1. Chapter 26

2. Dialysis PD vs HD 300,000 patients in the US on HD Destination therapy for most patients Increasing rates of DM and HTN in the US Upper extremity is preferred site for permanent access. Stays cleaner; more comfortable

3. Patient population High incidence of CRF, which is increasing Some patients will present with pre- existing access Issues with long-term access: thrombosis; infection; aneurysm Percutaneous access for new RF patients and those with access problems

4. So where do you place it? IJ Femoral Subclavian Why? Why not? What are your concerns for these sites?

5. Question(s) Incidence of thrombosis or stenosis in SUBCLAVIAN HD caths: A. 10% B. 30% C. 40% D. 70% Incidence of thrombosis or stenosis in IJ HD caths: A. 10% B. 30% C. 40 % D. 70%

6. Answer (s) Subclavian 50-70% IJ 0-10%

7. Subclavian: If stenosis occurs: Small percentage spontaneous recanalization after 3-6mo Angioplasty Stents Venous flow is never renormalized in the extremity

8. Graft function Highly dependant on venous outflow Decreased outflow can cause severe edema Wounds, breakdown, nerve injury, etc.

9. True / False A smaller (7 FR TLC, 9 FR introducer) line decreases the chance of injury and subsequent stenosis / thrombosis of the subclavian vein A. TRUE B. FALSE

10. TRUE... but Decreased incidence, but does still occur enough to be clinically relevant Subclavian approach should be avoided in patients who currently require or may in future require HD access, no matter the line size.

11. Quick nomenclature stuff Quinton (Permacath) - Non-tunneled HD cath Hickman – tunneled HD cath Port-a-cath – subcutaneous silicone septum

12. Take home points: The rates of both CRF and antecedent HTN and DM are on the rise in the US Many of these patients will eventually require HD access Because of the risk of vessel injury, thrombosis or stenosis, the SC vein should be avoided if possible for line placement in these patients, especially HD catheters.