Related Experiment Videos
[Vascular access for chronic hemodialysis: current status and new directions in the Piedmont]
F Quarello1, G Forneris, R Boero
1Divisione di Nefrologia e Dialisi, Azienda Regionale USL 4, Ospedale G. Bosco, Torino.
Insights
Vascular access for dialysis patients is critical, especially for the elderly. While arteriovenous (AV) fistulas are preferred in some regions, synthetic grafts are common in the US, with jugular vein catheters showing promise for specific situations.
Area of Science:
- Nephrology
- Vascular Surgery
- Dialysis Access
Background:
- Long-term dialysis and an aging patient population increase the demand for reliable vascular access.
- The choice of vascular access varies geographically, with implications for patient outcomes.
- High-risk patients and extended dialysis duration necessitate careful consideration of access type.
Purpose of the Study:
- To analyze the current landscape of vascular access methods for uremic patients.
- To evaluate the efficacy and limitations of different dialysis access types, including AV fistulas, synthetic grafts, and central venous catheters.
- To assess the potential role of internal jugular vein catheters in specific clinical scenarios.
Main Methods:
- Review of vascular access utilization patterns in uremic patients.
- Analysis of data on the prevalence of arteriovenous fistulas (AV fistulas), PTFE/bovine grafts, and other access types.
- Evaluation of preliminary data on internal jugular vein catheter (Canaud/Tesio catheter) outcomes, including permanence and complication rates.
Main Results:
- Arteriovenous fistulas, particularly Cimino-Brescia fistulas, are the predominant access in some regions (e.g., Piedmont, ~90%), while synthetic grafts (PTFE/bovine) are more common in the USA (~75%).
- The use of synthetic grafts increases with patient age and time on dialysis.
- Internal jugular vein cannulation showed a preliminary permanence rate of ~55% in 51 cases, but high rates of systemic (9.8%) and exit site infections (13.7%) were noted, suggesting limited long-term use.
Conclusions:
- Arteriovenous fistulas remain a preferred vascular access method due to their long-term efficacy.
- The selection of vascular access should be tailored to individual patient factors, including age, comorbidities, and dialysis duration.
- Internal jugular vein catheters may serve a role as a temporary or bridge access in selected cases, but infection risks necessitate careful management and limited dwell times.
Abstract:
Long survival on dialysis and wide admissions of very old and high risk patients, have focused attention to the problem of vascular access in uremic patients. The situation is critical in the USA, where PTFE/bovine grafts are utilized in about 75% of the cases. conversely, AV fistulas are the main type of access in Piedmont, where their use approaches 90% of the cases, Cimino-Brescia fistulas account for 58% of vascular accesses versus 25% and 9% of proximal AV fistulas and PTFE/bovine grafts, respectively. However, the latter progressively increase as age and time on dialysis increase. Snuff box fistulas are used only for 3% of the cases and this figure is steadily decreasing. In the meanwhile basilic vein superficializations, even if limited in numbers (1%), provided in some centres satisfactory results in term of survival and function. However, the type of access that deserved in the last few years the highest interest is the internal jugular vein cannulation (Canaud/Tesio catheter). In a preliminary series of 51 cannulations in 47 patients, this vascular access was permanent in 28 cases. A possible future routine utilization of jugular vein catheters is advisable in cases where a waiting period (up to a few months) is requested to allow a new fistula to mature or to maintain an empty abdomen in a patient temporarily withdrawn from peritoneal dialysis. Due to the heavy engagement for catheter maintenance and the high number of removals for systemic (9.8%) or skin exit infections (13.7%), a longer stay of indwelling catheters, although actually safe, should be limited to selected cases.