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Hemodialysis requires frequent access to the patient's blood stream (vascular system). Vascular access has been called the "Achilles' Heel" of hemodialysis care. Hemodialysis vascular access procedures and associated costs come to $8,000-10,000 per patient per year. This amount represents approximately 25 percent of total ESRD medical costs. The most common problems are stenosis (narrowing of graft/blood vessel), infection, and thrombosis (clotting).

At present, three types of vascular access are predominant: AV (arteriovenous) fistulas, AV grafts, and catheters. AV fistulas are surgically created by connecting a patient's own artery and vein, usually in the forearm. AV fistulas have the lowest rate of complications, but take from several weeks to several months to mature, heal, and develop in size. Over time, an AV fistula becomes large enough to accommodate the needles required for hemodialysis. AV grafts are also created surgically, but use a synthetic blood vessel to connect the vein and artery. The needles are inserted into this synthetic graft. AV grafts require shorter times (if any) to heal before they can be used, but tend to have more incidents of stenosis and thrombosis than AV fistulas. Catheters are most often used as "bridge" devices, used to bridge the time between from start of dialysis treatments (often an emergency) to when the patient's AV fistula or AV graft has matured and is ready for use. Catheters are generally not used as long-term devices as they tend to have higher rates of infection and thrombosis.

Warning:  Changes should never be made in a patient's treatment or care based solely on the information found here.  Every patient has unique healthcare concerns and considerations and all these factors must all be taken into account before any changes can be safely made.  All medical and therapeutic decisions must come from a qualified health care provider.  Read RenalWEB's Legal Disclaimer before proceeding.


  NEWS AND LATEST ARTICLES
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Impact of Arteriovenous Fistula Cannulation on the Quality of Dialysis - Early View Abstract from Hemodialysis International. - March 6, 2017

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Early Use of Autogenous Arteriovenous Fistula in Patients with Urgent Hemodialysis - First Online abstract from International Urology and Nephrology. - March 2, 2017

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Effects of Cardiac Function with Postoperative Arteriovenous Fistula Blood Flow in Patients with Hemodialysis - Issue-in-Progress Abstract from Blood Purification. - February 25, 2017

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Venous Hemodialysis Catheters and Cardiac Implantable Electronic Devices: Avoiding a High-Risk Combination - Early View abstract from Seminars in Dialysis. - February 23, 2017

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Vascular Access Conversion and Patient Outcome after Hemodialysis Initiation with a Nonfunctional Arteriovenous Access: a Prospective Registry-based Study - Free, Open Access article from BMC Nephrology. - February 22, 2017

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Thirty-Day and 90-Day Hospital Readmission after Outpatient Upper Extremity Hemodialysis Access Creation - Article in Press abstract from Journal of Vascular Surgery. - February 19, 2017

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An Increase in Mean Platelet Volume/Platelet Count Ratio Is Associated with Vascular Access Failure in Hemodialysis Patients - Free, Open Access Article from PLOS ONE. - January 17, 2017

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Role of Intravascular Ultrasound Imaging during Endovascular Interventions of Failing Hemodialysis Access Grafts - Article in Press abstract from Journal of Vascular Surgery. - February 16, 2017

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Self-Care on Hemodialysis: Behaviors With the Arteriovenous Fistula - Early View Abstract from Therapeutic Apheresis and Dialysis. - February 14, 2017

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Does Guidewire Exchange Influence Infection Rate Related to Catheters Used for Vascular Access in Children on Chronic Hemodialysis? - Free February 2017 Issue of Therapeutic Apheresis and Dialysis; Articles Include. - February 2017

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Air Embolism Following Removal of Hemodialysis Catheter - Free Issue (January 2017) of Hemodialysis International; Included among the 23 Articles and Case Reports. - January 2017

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  WEB RESOURCES
blueball Latest Scientific Journal Articles on Vascular Access
Latest issue of the Journal of Vascular Surgery
Buttonhole Technique from the Northwest Renal Network - June 2010
Cannulation of the Arteriovenous Fistula (AVF) video from the Network Coordinating Center (NCC) web site
Caring For & Developing Your New Fistula from the Northwest Renal Network web site
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Catheter Reduction Toolkit - Resources from the National Forum of ESRD Networks web site

'Change Concepts' from Fistula First

Routine CQI review of vascular access
Timely referral to nephrologist
Early referral to surgeon for "AVF only" evaluation and timely placement
Surgeon selection based on best outcomes, willingness, and ability to provide access services
Full range of appropriate surgical approaches to AVF evaluation and placement
Secondary AVF placement in patients with AV grafts
AVF placement in patients with catheters where indicated
Cannulation training for AV fistulas
Monitoring and maintenance to ensure adequate access function
Education for caregivers and patients
Outcomes feedback to guide practice
Modify hospital systems to detect CKD and promote AV fistula planning and placement
Support patient efforts to live the best possible quality of life through self-management

Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America - full-text article from Clinical Infectious Diseases. - July 1, 2009
Creating AV Fistulas in All Eligible Hemodialysis Patients from the University of Oklahoma College of Medicine web site
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Dialysis Access from the VascularWeb web site

Dialysis Audit Tools: Includes pdfs for hemodialysis hand hygiene, catheter connect/disconnect, exit site care, and AV fistula/graft decannualationfrom the Dialysis Bloodstream Infection (BSI web page) Prevention Collaborative

Video: Dialysis Patients Speak: a Conversation about the Importance of AV Fistulas - 12-minute video on YouTube produced in 2005 for the ESRD Network of New England. - December 13, 2012

Fistula First web site, Fistula First Data, Annual Reports, and Patient Section
Fistula First: Patient Educational Materials - from the ESRD NCC web site
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Free, Full-Text Articles from Canadian Journal of Kidney Health and Disease - September 27, 2016

Frequently Asked Questions about the ArterioVenous Fistula from the Northwest Renal Network web site
Guidelines for the Prevention of Intravascular Catheter Related Infections from Morbidity and Mortality Weekly Report web site - August 2002
Just the Facts: Vascular Access and Información esencial: Acceso vascular (pdf format requires Adobe Acrobat Reader) from the Life Options web site
Keeping Your Access Uncovered - (2-page pdf) from the Northwest Renal Network
Let's Talk About Fistulas - 3 minute video from the Fistula First Breakthrough Iniiative (web site)
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ESRD NCC Resource Downloads - vascular access tools from the ESRD National Coordinating Center web site

The natural history of autologous fistulas as first-time dialysis access in the KDOQI era - full text article from the Journal of Vascular Surgery - February 2008
Please be careful with my veins - An information page to be given to nurses or phlebotomist who are about to start an IV or draw blood on dialysis patients (1998). All information from the Nephron Information Center web site.
Prevent Dangerous Hemodialysis Catheter Disconnections article from FDA's Center for Medical Devices

Poster: Protect Your Access – It's Your Lifeline! from the Northwest Renal Network web site

Revised European Best Practice Guidelines for Hemodialysis - Vascular Access - guidelines endorsed by the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)

Self-Cannulation - Video via Renal Fellow Network web site

Vascular Access - A Lifeline for Dialysis - new module at the KidneySchool™.
Vascular Access Fact Sheet (pdf format requires Adobe Acrobat reader.) from the American Nephrology Nurses’ Association
Vascular Access for Hemodialysis from the NIDDK Publications Online for Kidney Disease
Vascular Access for Hemodialysis from the Northwest Renal Network web site

Vascular Access POC Algorithm - Tool (1-page pdf) from ESRD Network 11

Venous Needle Dislodgement - How To Minimize the Risks - (pdf) poster from the EDTNA/ERCA
Vital Signs: Central Line--Associated Blood Stream Infections --- United States, 2001, 2008, and 2009 - Article from the CDC's Morbidity and Mortality Weekly Report. The article mentions the word "dialysis" 42 times. - March 2011
"The majority of central line--associated blood stream infections are now occurring outside of ICUs, many outside of hospitals altogether, especially in outpatient dialysis clinics."
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  PUBMED SEARCHES (National Library of Medicine's MEDLINE Database)
vascular access and hemodialysis articles   Continually Updated!
catheter AND hemodialysis articles   Continually Updated!
anticoagulants AND catheter AND hemodialysis articles   Continually Updated!
graft survival AND hemodialysis articles   Continually Updated!
cost AND access AND dialysis Continually Updated!
MEDLINE / Pubmed Information from the National Library of Medicine
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K/DOQI™ -  Kidney Disease Outcomes Quality Initiative ( pronounced "kay DOE key" )

Clinical Practice Guidelines for Vascular Access 2006 Updates

I. Clinical Practice Guidelines for Vascular Access

Guideline 1. Patient Preparation for Permanent Hemodialysis Access
Guideline 2. Selection and Placement of Hemodialysis Access
Guideline 3. Cannulation of Fistulae and Grafts and Accession of Hemodialysis Catheters and Port Catheter Systems
Guideline 4. Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Guideline 5. Treatment of Fistula Complications
Guideline 6. Treatment of Arteriovenous Graft Complications
Guideline 7. Prevention and Treatment of Catheter and Port Complications
Guideline 8. Clinical Outcome Goals

II. Clinical Practice Recommendations for Vascular Access

Clinical Practice Recommendations for Guideline 1: Patient Preparation for Permanent Hemodialysis Access
Clinical Practice Recommendations for Guideline 2: Selection and Placement of Hemodialysis Access
Clinical Practice Recommendations for Guideline 3: Cannulation of Fistulae and Grafts and Accession of Dialysis Catheters and Ports
Clinical Practice Recommendations for Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Clinical Practice Recommendations for Guideline 5: Treatment of Fistula Complications
Clinical Practice Recommendations for Guideline 7: Prevention and Treatment of Catheter and Port Complications
Clinical Practice Recommendation 8: Vascular Access in Pediatric Patients

 

K/DOQI Home Page from the National Kidney Foundation web site
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  DISCUSSION FORUM
Vascular Access Issues on RenalWEB
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  UPCOMING EVENTS
Listing of Vascular Access Society meetings and events
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  INPUT / SUGGESTIONS
E-mail to RenalWEB on the Vascular Access Topic
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