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How to Make Hemodialysis Access Last, and What to Do When it Doesn’t

OCTOBER 29, 2019
Clinical Congress Daily Highlights, Tuesday Early Edition

“The right access for the right patient at the right time” should be the guiding principle in hemodialysis access, said Peter R. Nelson, MD, MS, University of Oklahoma-Tulsa School of Medicine, Tulsa, OK, at the outset of a Tuesday session on the topic.

Arteriovenous fistulas (AVFs) remain the access of choice for low-risk patients, and the first AVF should be placed as distally as possible, to enable more proximal placement of subsequent accesses if the first fails. For higher-risk patients (those expected to survive less than a year), options include an upper arm AVF, arteriovenous graft, or tunneled catheter.

Pre- and intraoperative ultrasound assessments are the gold standard for planning and guiding access surgery. In addition, there are now two U.S. Food and Drug Administration (FDA) approved devices for creating percutaneous AVFs: WavelinQ and Ellipsis. Contingency plans should be made for remedial measures and/or subsequent access approaches in the event the first access fails.

AVFs take six to nine months to mature before they can be used. Elina Quiroga, MD, MPH, University of Washington School of Medicine, Seattle, WA, discussed the management of AVFs that fail to mature properly. She said that physician judgment about whether an AVF is failing to mature well is often intuitive, but also based on physical characteristics such as thrill, pulsatility, and depth.

Anastomotic stenosis and “steal syndrome” (ischemia distal to the AVF) are the most common issues preventing AVF maturation. Both can be addressed using balloon-assisted maturation (repeated balloon angioplasty).

Ellen D. Dillavou, MD, Duke University School of Medicine, Durham, NC, discussed how to manage stenosis and occlusion of central venous accesses. First-line therapy for stenosis is balloon angioplasty, which has now been refined through the use of drug-coated balloons. Dr. Dillavou believes these are “a game-changer that will become the standard of care.”

Most central venous access occlusions can be traversed for access replacement. For patients with limited options (such as those with only one vein, and that vein containing a tunneled catheter), HeRO grafts and immediate use grafts allow for immediate hemodialysis access.

Manuel Garcia-Toca, MD, Stanford University School of Medicine, Palo Alto, CA, discussed guidelines for access surveillance and repair. He said that angioplasty with balloons or stents is the initial treatment of choice for access stenosis, but that recurrence is common.

Dr. Garcia-Toca said that “intimal hyperplasia is the Achilles’ heel of failing hemodialysis access.” However, repeated angioplasty can result in a vicious cycle of stenosis and repair. Better understanding of the biological mechanisms of vascular remodeling will help improve access success rates.

Sherene Shalhub, MD, MPH, University of Washington School of Medicine, Seattle, WA, discussed the two major non-thrombotic complications of arteriovenous access: steal syndrome and AVF aneurysm.

Dr. Shalhub described the clinical features of grades 1, 2, and 3 steal syndrome, and said it is best addressed with distal revascular interval ligation or proximalization of the arterial inflow. In the case of AVF aneurysms, it is not necessary to intervene as long as the AVF continues to function well. If the AVF fails, then the options are angioplasty and open surgery.

Additional Information:

The Panel Session, Current Options in the Management of Hemodialysis Access, was held Tuesday, October 29 at the American College of Surgeons Clinical Congress 2019 in San Francisco (program, webcast and audio information).