What is Complex Hemodialysis Access?
Complex hemodialysis access is a procedure to create a vascular opening, usually in the arm, so that a needle can be inserted for the purpose of hemodialysis in complex patients with kidney failure.
Kidney failure is a condition in which the kidneys lose the capacity to remove waste and balance the fluids in your body as a result of chronic kidney disease or acute kidney injury.
In this context, “complex” refers to patients for whom hemodialysis is challenging, due to reasons such as obesity, previous access failures, inadequate arterial inflow, central vein occlusion/stenosis, and inadequate ipsilateral vein access.
Despite these challenges, it is possible to facilitate hemodialysis access in almost all individuals using standard principles of vascular surgery that are based on establishing sufficient arterial inflow, sufficient venous outflow, and choosing an appropriate conduit.
Indications for Complex Hemodialysis Access
Your surgeon may recommend complex hemodialysis access for patients with kidney failure.
The kidneys perform crucial functions necessary for sustaining life. They consist of tiny cells called nephrons, which act as filters that remove waste and excess fluid from the blood to form urine. Kidneys also maintain blood pressure in the body and mineral levels in the bones. In kidney failure, the nephrons become damaged and less able to filter waste. This causes fluids and waste products to build to dangerously high levels that can lead to coma and even death.
A kidney transplant is the standard treatment for kidney failure, in which a damaged kidney is replaced with a healthy donor kidney. However, it often takes months or years to find a suitable donor. Hemodialysis is an alternative procedure where a vascular opening is used to remove blood from your body, where it is cleaned using a machine called a dialyzer, and returned to your body. Hence, the process of hemodialysis acts as an artificial filter, doing the work of the kidneys to prolong the life of individuals with kidney failure.
Preparation for Complex Hemodialysis Access
Preparation for complex hemodialysis access procedure may involve the following steps:
- Blood tests to check for normal kidney function, to ensure that your blood clots normally, and to obtain other information.
- Venography or Doppler ultrasound tests may be performed to locate a suitable access site.
- You need to inform your physician if you have allergies to certain medications, local anesthetic, or latex.
- You should also inform your doctor of any medications or supplements you are taking, or any heart or lung conditions.
- You may be asked to stop taking blood-thinners, anti-inflammatories, aspirin, or other supplements for a week or two.
- You should not consume solids or liquids at least 6 hours prior to the procedure.
- Arrange for someone to drive you home after the procedure as you may not be alert enough to drive yourself.
- Written consent will be obtained from you after the procedure has been explained in detail.
Procedure for Complex Hemodialysis Access
Complex hemodialysis access procedure can be achieved via several types of vascular access. Your surgeon and nephrologist (kidney specialist) will discuss with you to determine the best option for your condition.
In general, the complex hemodialysis access procedure will involve the following steps:
- You will lie on your back on the table and the area of vascular access in your arm, neck, leg, or chest is cleaned with an antiseptic solution.
- A local anesthetic is used to numb the access area. Sedative medicine may also be used to help keep you comfortable and calm during the procedure.
- Once you are comfortable, your physician will make a small incision in the area to establish one of three vascular access types:
- Arteriovenous (AV) Fistula: In this type, a direct connection is established between an artery and a vein in your forearm, wrist, upper arm, or inner elbow, normally on the surface of the arm. A fistula requires one to four weeks to form.
- Arteriovenous (AV) Graft: This type is used if you have small veins that cannot develop into a fistula. Here your surgeon joins the artery and vein in your elbow or armpit using an artificial tube called a graft just under the skin. A graft requires 3 to 6 weeks to heal.
- Tunneled (subcutaneous) Catheter: In this type of access, a connection is made through a catheter (a thin tube) inserted under the skin. The catheter is inserted into a vein in the neck, chest, or upper leg. This is used when hemodialysis is needed immediately and there is no time for graft or fistula access.
- Your physician will use image guidance such as fluoroscopy (continuous live X-rays), ultrasound, or contrast dye visualization of the blood vessels in your legs and arms to assist with these procedures.
- Once the procedure is complete, the incision site is sutured or glued and a bandage is applied to cover the treatment area.
Post-Procedure Care and Recovery
Following the procedure, you may experience pain, swelling, and bruising in the access area for which your physician will prescribe appropriate medications. These symptoms should resolve within a week. Place a pillow under your arm and keep your elbow straight to help reduce swelling. You can go home after a few hours of observation in the medical facility. You may resume work and your normal daily activities the following day, but with certain activity restrictions. Incision site care and bathing instructions will be provided to keep the wound clean and dry. Tips on maintenance of the access site and catheters are also provided. Refrain from strenuous activities or lifting anything over 15 pounds for a defined period. Call your physician if you experience fever or other signs of infection such as tenderness, bleeding, and redness at the incision site.
Risks and Complications
Complex hemodialysis access is a relatively safe procedure; however, as with any procedure, the following risks and complications can occur:
- Arterial puncture
- Abnormal heart rhythm
- Bleeding
- Bruising and soreness
- Wound infection
- Catheter fracture
- Accidental catheter dislodgement
- Catheter occlusion (blockage)
- Vein occlusion
- Blood clots
- Pneumothorax or collapsed lung (rarely)
- Air embolism (rarely)
