Review Articles: Approach to Patients with “Complex” Hemodialysis Access Problems

Abstract

The approach to patients with "complex" permanent hemodialysis (HD) access problems remains poorly defined. The purpose of this review is to outline our current algorithm for patients presenting for dialysis access and to address the management of specific problems that complicate this objective of establishing permanent access. The key components of the algorithm include noninvasive imaging in the diagnostic vascular laboratory to determine all the possible access configurations and invasive imaging with both venography and arteriography to confirm the optimal choice. The specific access-related problems addressed include inadequate ipsilateral vein, inadequate arterial inflow, central vein stenosis/occlusion, multiple previous access failures, and obesity. Despite the label of "complex" access problems, it is possible to construct native arteriovenous fistulas (AVFs) in almost all patients presenting for access using the standard principles of vascular surgery that are based on establishing adequate arterial inflow, adequate venous outflow, and selecting an appropriate conduit.

Obesity as a Predictor of Vascular Access Outcomes: Analysis of the USRDS DMMS Wave II Study

“…It would be prudent to take these patients as well as the obese and start with preoperative noninvasive and invasive mapping, then proceed with AVF or AVG configuration, with or without adjuncts for fistula first. Huber and Seeger outline a concise approach to these “complex” access issues (45).…”

Interventional Nephrology and Dialysis: Managing the Complications of Long‐Term Tunneled Dialysis Catheters

“…While the use of flexible subclavian stents (Fig. 10) is growing in popularity, the long‐term outcome with these appliances is still a subject of debate (18,19).…”

Brachio-cephalic ('Gracz') fistula use for continuous hemofiltration in a hemodynamically unstable hemodialysis patient without venous vascular access: a case report

“…To perform such treatments a reliable vascular access is of vital importance. Unfortunately, multiple vascular access problems are frequently seen among chronic HD or HF patients despite the reliability of the conventional arteriovenous fistula [4]. Since the introduction of large-bore catheters for acute HD, many problems with handling, material, and contamination of these catheters have been described.…”