Options for end stage vascular access: Translumbar catheter, arterial-arterial access or right atrial graft?

Abstract

Background: Running out of vascular access for dialysis is thankfully rare, but despite this, most units will have a number of patients with few options and in a precarious state. The increasing longevity of dialysis patients portends more patients will reach minimal access options. End stage vascular access is poorly defined but classification may enable assessment and comparison of treatment options. Three options for patients with end stage access are a central venous catheter through a translumbar or transhepatic route, arterial-arterial prosthetic loop or a right atrial graft. Aims: The aims of this study are to provide a structured review of evidence for these procedures to allow application and guide practice for patients with end stage vascular access. Methods: A standardised search of published literature was performed of relevant studies. In addition, the references cited in those papers were assessed for any further available articles. All study types were included and reviewed by two authors independently. Primary outcomes were patient survival and secondary patency rate at 3 and 12 months. Secondary outcomes were long-term patency rates, mean time to cannulation and complications such as access dysfunction, thrombosis and infection. Summary: Based on the available evidence, it would appear that arterial-arterial prosthetic loop is a definitive option for maintaining dialysis access in patients with no more arteriovenous access options. Translumbar and transhepatic dialysis catheters may offer short- and medium-term options and right atrial grafts may also be suitable as an option where arterial-arterial prosthetic loop is unsuitable.

Alça arterial subclávio-axilar para hemodiálise

“…A aplicação de cateteres translombares e trans-hepáticos tem sido alternativa importante, porém o risco de infecção e a patência por longo prazo são um empecilhos para uso destes dispositivos como acesso definitivo. Poucos estudos avaliaram o uso de pontes diretas para o átrio direito como uma medida extrema nos casos de falência vascular, porém apresenta complicações potencialmente graves como falência cardíaca por aumento da pré-carga e relacionadas à cirurgia, como mediastinite 2,3 .…”

The Michigan Appropriateness Guide for Intravenous Catheters in children with congenital heart disease: miniMAGIC-CHD

“…The feasibility of these alternative routes of access have been previously reported in patients with congenital heart disease. Utilization of transhepatic catheters may be associated with increased rates of complications, such as thrombus formation, catheter dislodgement, and infection, in comparison to traditional catheter routes; however, no long-term complications or increase in infection-related catheter removal have been found [13][14][15][16][17]. Thus, consideration of these alternative access devices and approaches should be considered, though reserved for children with limited availability of other sites [2].…”

“…Utilisation of trans-hepatic catheters may be associated with increased rates of complications, such as thrombus formation, catheter dislodgement, and infection, in comparison to traditional catheter routes; however, no long-term complications or increase in infectionrelated catheter removal have been found. [14][15][16][17][18] Thus, consideration of these alternative access devices and approaches should be considered, though reserved for children with limited availability of other sites. 2 Vessel visualisation with ultrasound should be employed whenever achievable to minimise vessel trauma and the number of access attempts.…”

Exhaustion of Vascular Accesses for Haemodialysis: Access by Thrombosed Vein

“…a. Translumbarpuncture of the inferior vena cava [3,4] Renal Replacement Therapy b. Direct puncture of the superior vena cava [5] c. Transliver puncture [6],…”