Approach to patients with "complex" hemodialysis access problems

Area of Science:

• Vascular Surgery
• Nephrology
• Interventional Radiology

Background:

• Management of complex permanent hemodialysis access is not well-defined.
• Patients with difficult access present unique surgical challenges.

Purpose of the Study:

• To outline an algorithm for patients with complex hemodialysis access needs.
• To address specific complications hindering permanent access creation.

Main Methods:

• Utilizes noninvasive imaging (vascular laboratory) to assess access configurations.
• Employs invasive imaging (venography, arteriography) to confirm optimal access.
• Applies standard vascular surgery principles for arteriovenous fistula (AVF) construction.

Main Results:

• An algorithm is proposed for diagnosing and managing complex hemodialysis access.
• Specific problems like inadequate veins, arterial inflow issues, central vein stenosis, prior failures, and obesity are addressed.
• Native AVFs can be successfully created in most complex cases.

Conclusions:

• A structured approach involving advanced imaging and surgical expertise can overcome complex hemodialysis access challenges.
• Successful creation of permanent hemodialysis access, particularly native AVFs, is achievable in nearly all patients.
• Adherence to fundamental surgical principles ensures optimal outcomes for challenging vascular access cases.