2011 update<scp>J</scp>apanese<scp>S</scp>ociety for<scp>D</scp>ialysis<scp>T</scp>herapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis

Abstract

The first edition of the Guidelines for the Construction and Repair of Vascular Access in Chronic Hemodialysis was published by the Japan Society for Dialysis Therapy (JSDT) in 2005, under Seiji Ohira, Chairman. Recently, many presentations making reference to the guidelines have appeared in conferences and journals. The 2011 version uses this first edition as a foundation and was formed with a collection of data following the publication of the first edition. During this time, in 2008, the JSDT conducted a survey on the conditions of vascular access (VA), where it found that native arteriovenous fistula (AVF) made up 89.7%, synthetic arteriovenous grafts (AVGs) were 7.1%, superficialization 1.8%, other direct arterial puncture 0.1%, long-term indwelled catheters 0.5%, temporary venous catheters 0.5%, single-needle dialysis 0.2%, and other methods 0.1% 1. In a survey conducted 10 years earlier, in 1998, AVF usage was at 91.4%, AVGs were 4.8%, superficialization was 2.5%, external shunts 0.2%, and other methods 1.1% 2 (Table 1). In other words, with an increase in long-term dialysis cases and damage to native vessels due to advanced age, internal shunts with native vessels are on the decrease; this implies that the use of AVG will increase. In the 2008 survey, other methods made up 0.1%: catheters were not categorized within this survey but may have been included. In these guidelines, in addition to the level of evidence, the level of recommendation has been included, and the categories are evaluated with both. As the Kidney Disease: Improving Global Outcomes (KDIGO) 3 uses the Grading of Recommendations Assessment, Development and Evaluation (GRADE) as a method of evaluating evidence, the Evidence Level Evaluation Committee of the JSDT made considerations 4 and based their method on that. With regard to study design, random controlled trials (RCT) were rated as high, observational studies as low, and all others as very low. Considerations for contents, quality, bias, etc. were given a two-level plus or minus point; in the end, they were divided into four levels, "A–D" (Table 2). "A" may represent high, "C" low, and "D" very low, and plus and minus points assigned accordingly. Where evidence is not shown, the committee has assigned an expert opinion (O). Because the number of RCTs in kidney-related fields is extremely limited, the evidence level was expected to be low, and there was a possibility that most proposals would be weak. Levels of recommendation have been divided into Level 1: Strong and Level 2: Weak, but if an "expert judgment" has shown them to be clinically important, even though the evidence level may be weak, they were strongly recommended. The opposite is also true. In this manner, the level of recommendation is denoted together with the evidence level. As an example, where the evidence level is "low" but the level of recommendation is "strong," would be written as "1C." In the case where the evidence level is "medium" and the level of recommendation is "weak," would be written as "2B" (Table 2). "Expert judgment" was decided in various meetings as listed. Purpose of VA construction VA construction method (surgical method) and presurgery examinations Anesthesia Time required for surgery What to be careful of following surgery Actual usage (actual cannulation) VA surgeon Patency rates for various Vas Importance of periodic examinations of function and shape Anticipated VA complications Repair methods for VA complications Others Inadequate blood flow Stenosis (arterial/venal stricture) Thrombosis (VA obstruction) Infection of cannulation sites Aneurysms Vascular hypertension (sore thumb or sore hand syndrome) Steal syndrome (ischemia) Excess blood flow, high-output cardiac failure Recirculation Cannulation difficulty, limited cannulation area Others 1. 2. The attending physician has the duty to explain to end-stage renal disease (ESRD) patients about the treatment methods deemed necessary for them 5, 6. 3. Topics that the explanation should cover are listed in Table 1; however, it is best to discuss these based upon the stage of disease, condition, and degree of understanding of the patient. Information should not be limited to what the medical side thinks is necessary; information the patient desires or what we imagine they would want should be included as part of the explanation. It is best not to explain everything at one time but to repeat the explanation in a series of meetings 7, 8. 4. The dialysis physician should provide a broad general explanation, but it falls upon the access surgeon to provide a detailed explanation of the actual VA construction. 5. When the method of VA has been decided upon, a detailed explanation of the necessity and characteristics should be provided, especially in the case of grafts 9. 6. The explanation of VA should include discussion of the various complications that could develop. 1. Taking into consideration the availability of the simple eGFR conversion equation, giving importance to convenience, it was decided to make use of eGFR 8, 10, 11. Patients who have been introduced to a specialist at the early stages of the onset of renal disease and have received education and guidance as well as overall management have more time until the initialization of dialysis and, when introduced to dialysis, they will have a better survival rate 10. An explanation to each medical department regarding this, as well as obtaining their cooperation, is also vitally important. 2. In the case that hemodialysis (HD) has been chosen as the form of renal replacement therapy (RRT) by the ESRD patient, the nephrologist should explain the necessity and importance of VA to the patient and then refer them immediately to a VA surgeon (Fig. 1) 8, 11. A part and classification of access related pain 3. The patency of the VA is affected by the patient's age, gender vascular condition, underlying disease, as well as other factors and is clearly affected by the surgeon's ability 12. 4. Angiography clarifies the path, diameter, and secondary route of the vessels. It is extremely useful when choosing the vessels for VA construction 13. 5. 6. The VA surgeon is in constant contact with the nephrologist and, when eGFR is 15 mL/min/1.73 m2, considers VA construction. This eGFR value takes into account the time needed for the AVF to mature for cannulation. In cases of diabetic nephropathy, VA construction should be considered at a lower value 13-15. 7. Currently, AVF is the best choice for VA if cardiac function and vascular conditions allow it 16, 17. 8. AVF and AVG construction can have adverse effects on cardiac function such as an increase in cardiac output, etc. Therefore, thorough examination of pre- and post-surgery cardiac function is required 18, 19. 9. Although intravascular indwelled catheters are simple and very useful, because of the various complications reported (injury to the vascular wall, thrombosis, luminal narrowing), their use should be avoided as much as possible 20-25. 1. Preoperative evaluation of overall condition is a requirement. In case of systemic infection or clear cases of malnutrition, dehydration, overhydration, or edema, treatment should be undertaken, and once symptoms have improved, only then should surgery be performed. In patients where diabetes, collagen disease, or arteriosclerosis has led to peripheral circulation disorders, it is necessary to consider the possible development of steal syndrome following AVF/AVG construction. After construction of AVF or AVG, especially in the elbow, because access blood flow volume increases, the risk of steal syndrome becomes higher 26. 2. Physical examination of the vessels prior to the construction of AVF is the most important aspect in determining AVF's success or failure, and it is vital to spend time performing it. Examination of not only the lower arm but also the upper arm is required. Before performing an evaluation of the vessels, examination of the entire arm is necessary (Table 1). Presence of swelling Presence of hemiplegia Elbow joint contracture Dryness or redness of skin, presence of infection If AVF/AVG were to be constructed on the side where a hemodialysis catheter or pacemaker was placed in the subclavian vein or there has been a past history of breast cancer surgery, venous hypertension 27-29 can occur following construction. 3. For vascular evaluation, as stated previously, visual inspection and palpation are most important. In recent years, ultrasound has gained attention as a method for objectively evaluating vasculature 30-33. The goals of examination by ultrasound are shown in Table 2. Map veins unclear via palpation Obtain deep vein information, upper extremity basilic vein, etc. Measure diameter of vessels to be used for anastomosis Determine thickness of vessel walls (esp. arterial walls), determine presence of calcification Measure arterial blood flow volume Research on the diameter of the radial artery needed for a successful radiocephalic AVF (RCAVF) has shown that the smallest size is between 1.5 mm and 2.0 mm 30, 34-36. The diameter of the radial artery should be at least 1.5 mm: anything smaller will have a lower success rate. Construction in the central region should be considered. But the diameter of the artery is only one indicator for a successful AVF; wall thickness and function should also be included for consideration and then evaluated. The required blood flow for a radial artery anastomosed for use in an AVF is between 20 and 40 mL/min with no set rate 37, 38; at this time there is no satisfactory indicator. The differences in the size of the veins are recorded before and after application of a tourniquet. Veins of diameter between 1.6 and 2.5 mm after tourniquet application are recommended 30, 34, 35, 39. Ultrasound examination is effective but whether or not it should be applied to all cases is a subject of debate. Nursal et al. 40 evaluated the effectiveness of ultrasound evaluation in an RCT of patients in whom AVF construction was shown possible by physical examination. There was no significant difference in the results between a group that underwent ultrasound examination and a group that did not. They concluded that if the patients had arteries and veins that were in good condition, ultrasound examination was not a requirement. 4. Conditions where central venous stenosis can be suspected are shown in Table 3. Patients with clear signs of edema (esp. with bilateral difference, clear sign of edema on side for VA construction) Patients with developed upper extremity collateral circulation Patients with a history of catheter or pacemaker indwelled in the central vein Patients with previous breast cancer surgery Patients with a history of surgery in the upper extremity or neck 1. The advantages of an RCAVF in the distal forearm are listed in Table 1. Preserves more veins for AVF construction in the future Fewer complications (steal syndrome, thrombosis, infection) Patency rates are high if construction is successful Long-term use of veins for cannulation Reconstruction in a proximal region is possible if occlusion occurs If the arteries and veins of the anastomosed snuff box are of adequate size, construction of a tabatière AVF is also possible, but in this case an RCAVF can also be chosen. Hatakeyama et al. 41. reported that of 1560 AVF examples, the 1-, 3-, and 5-year secondary patency rates listed by modalities were 61%, 53%, and 44% for tabatière AVFs and very much similar at 70%, 59%, and 54% for Brescia-Cimino AVFs. However, in contrast, there are also reports stating that the secondary patency rates of the tabatière AVF are significantly poorer 42, 43. Because there has been no RCT, it is difficult to choose between the two, and at this point, whichever can be chosen as a first choice. If no appropriate vessels can be located on the radial side, an AVF constructed on the ulnar side should be considered. An AVF on the ulnar side generally consists of the ulnar artery anastomosed to the basilic vein (ulnobasilic AVF: UBAVF). But if the ulnar arteries are too narrow, an extended length of the basilic vein can be mobilized and anastomosed to the radial artery. The patency rate of the UBAVF is lower than that of RCAVFs 44, but by performing PTA, the secondary patency rates are reported to show no significant difference when compared with RCAVFs 45. The site of construction should be decided based on the background of the patient, their overall condition, and local findings. Factors that should be considered when deciding on the site for construction are shown in Table 2. Diameter of artery and wall calcification Diameter of vein and continuity Path of arteries and veins and relative positions Patient's overall condition and prognosis Presence of distal circulation disorder Cardiac function 2. If the cephalic vein in the upper arm is unusable for AVF construction, the basilic vein can be superficialized and anastomosed to the brachial artery at the elbow to form a transposed brachial-basilic arteriovenous fistula (TBBAVF). If a TBBAVF is to be constructed, ultrasound or angiography should be used to check the path, size continuity, and anastomosis point with the brachial artery of the basilic vein. It is also important to determine if an adequate length can be mobilized. Patency rates of the TBBAVF have been reported to be better than an AVG 46, 47, but stenosis easily develops at cannulation sites. If occlusion occurs, the vein can no longer be used for graft placement; therefore, application of a graft (AVG) should be carefully examined. 3. Numerous reports have found the patency of primary accesses to be low in females, the elderly, and diabetic patients. The patency rates of AVFs in the elderly are significantly low 48, 49. Woods et al. 48 studied 245 examples of AVF failures. In a comparison of the patency rates in those over 65 years of age and those below 65 years of age, they report that those over 65 years of age had a significantly lower patency rate. In a meta-analysis of the AVF outcomes in elderly patients, elderly and younger patients were compared, and at 12 months and 24 months, elderly patients were shown to have a significantly greater number of RCAVF failures 50. Also, there are numerous studies reporting that the patency rates for females 51, 52 and diabetes patients 52, 53 are significantly low. 4. The general method of anastomosis for an AVF is an artery side to vein end anastomosis. The blood flow rates of end-to-end, side-to-end, and side-to-side anastomoses were compared by Kukita et al. 54, and although they found no significant difference, the blood flow in the end-to-end anastomosis was shown to be low. Taking into consideration the ease of anastomosis, low initial failure rate, and lack of complications, we recommend a side-to-end anastomosis. 5. Because of this, the access should be checked for thrill immediately following surgery. If the thrill is weak, an intravenous injection of 2000–3000 units of heparin or low-molecular-weight heparin should be administered. 6. Ohira et al. 55 conducted a questionnaire survey of 23 facilities, calculating the primary failure rates in 5007 RCAVFs. The primary failure rate was reported to be 0.8–23.6% (average: 7.6%), varying widely between different facilities. Approximately 70% of these were reported to be salvageable. In a meta-analysis by Rooijens et al. 56, the primary failure rate was 15.3% (6–34%). Allon and Robbin 57 reported a primary failure rate of 2–53%, showing a wide variation even among authors. In a recent systematic review regarding the effects of non-maturity following surgery, 21% were reported to be attributed to pre-operation clinical risk factors, 24% to pre-operation hemodynamic factors, while 50% can be attributed to postoperative hemodynamic factors 58. Murakami et al. 59 measured the resistive index (RI) within 1 week of AVF surgery and compared it to the 6-month patency rate. For the 39 examples whose RI was less than 0.6, the patency rate was 92.3%, significantly higher than the 46 examples whose RI was greater than 0.6 with a patency rate of 69.6%. It was reported that in examples where the RI measured soon after surgery was greater than 0.6, the patency rate was low, and examination should be performed for the presence of stenosis. It has been reported that if the cross-sectional area of the radial artery is greater than 8.5 mm2 or venal blood flow rate is greater than 425 mL/min, the rate of maturity for a functional access is 95–97%, respectively 60. 7. From the Dialysis Outcomes and Practice Patterns Study (DOPPS) data presented by Rayner et al. 61, a 2.27 times increased risk of access failure in AVFs that were cannulated within 14 days of construction was reported as opposed to those that were cannulated 43–84 days after construction. 8. A number of RCTs regarding antiplatelet agents following AVF surgery have taken place with ticlopidine and aspirin being reported to be effective 62-65. 1. As an access, the AVF has a better patency rate and lower frequency of complications. For these reasons, AVF is the first choice for an access, but if the appropriate veins cannot be located, an AVG would be the next choice 66-68. Because the access blood flow rate of the AVG is approximately 1000 mL/min 3 weeks after construction, it places a burden on cardiac function soon after surgery 69, 70. However, the limit of the burden placed on the heart with respect to cardiac function that can be tolerated is still unclear. 2. If the AVG is implanted where the vessels are of larger diameter, in a more proximal location, blood flow will be increased and the patency rates improved 71. In order to have as many possible sites for future implants, normally start in the forearm. If the AVG is placed in the thigh, by infection or circulation are more than if the AVG were placed in the Because of this, it is to those cases in the AVG can no longer be placed in the arm 3. The simple has while the more for the vessels that can be anastomosed as well as a larger area for giving it a higher frequency of use 4. In there are of vessels that can be used with grafts up to has shown them to be better than other with regard to to long-term and ease of use However, following a to is required before cannulation can and in of the is a however, can be cannulated early and have early and patency rates to those of However, the graft has a as it easily There are grafts that are or on the arterial end and others that are with a on the venous It has been reported that the grafts graft patency rates is also reported to the patency rate In can be used are easily and have good in The patency rates are or better than or grafts 5. with the vein or internal vein however, general 6. of approximately of heparin following the was found to be effective in those cases in In a report by et al. the primary patency rate improved to for the with the of plus with the patency rates in Japan of it is clearly 7. of prior to and surgery is recommended. 8. primary patency rates for AVG are reported to be with secondary patency rates reported to be The of occlusion is the development of stenosis in the vein. patency rates can be improved with for stenosis and treatment before occlusion With this, the of secondary patency rates at 1 of 3 years of and years of is where it can be that cardiac burden by the internal cannot be This method is recommended when is or where surgery to the access would be difficult due to damage of veins where there are no appropriate veins for anastomosis where steal syndrome has developed or where there is a possibility of development where venous hypertension has developed or may due to AVF construction As a in patients with VA For long-term blood therapy as in the case of The superficialized artery is used as the and cannulation of a vein is necessary at each hemodialysis 1. for arterial superficialization (Table 1) are can be divided into four 1 those patients in whom cardiac function is and construction of an AVF (AVG) will to cardiac failure 2 cases in vascular damage has making AVF (AVG) construction difficult 3 consists of those whose AVF (AVG) has steal syndrome to and 4 those where it is used as a because of VA It is that AVF (AVG) has an on cardiac function However, there is evidence to show what blood flow rate a and is a direct for cardiac 2. The arteries used in superficialization are the brachial artery located between the elbow and upper arm and artery In more than make use of the brachial artery The advantages of the brachial artery ease of and possibility to with the use of local 3. Because superficialization of the artery a greater area to be than the brachial attention should be taken for complications such as and 4. The length of the should allow for an adequate area for cannulation points to be of are the following there is between the vessel and and in many are formed after Because of this, it is best to until the has before 2 weeks or more weeks if should be as as necessary blood not Approximately should be to the in a superficialized artery. In complications in arterial be careful of included and occlusion catheters are used for conditions that blood use is recommended (O). catheters are used for of long-term blood for of 3 months or use is recommended (O). where use of a catheter is cases where AVF/AVG cannot be cases with cardiac cases where the patient's condition this the most appropriate VA for example, contracture in the making cannulation or where there is a high risk of hemodialysis a catheter should place in a or an area the of the It is recommended that the method be used in a It is recommended that a catheter should place under conditions as in an with the use of an and the method It is recommended that an be taken immediately following the It is recommended that the catheter the point of to distal be upon It is recommended to by that there are no complications with the It is important to for complications with It is to of and antiplatelet agents at an appropriate time before the appropriate for if occurs as required is blood or increased blood can a It is recommended that be performed. 1. make hemodialysis catheters more and to increase with the medical the committee has decided to the of vascular access and vascular access and use the categories of and Hemodialysis catheters are with different in different and there is no however, in many they are by their shape 2. The of the catheter in the treatment of hemodialysis patients hemodialysis in end-stage renal failure patients and a method to on in the that other methods of VA are one in that usage should be limited to 1 though cases of long-term usage with adequate infection of a method of VA should be as soon as possible 3. for catheter use include cases where AVF/AVG cannot be constructed due to vessels in the or cases with cardiac failure cases with to the pain of making cannulation or a high possibility of the being make this a appropriate method of This method is one method of VA that is appropriate for patients When an AVF/AVG cannot be constructed and the choice is between arterial superficialization and this the condition of the patient should be taken into careful consideration when making the It is recommended that immediately following surgery, be taken of the appropriate to the of the catheter and to that there are no complications with the surgery attention should be to the of the catheter cardiac or venous a or of the or A check for and is required. 6. It is recommended that the appropriate for the management of be taken as well as performing necessary to the of complications complications with of a central venous catheter are complications related to complications include of the catheter and in the case of cannulation of the internal or increased and increased related to a catheter can be evaluated by postoperative inspection of the access prior to cannulation is recommended (O). AVF An appropriate following construction until the time of use is (O). When cannulation of a of an AVF is it is recommended to whether the vessel being cannulated is an artery or an vein (O). It is recommended that the site of cannulation be chosen that it the area the anastomosis and a site chosen that the will not with in the the VA dialysis (O). of the arterial puncture site should be to the anastomosis than the venal puncture site and the should be as much as possible (O). The cannulation site should be each time and sites should be chosen over as wide an area as possible a or use the method for patients who of cannulation pain (O). The of cannulation for an AVF should be approximately (O). When the and the the should be the should be with a and the the is a can be placed over the and applied to (O). The The method of cannulation can be applied to those patients of pain cannulation (O). For