Angiography of upper extremity access fistulas for dialysis.

Abstract

One-hundred twenty-five cases of upper extremity internal arteriovenous and graft fistulas were reviewed. Clinical problems requiring study were poor fistula flow during dialysis, difficulty in cannulation, diminished graft pulsations, extremity edema or varicosities, the appearance of pulsatile or nonpulsatile masses in the graft or fistula, and distal ischemia. Angiography demonstrated venous occlusion (13 cases), venous stenosis at or near the anastomotic site (32 cases), thrombi within shunts (9 cases), venous aneurysms or pseudoaneurysms related to either proximal obstruction or traumatic dialysis (23 cases), distal venous overdistention due to proximal obstruction or overcirculation (15 cases), and radial artery steal of blood from the distal extremity (15 cases). The causes and predisposing factors leading to the complications are presented along with a discussion of the angiographic techniques that were used.

Novel Therapeutic Paradigms to Treat Hemodialysis Access Dysfunction

“…Since 1980`s when angiography was employed for evaluation of vascular access dysfunction, angioplasty has been the standard of care in maintaining luminal patency by treating venous stenosis [31,32]. Over the course of 3 decades, this technique evolved from a hospital based inpatient setting to being an outpatient office based procedure enabled by advances in hardware utilized for these procedures.…”

Balloon Expandable Stents to Treat Central Venous Stenoses in Hemodialysis Patients

“…The clinical presentation of dialysis access failure is varied [8,9], Thrombosis is the most common presenta tion and is frequently the result of venous limb stenosis and resultant decreased blood flow. High venous resis tance measured during dialysis may be the first clue to impending access failure.…”

“…Stenoses at the site of arterial or venous anastomoses are probably the result of fibrosis from local trauma during surgery [8]. Proximal venous limb stenoses may develop due to the institution of turbulent arterial flow into the veins resulting in endo thelial injury, platelet deposition and intimal prolifera tion [10,11].…”

“…Proximal venous limb stenoses may develop due to the institution of turbulent arterial flow into the veins resulting in endo thelial injury, platelet deposition and intimal prolifera tion [10,11]. Turbulent flow may also cause hypertrophy of venous valves creating an impediment to venous out flow [8], The etiology of central venous stenoses is very different. These are nearly always the result of fibrosis from the repeated trauma of percutaneous cannulation of the central veins for temporary dialysis access [4,5],…”

“…The multiple possible locations for stenoses creating fistula failure necessitates extensive angiographic investi gation [8]. The arterial and venous anastomoses must be visualized along with the entire course of the venous return up to and including the central venous circulation.…”