1.

Hemodialysis
a. Poor arterial inflow leads to low flow volumes within the fistula
b. Regional anesthesia is associated with better flow in the fistula
c. Banding of AVF should only done if high output cardiac failure
i. Another option is the re-sit the anastomosis distally
d. Button-hole has decreased hematoma risk, but increased infection risk.
e. AVG’s are more expensive in the long run due to increased need for declots.
i. AVFs are cheapest
f. Short term anti-platelet therapy decreases risk of early thrombosis.
g. Regardless of method of therapy, open vs endovascular, lower extremity
revascularization in dialysis patients resulted in poorer amputation-free survival at
2 years compared with patients without end-stage renal disease.
i. This study suggests that the poor results of lower extremity
revascularization in patients with end-stage renal disease (ESRD) are not
influenced by the method of treatment.
ii. Open and endovascular repair should be used as complimentary options.
iii. Type of treatment therefore may be based on individual risk estimation
and lesion characteristics.
1. Analysis of reintervention rates revealed no remarkable differences
after 24 months between ESRD and non-ESRD
h. Autogenous Access Cellulitis:
i. The standard duration for antibiotics given to treat access-related cellulitis
is 2 to 4 weeks.
ii. Extended oral antibiotics can be given for 4 to 6 weeks in the presence of
a stent.
iii. Cellulitis can usually be treated with a short course of antibiotics.
i. Ischemic Monomelic Neuropathy
i. The complication is seen almost exclusively in diabetic patients and
presents immediately after creation of an arteriovenous access in the
brachiocephalic (more common) or antecubital position.
ii. IMN is characterized by acute pain and weakness or paralysis of the
forearm and hand muscles; it is often accompanied by sensory loss.
Affected patients frequently have wrist drop.
iii. In contrast to vascular steal syndrome, the hand is often warm and the
radial pulse may be palpable.
iv. The underlying cause is sudden diversion of the blood supply to the nerves
of the forearm and hand with resulting injury to nerve fibers.
v. Untreated patients develop a claw-hand deformity
j. Primary and secondary patency rates for autogenous arteriovenous accesses are
higher than those for prosthetic arteriovenous grafts. In addition, prosthetic
arteriovenous grafts require more interventions than autogenous fistulas to
maintain secondary patency
k. Diabetes mellitus negatively impacts maturation and primary patency rates for all
autogenous AV accesses.
l. The proximal radial artery can provide excellent inflow for autogenous and
prosthetic arteriovenous accesses.
 i. This option can be used in diabetics even in the presence of extensive
calcification of the distal radial and ulnar arteries at the wrist.
ii. Ischemic complications are minimized with proximal radial artery inflow
when compared to use of the brachial artery for inflow.
m. The optimal study to establish the diagnosis of arterial steal is digital
plethysmography with and without compression of the fistula. Once the diagnosis
and its severity is established, a treatment algorithm can be applied.
n. Late thrombosis and failure of arteriovenous fistulas for dialysis access is often
associated with intimal hyperplasia in the fistula at the site of cannulation or
venous anastamosis
i. Many studies have reported a higher incidence of early and late fistula
failure in smokers.
ii. Chronic hypotension, a low mean diastolic pressure, has been correlated
with poor AV fistula survival in prospective series.
o. Current guidelines recommend placement of autogenous access, if feasible, in
patients with GFR < 25 ml/min.
i. However, if autogenous access is not feasible and prosthetic access is
required, placement should be delayed until 4 to 6 weeks before the
initiation of hemodialysis, or when GFR < 10ml/min
p. Access failure that occurs within 30 days of surgery is defined as early access
failure. In the absence of a technical failure, such as a twisted or stenotic
anastomosis, it is most commonly associated with inadequate venous outflow
which may be secondary to inadequate caliber of the outflow vein or central
venous stenosis.
i. However, in patients with early failure, also asses presence of distal pulse,
since 40% of patients have inflow disease as the result of failure
ii. The most common causes of early failure, within 30 days, are most
commonly due to technical error, followed by venous (inadequate ouflow
vein size, or central stenosis), followed by arterial stenosis within the
access circuit and then followed by presence of accessory veins.
1. Angioplasty of the arterial or venous stenosis can result in long-
term graft salvage in the vast majority of cases.
q. AV access should be monitored routinely while on dialysis; the preferred method
of monitoring is monthly determinations of access flow by ultrasound dilution,
conductance dilution, thermal dilution, or Doppler technique.
i. Access flow less than 600 mL/min, or access flow less than 1000 mL/min
which has decreased by 25% over 4 months, should be further evaluated
with duplex surveillance followed by fistulagram
ii. Routine duplex surveillance may identify hemodynamically significant
stenosis of an AV access.
1. However, without any flow limitations noted on dialysis there is no
long term benefit to prophylactic repair.
r. Steal Syndrome:
i. Treatment of the proximal artery alone with either endovascular or open
surgical techniques may resolve symptoms.
 ii. In patients without proximal arterial stenosis or who do not resolve their
symptoms with treatment of the inflow stenosis surgical options include:
1. Banding of the access outflow tract increases the resistance in the
fistula.
a. However, it may be difficult to judge the degree of stenosis
required to alleviate the steal without causing thrombosis of
the access.
2. Distal revascularization with interval ligation (DRIL) involves
ligation of the arterial outflow tract just distal to the arterial
anastomosis, followed by a bypass from the artery proximal to the
anastomosis to the artery distal to the area of ligation.
a. The DRIL procedure is effective in treating ischemic pain
and tissue loss, but may be less effective for neurologic
deficits that have already occurred.
s. Central venous stenosis should be suspected if there are any prominent venous
collaterals or edema, a differential in extremity diameter, any history of previous
central venous catheters, or multiple previous accesses in the planned extremity to
be used for access. If any of these abnormalities are identified, the patient should
be further evaluated with either deep venous duplex or venography. 
t. Pacemaker and defibrillator leads commonly result in fibrotic stenosis of the
central venous subclavian vein
i. Thus prior to fistula creation, a ipsilateral venogram should be done to
evaluate for central venous stenosis
ii. venography should be performed prior to or during the access construction
so that any significant venous outflow lesion can be treated with
angioplasty and adjunctive stenting to prevent venous hypertension,
congestion, and inadequate dialysis.
iii. Caution should be observed when stenting in proximity to pacemaker or
defibrillator leads since stent contact can be damaging to the leads.
u. Perigraft seromas consist of sterile, clear, ultrafiltered serum surrounded by a
fibrous tissue pseudocapsule
i. The underlying cause is failure of the synthetic graft to become
encapsulated.
ii. For recurrent perigraft seromas, the treatment is removal of seroma and
replacement of the affected of the graft
iii. Perigraft seromas may lead to graft infection, skin necrosis, graft
thrombosis, or loss of graft puncture area.
iv. Some perigraft seromas resolve spontaneously but most require
intervention.
1. Removal of the seroma and replacement of the involved portion of
graft have the highest cure rate.
v. High-output cardiac failure
i. Cardiac effects seen in all renal patients with AVFs include increased left
ventricular end-diastolic dimensions and left ventricular hypertrophy,
which are usually reversed with fistula closure.
 ii. In a small percentage of patients with risk factors for high-output CHF in
patients with AVF include underlying cardiac disease, anemia, upper arm
AVF (vs. forearm), male sex, and an upper arm fistula in the same arm as
a previously functioning forearm fistula.
iii. Treatment of high-output CHF in patients with high-flow AVF should be
directed at reducing peripheral resistance
1. Ligation of the fistula has been used to manage this condition, but
results in loss of access.
2. Banding of the fistula has been recommended, using intraoperative
measures of fistula flow to assess efficacy.
3. Re-siting the AV anastomosis to a smaller, distal artery has been
used successfully to reduce fistula flow
w. Uremic Bleeding:
i. Template Bleeding Time is a reliable test to determine patients at risk for
bleeding.
ii. Management of acute bleeding should include administration of 1-
deamino-8-D-arginine vasopression (DDAVP) as a single dose (0.3 μg/kg
IV added to 50 mL of saline over 30 minutes).
1. DDAVP provides a hemostatic effect that is maximal at 1 hour and
lasts 4-6 hours.
x. Brachiocephalic arteriovenous fistulas offer several advantages over radiocephalic
arteriovenous fistulas, including a higher maturation rate, decreased time to
maturity, and higher primary patency and functional primary patency.
i. Despite these benefits, radiocephalic fistulas are generally preferred if
there is adequate conduit available to prolong sites for future access
placement, as many patients are on long-term dialysis and need all access
options preserved
y. Arteriovenous accesses created ipsilateral to an AICD have a higher primary
failure rate compared with the contralateral arm and should be avoided as much as
possible.
i. If adequate vein is unavailable in the contralateral arm, it would be
appropriate to consider a venogram to assess patency of the central veins.
z.

aa. Lower extremity access creation is an excellent option and is indicated in the
presence of upper extremity central venous occlusive disease.
 i. HeRO Grafts have inferior patency rates compared to autologous lower
extremity fistula creation in the setting of upper central venous occlusion
1. However, should still be considered prior to moving to the lower
extremity.
ii. Studies have demonstrated the best outcomes for femoral vein
transpositions. Patients undergoing femoral vein transpositions should
have minimal to no peripheral arterial disease or ischemic symptoms of
the lower leg can develop after the fistula is created.
iii. Saphenous vein transpositions are another option and have superior
patency to synthetic grafts.
bb. Studies for single-stage vs 2-stage BVT has showed no difference in failure rates,
primary or secondary 1-year patency, or secondary 2-year patency.
i. However, there was a significant improvement in 2-year primary patency
in the two-stage group
ii. There was is a trend toward increased postoperative thrombosis in the one-
stage procedure, although that did not reach statistical significance.
cc. HeRO Graft:

i.
dd. Flow rate of the fistula can help determine the type of treatment option for steal
syndrome.
i. For high flow fistulas, it is likely that the access is causing the problem
itself.
ii. Low flow rates may indicate an underlying inflow arterial issue that needs
to be addressed.
iii. Reversal of flow is neither necessary nor sufficient to cause distal
ischemia, since is also commonly seen after access creation as physiologic
steal phenomenon
ee. Greater than 50% stenosis of the inflow artery associated with a non-functioning
AVF is considered significant and should be treated.
ff. Tapered grafts are often used with the intent of decreasing the incidence of
ischemic steal.
i. Recent studies have demonstrated that tapered grafts for upper extremity
access do not affect primary patency, development of steal, or
complication rates. 
gg.  Translumbar IVC catheters placed for hemodialysis have risk of catheter
migration into the subcutaneous tissues in obese patients.
i. Obesity in considered a relative contraindication to this approach.