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Approach to patients with "complex" hemodialysis access problems
Thomas S Huber1, James M Seeger
1Division of Vascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610, USA. Huber@surgery.ufl.edu
Insights
This review presents an algorithm for managing complex permanent hemodialysis access, emphasizing imaging and surgical principles to create arteriovenous fistulas (AVFs) even in challenging cases.
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.
Abstract:
The approach to patients with "complex" permanent hemodialysis (HD) access problems remains poorly defined. The purpose of this review is to outline our current algorithm for patients presenting for dialysis access and to address the management of specific problems that complicate this objective of establishing permanent access. The key components of the algorithm include noninvasive imaging in the diagnostic vascular laboratory to determine all the possible access configurations and invasive imaging with both venography and arteriography to confirm the optimal choice. The specific access-related problems addressed include inadequate ipsilateral vein, inadequate arterial inflow, central vein stenosis/occlusion, multiple previous access failures, and obesity. Despite the label of "complex" access problems, it is possible to construct native arteriovenous fistulas (AVFs) in almost all patients presenting for access using the standard principles of vascular surgery that are based on establishing adequate arterial inflow, adequate venous outflow, and selecting an appropriate conduit.