserved cadaver femoral vein We do not recommend percutaneous thrombolysis for this conduit. Potential to increase a patient’s PRA and make transplantation more difficult. Only have to match blood type, no immunosuppression.