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Review
. 2014 Jul 8:7:281-94.
doi: 10.2147/IJNRD.S46643. eCollection 2014.

Vascular access for hemodialysis: current perspectives

Domenico Santoro  1 , Filippo Benedetto  2 , Placido Mondello  3 , Narayana Pipitò  2 , David Barillà  2 , Francesco Spinelli  2 , Carlo Alberto Ricciardi  1 , Valeria Cernaro  1 , Michele Buemi  1
Affiliations
Review

Vascular access for hemodialysis: current perspectives

Domenico Santoro et al. Int J Nephrol Renovasc Dis. .

Abstract

A well-functioning vascular access (VA) is a mainstay to perform an efficient hemodialysis (HD) procedure. There are three main types of access: native arteriovenous fistula (AVF), arteriovenous graft, and central venous catheter (CVC). AVF, described by Brescia and Cimino, remains the first choice for chronic HD. It is the best access for longevity and has the lowest association with morbidity and mortality, and for this reason AVF use is strongly recommended by guidelines from different countries. Once autogenous options have been exhausted, prosthetic fistulae become the second option of maintenance HD access alternatives. CVCs have become an important adjunct in maintaining patients on HD. The preferable locations for insertion are the internal jugular and femoral veins. The subclavian vein is considered the third choice because of the high risk of thrombosis. Complications associated with CVC insertion range from 5% to 19%. Since an increasing number of patients have implanted pacemakers and defibrillators, usually inserted via the subclavian vein and superior vena cava into the right heart, a careful assessment of risk and benefits should be taken. Infection is responsible for the removal of about 30%-60% of HD CVCs, and hospitalization rates are higher among patients with CVCs than among AVF ones. Proper VA maintenance requires integration of different professionals to create a VA team. This team should include a nephrologist, radiologist, vascular surgeon, infectious disease consultant, and members of the dialysis staff. They should provide their experience in order to give the best options to uremic patients and the best care for their VA.

Keywords: arteriovenous fistula; central venous catheter; infection; prosthetic grafts.

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Figures

Figure 1
Figure 1
Native radio-cephalic arteriovenous fistula for hemodialysis, with latero-terminal anastomosis.
Figure 2
Figure 2
Synthetic axillo–axillary graft in polytetrafluoroethylene material.
Figure 3
Figure 3
Photograph of neck in a malnourished patient demonstrating surface anatomy. Note: It shows Sedillot’s triangle, formed by the sternal (SH) and clavicular (CH) heads of the sternocleidomastoid. Inside this triangle is the approximate normal course of the internal jugular vein.
Figure 4
Figure 4
Percentage of variation in anatomical relations between the right and left internal jugular vein (in blue) and common carotid artery (C).
Figure 5
Figure 5
Ultrasound cross-sectional (left) and Doppler ultrasound (right) image of right internal jugular vein (IJV) and carotid artery (CA). Note: Both vessels are very superficial since they are in a range of depth of field between 1 and 2.5 cm.
Figure 6
Figure 6
External abdomen location of cuffed tunneled central venous catheters in femoral vein, as a variant of the normal external leg location.
See this image and copyright information in PMC

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