SURGICAL MANAGEMENT OF DIALYSIS ACCESS STEVE WORATYLA, MD SURGICAL SPECIALISTS OF LANCASTER

 1. CENTRAL VENOUS CATHETERS  TEMPORARY  TUNNELLED (CUFFED)  2 ARTERIAL VENOUS GRAFTS  PROSTHETIC  PTFE (GORTEX)  VECTRA (immediate access)  HeRO graft  BIOPROSTHESIS  BOVINE CAROTID ARTERY  3. ARTERIAL VENOUS FISTULAS  4. PERITONEAL CATHETERS

Historical Background Era of modern dialysis began in the 1960’s with the creation of the radio-cephalic av fistula

 Use best vein and best artery available  Usually upper extremity (vein map preop)  Cephalic vein and Basilic vein  Radial artery and Brachial artery  Start distal and work proximal in the arm  Requires 6-8 weeks for maturation  Allows vein to dilate and thicken  80-85% success rate (supports dialysis)  May be improved with aggressive followup program  Physical exam, ultrasound, Fistulogram

 Lower cost  Lower morbidity  Lower mortality

 Nomenclature : Artery-Vein  Radial-Cephalic  Radial-Basilic  Brachial-Cephalic  Brachial-Basilic  Brachial-Brachial  Transposing Vein to more superficial and accessible location  Basilic Veins  Deep Veins

 Brachial artery to antecubital vein  Forearm loop graft  Radial artery to antecubital vein  Brachial artery to Axillary vein  Axillary artery to Axillary vein

 Thrombosis  Stenosis  Pseudoaneurysm  Infiltration  Infection  Bleeding  Poor maturation  Tortuosity  Depth of AVF  Steal syndrome

 Autologous AV Fistula is best  Requires good communication and planning between Nephrologist, Patient, and Surgeon  Peritoneal dialysis catheter is viable alternative to hemodialysis in most patients  Requires more active patient involvement  Avoid CVC’s and PICC’s  Central venous stenosis is achilles heel of upper extremity AV access