Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery

Abstract

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

Keywords: guideline; kidney dialysis; vascular access.

Figure 1. Kaplan-Meier analysis showing relationship between presence of central venous catheter and diminished access survival.

Figure 2. Analysis of survival of arteriovenous fistulae with presence of ipsilateral and contralateral central venous catheter.

Figure 3. Maturation rates and primary patency according to vein diameter.

Figure 4. Kaplan-Meier analysis showing relationship between early cannulation and diminished access survival.

Figure 5. A) Schematic representation of brachiocephalic arteriovenous fistula. Adapted from Minion et al.B) Schematic representation of distal revascularization interval ligation, consisting of ligation of the distal brachial artery to the anastomosis, with interruption of the reverse flow, and distal revascularization with bypass, placing the proximal anastomosis 5 cm above the arteriovenous anastomosis, thus avoiding a low blood pressure zone. Adapted from Minion et al.C) Schematic representation of revision surgery using distal inflow consisting of proximal radial artery bypass (approximately 2 to 3 cm from its source) to the arteriovenous fistula vein, with ligation of the same juxta-anastomotic arteriovenous fistula. Adapted from Minion et al.

Figure 6. Schematic representation of proximalization of the arterial inflow surgery, consisting of converting the arterial supply of the arteriovenous fistula to the proximal artery with greater diameter and higher flow (axillary), leading to a lower arterial pressure drop distal to the anastomosis, associated with greater blood flow restriction from the use of a 4 or 5 mm expanded polytetrafluoroethylene graft. Adapted from Zanow et al.

Figure 7. Categorization of arteriovenous fistula graft infection. Adapted from Kingsmore et al. CPB, positive culture; AVG, arteriovenous graft.

Figure 8. Asymptomatic true aneurysm.

Figure 9. A) Ulcerated true aneurysm in brachiocephalic fistula associated with hyperflow and stenosis of the arch of the cephalic vein. B) Intraoperative appearance during aneurysmorrhaphy and reduction of hyperflow. C) Postoperative appearance.

Figure 10. A) Voluminous pseudoaneurysm at expanded polytetrafluoroethylene graft puncture site. B) Appearance after correction with covered stent.

Figura 1. Análise de Kaplan-Meier demonstrando a relação entre a presença de um cateter venoso central e a diminuição da sobrevida do acesso.

Figura 2. Análise de sobrevidas das fístulas arteriovenosas com a presença de cateter venoso central ipsilateral e contralateral.

Figura 3. Taxas de maturação e de perviedade primária de acordo com o diâmetro da veia.

Figura 4. Análise de Kaplan-Meier demonstrando a relação entre a canulação precoce e a diminuição da sobrevida do acesso.

Figura 5. (A) Representação esquemática de fístula arteriovenosa braquiocefálica. Adaptada de Minion et al.. (B) Representação esquemática da cirurgia de revascularização distal com ligadura de intervalo, que consiste na realização de ligadura da artéria braquial distal à anastomose, com interrupção do fluxo reverso, e revascularização distal com ponte, sendo a anastomose proximal 5 cm acima da anastomose arteriovenosa, evitando assim zona de baixa pressão arterial. Adaptada de Minion et al.. (C) Representação esquemática da cirurgia de revisão utilizando influxo distal, que consiste na realização de ponte da artéria radial proximal (cerca de 2 a 3 cm após a sua origem) para a veia da fístula arteriovenosa, com ligadura da mesma justa anastomose arteriovenosa. Adaptada de Minion et al..

Figura 6. Representação esquemática da cirurgia de proximalização do influxo arterial, que consiste na conversão do suprimento arterial da fístula arteriovenosa para artéria proximal com maior diâmetro e fluxo (axilar), promovendo assim menor queda da pressão arterial distal à anastomose, associado a maior restrição do fluxo com a utilização de politetrafluoroetileno expandido n°4 ou 5. Adaptado de Zanow et al..

Figura 7. Categorização de infecção de fístula arteriovenosa com enxerto. Adaptado de Kingsmore et al..

Figura 8. Aneurisma verdadeiro assintomático.

Figura 9. (A) Volumoso pseudoaneurisma em sítio de punção de enxerto de politetrafluoroetileno expandido; (B) Aspecto após correção com stent revestido.

Figura 10. (A) Aneurisma verdadeiro ulcerado em uma fístula braquiocefálica associado a hiperfluxo e à estenose do arco da veia cefálica. (B) Aspecto intraoperatório durante a aneurismorrafia e redução do hiperfluxo. (C) Aspecto pós-operatório.