Frequently Asked Questions
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question to Fistula First
General
Change Concept 1 - Routine CQI Review of Vascular
Access
Change Concept 2 - Timely Referral to Nephrologist
Change Concept 3 - Early Referral to Surgeon for "AVF
Only" Evaluation and Timely Placement
Change Concept 4 - Surgeon Selection Based
on Best Outcomes, Willingness, and Ability to Provide Access Services
Change Concept 5 - Full Range of Appropriate Surgical
Approaches to AVF Evaluation and Placement
Change Concept 6 - Secondary AVF Placement
in Patients with AV Grafts
Change Concept 7 - AVF Placement in Patients with
Catheters Where Indicated
Change Concept 8 - AV Fistulas Cannulation
Resources for Staff
Change Concept 9 - Monitoring and
Maintenance to Ensure Adequate Access Function
Change Concept 10 - Education for Care Givers and
Patients
Change Concept 11 - Outcomes Feedback to Guide
Practice
General
Q: We have been told that women, patients with diabetes, and elderly patients are not good AV fistula candidates. Is this true?
A: Studies have come to different conclusions on these issues. What is key is that strategies such as vessel mapping and vein transpositions will definitely increase the opportunities for all patient groups to have an AV fistula - regardless of demographics, co-morbidities, or other factors.
Q: I’m am an interventional radiologist. We’re initiating a vein
preservation program at our hospital for ESRD patients, following the KDOQI
guidelines. I was wondering if you would have any advice as far as the logistics
of implementing KDOQI guidelines for vascular preservation.
A: It is good to hear that your center recognizes the importance of this issue
and is being proactive. I would refer you to Change Concept #2 on the website,
with attention to both the bullet on "educating patients…on protecting vessels",
as well as "related tools". (There are also articles in the Literature section,
under Change Concept #7.) In my own program, we established a policy within the
hospital (especially ER and ICU/CCU services) that any patient with ESRD or a
diagnosis of CKD, is not to have a PICC or subclavian line, or an IV above the
wrist. IV access in the hand or via the Internal Jugular in these patients is
acceptable. Many use small IJ central catheters tunneled like cuffed catheters.
Dr. Scott Trerotola, a very experienced IR and a member of the Fistula First
coalition, wrote a paper on his group’s experience. We also have standing orders
on the charts of our patients, as well as an order for placement of a large sign
at the bedside stating "No Needle Sticks in…" (the access extremity or planned
access extremity), as well as "No PICC Lines". The patients and families are
educated not to allow any IV or blood-drawing above the wrist – and the patients
wear a medic-alert bracelet. Please navigate the website and inform your
colleagues about this resource as well. (L. Spergel, MD)
Q: I am a department director for a hospital. My floors are the CKD
floors. I am having an issue where the lab has just initiated a policy where
they want a physician’s order for lab draws on arms that have non-functioning AV
grafts or fistulas. I agree that on a functioning fistula or graft, a needle
stick below the graft or fistula should be limited and avoided, but when the
fistula or graft are not functioning and the physician cannot fix it by a
revision, that the lab should be able to draw (blood) from that arm. My
physicians are also in support of no order for a draw on a dead (AV) fistula or
graft. So I guess my question is, is there any literature or research out there
discussing the care/ability to draw blood below the fistula or graft for routine
labs? I have searched your website and other sites, but there does not seem to
be any information on studied on this.
A: I see that there is an issue related to distal blood draws on upper
extremities with a functioning access – as well as an issue related to the
extremity with a non-functioning access. I am not aware of any studies dealing
with this issue. With respect to the extremity with a functioning access, the
general recommended practice by Fistula First is that blood draws should be done
in the non-access hand, to preserve veins that may be needed for future access.
The next place to consider would be the access extremity hand, or possibly
higher but below the access, depending on the circumstances. If these peripheral
sites are not available, and this CKD or ESRD patient is going to require
multiple venipunctures, then a small internal jugular (IJ) catheter should be
placed. If only a few venous punctures are needed, consideration should be given
to using the femoral vein for the few or infrequent draws. (You can also
consider a temporary, reusable vein "lock" device, with a resealable top.) In
the extremity with a non-functioning access, although it would appear to be
unnecessary to require a written order for venipuncture on an extremity with a
non-functioning access, I do not agree with such a policy. Given all of the
options for access, especially AVFs, this extremity may well be needed for a
future vascular access, based on another vein in the same extremity – or even
the same vein attached to the abandoned graft. Therefore, the very veins that
will be used for blood draws are the veins that need to be preserved. In most of
these patients, a prior graft has produced mature, arterialized veins that can
be used for future access, often an AVF (secondary AVF). If these ideal veins
are destroyed by repeated venipunctures, the future AVF options will be
compromised. As a result, I advise that the site for blood draws be
individualized to each patient with CKD or ESRD following admission, the
decision being made by the informed nephrologists or access surgeon, after
examination and review of the access history and plans. Orders should then be
written in the chart with respect to the location for blood draws, along with an
MD to contact for any questions or problems, so that there is no guesswork
following admission. An alert should be posted both on the outside of the chart
and at the bedside to reduce the chance of a mistake. (L. Spergel MD)
Q: Should patients who self-cannulate wear gloves to do so? Why or why
not? Are there any guidelines on use of gloves for self-cannulation?
A: There is agreement from several cannulation experts associated with the AV
Fistula First project that patients should wear gloves when cannulating their
vascular access, especially with AVFs. Gloves can be awkward, etc. but it’s much
safer to err on the side of caution/safety when dealing with the possibility of
infection. The access is an open line to the bloodstream, and requires
meticulous care! (V. Peters, RN)
Q: Can a patient have a fistula created if they are MRSA/VRE/C difficile
positive (or any presence of infection) prior to discharge home to start home
dialysis treatment from the hospital? I know if it is a native vein/artery, the
chances of infection is very small (other than local) and most of these patients
are or have had the course (ongoing or completed) of antibiotic therapy.
A: It is true that AV fistulas in general have lower infection rates than
artificial vascular access (grafts and catheters), but no vascular access
procedures should be initiated if the patient is in the stages of an acute or
active infectious process. Once the active infection is either resolved or
adequately treated with antibiotics (evidenced by negative blood cultures and no
visible tissue infection), then vascular access procedures can be done. Patients
who are chronic carriers or have a history of recurrent infections are still
candidates for AVF, providing they are not having an acute episode. (AVF is a
particularly good access for home hemo patients, since it has fewer
complications of all types.) (V. Peters, RN)
Q: I should be grateful if you could let me know how to calculate the rate of
infections in AV fistulae.
A: There is a choice of several computations for infection rates: 1) A simple
percentage/proportion, i.e. #AVF with infection (numerator) divided by the #AVF
in the clinic (denominator). You can compute this on a monthly, quarterly, or
yearly basis. 2) You can also do comparative calculations with other types of
access: #AVF with infections (numerator) divided by total number of patients in
the clinic (denominator), then compare with the #grafts with infections divided
by total number of patients in the clinic, or the #catheters with infections,
etc. 3) There are also more sophisticated statistics you can use (e.g.
Chi-square), but you may need to find a statistics text or work with a
statistician on those. You can find more information and calculation ideas on
the United States Renal Data System (USRDS) website and in their annual report (www.usrds.org).
(V. Peters, RN)
Q: With tunneled venous catheters in place, do you advise your patients to
never shower or to wet the catheter? This is a simple issue but for a patient
not to shower, etc. for 2-3 months is becomes important. Personally, I feel that
soap and water (especially the heavily chlorinated variety from municipal
supplies) is preferable to unbathed skin and high bacterial counts. All my
referring nephrologists are adamant that these patients do not wet the catheter.
Any advice?
A: With regard to the catheter issue, after all these years the jury is still
out. There are those, including major dialysis providers, who permit patients
with well-healed exit sites to shower and cleanse gently with a mild soap and
reapply a simple dry dressing. At dialysis, the exit sites and catheter are
cleansed, disinfected and dressed according to a protocol. At the other end of
the spectrum, in order to be on the safe side, many recommend keeping the site
covered and dry at all times, not allowing water to come in contact with the
dressing at all, i.e. no showering. And in the middle there are those who allow
showering for the reasons you describe, but only if the dressing is in place and
an additional cover, such as plastic wrap, is taped over the dressing. The new
KDOQI practice guidelines continue to recommend keeping the site dry and no
showering. However, this is a recommendation based on opinion and an attempt to
be on the safe side to keep the risk of infection to a minimum. What we need is
a good study to determine if there is a difference in infection rate between
intermittently uncovered wet sites and sites which are always covered and dry.
One possible approach, which I use, is to choose an option based on the
particular patient. My general approach in the beginning of use is to follow the
keep-it-dry-no-shower routine. I will then continue this for patients who are
not active and/or do not have good hygiene, or are okay with sponge-bathing for
a long period. However, for patients who are active, work, have a social life,
play sports, etc. – as well as those who just want to continue showering – I
will either allow them to remove their dressing, wash gently and replace with a
sterile dry dressing, or if they can afford it, to purchase a specific covering
pouch that is available and made specifically for this use. I think that if the
exit site is well healed and this is a tunneled, cuffed catheter, that
intermittent clean running water will not cause any problem. However, this is
just a personal opinion and we still do not have the (scientific) answers. I do
believe that the inability to shower is a real problem for many people, and
whether or not a covering is used to protect the exit site, the option of
showering should be made available. Separate from the water issue, many
(including myself) use an adherent dressing for the exit site, when available,
instead of a dry gauze dressing with tape, which doesn’t cover much and often
comes off. These hold up very well and some claim a lower infection rate with
this cover. I have been using these for years with the Groshong catheters, which
are left in place for long periods to treat AIDS patients, with a miniscule
infection rate in spite of the compromised immune state of these patients. Even
when patients showered with these dressings, I didn’t see an infection problem.
(This should further confuse the issue!) (L. Spergel, MD)
Q: I am a Social Worker in a dialysis clinic. I am interested in finding
out if there is any information about the social worker’s role in increasing
fistula use. It seems to me that attitudes and emotional or behavioral issues
are a big part of the picture. I appreciate any information you can refer me to.
A: The AV Fistula First Breakthrough Initiative definitely supports the
involvement of social workers in this initiative. We just posted an entire array
of patient education resources on the AV Fistula First website, and that
document addresses some behavioral and adjustment issues, with links to many of
the renal organizations that put out related materials and other resources. You
might also look through the National Kidney Foundation’s website since they have
social worker (CNSW) groups that meet in various regions of the country. (V.
Peters, RN)
Change Concept #1
Q: What are the responsibilities of the facility staff member in charge of vascular access continuous quality improvement (CQI)?
A: The vascular access coordinator (VAC) serves to coordinate and oversee vascular access information and care for the facility, with a focus on maintaining optimal access function and longevity. The VAC works closely with the facility medical director and assures that a facility-based vascular access CQI program is implemented and functioning.
Among his/her duties, the VAC maintains and reports vascular access data to assure tracking and trending of pertinent vascular access-related performance indicators and outcomes, handles communication and collaboration duties as liaison with the multidisciplinary access care team, and oversees and directs vascular access planning for current and future accesses. At a minimum, the VAC should meet with the medical director and other facility staff on a monthly basis to review VA issues. A meeting of all members of the multidisciplinary vascular access team ideally takes place at
least quarterly.
See the following related information:
Routine CQI Review of Vascular Access
Q: What are the most effective ways to teach a patient about access options and the superiority of an AVF - and who should provide this education?
A: All members of the health care team have a professional obligation for patient teaching. However, to optimize effectiveness and avoid duplication of effort it can be beneficial to plan a comprehensive patient teaching approach that clarifies responsibilities and involves a multidisciplinary perspective. This should be part of the organization’s vascular access management plan.
See the following related information:
Routine CQI Review of Vascular Access
Education for Care Givers and Patients
Q: What indicators should facilities track that will provide meaningful data for evaluating vascular access programs?
A: Facilities can start by measuring performance on a monthly basis by access type - catheter, arteriovenous (AV) graft, and AV fistula - since access type is the major determinant of outcomes and directly affects dialysis delivery and adequacy. It is also important to focus specifically on native AV fistula outcomes and performance, including tracking the monthly AV fistula placement and failure rate in incident as well as prevalent patients.
The National Vascular Access Improvement Initiative (NVAII) has developed a the
Vascular Access Tracking Tool (VATT), a data collection tool that can help facilities measure and track AV fistula rates (and all access types) in incident and prevalent patients. This data tool (in Microsoft Excel format) permits simple tracking of not only
AV fistulae that are in use but also AV fistulae that have been placed and are awaiting maturation.
In addition to access types, a summary of the minimum vascular access-related measurements that facilities should track and report include:
- Number and percentage of patients with catheter
- Number and percentage of patients with catheter only
- Number and percentage of patients with AV graft
- Number and percentage of prevalent patients with AV fistula
- Number and percentage of incident patients with AV fistula
- Number of vascular access-related hospital admissions
- Number and percentage of vascular access clotting events for AV graft and AV fistula
- Number and percentage of vascular access infections for catheter, AV graft, and AV fistula
- Number of vascular access-related outpatient events
- Number of missed treatments due to vascular access problems
- Number of vascular access-related deaths
Finally, facilities should measure and track the outcomes of access-salvage interventions, as studies have shown that a significant percentage of interventions are either not successful or fail within a short period of time.
Q: For tracking and reporting purposes, please define the terms "incident" and "prevalent."
A: "Prevalent" refers to all chronic (maintenance) hemodialysis patients on dialysis in the provider facility at a given time.
"Incident" is the subset of prevalent patients who are new hemodialysis patients. That is, they are patients who have their first outpatient chronic hemodialysis treatment in the provider facility during the month being reported.
Change Concept #3
Q: What is the purpose of referring a new patient to the surgeon for "AVF only" - and what is the role of vessel mapping?
A: Such a referral ensures that a surgeon will initially evaluate the patient for an AV fistula. It also serves to focus everyone’s attention on the goal of providing the patient with the best chance of having an autogenous (native) AV fistula before considering an AV graft or catheter for maintenance hemodialysis.
If the surgeon cannot find suitable blood vessels for an AV fistula on physical exam with a tourniquet, Doppler ultrasound or alternate technique should be used to do vessel mapping (identification of vessel anatomy) to search for suitable vessels that may be too deep to be identified on physical exam. Numerous studies have shown that vessel mapping identifies vessels suitable for an AV fistula in the majority of patients where physical exam alone classified the patient as not being a candidate for an AV fistula.
See the following related information:
Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement
Q: When an artery is scanned as a part of preop vessel mapping, do you
"routinely" scan the entire artery from wrist to elbow?
A: It is recommended to do so, because there are often arterial stenoses (higher
in the extremity), some studies reporting it in up to 30% of patients.
Q: I am a wound care nurse for an area hospital, and being a dialysis
nurse for 17 years I watch how our hospital treats new ESRD patients. I get
disappointed when a nephrologist tells the discharge planner to start working on
locating a suitable outpatient unit for the patient, and it seems like it ends
there. I expect them to pick up the phone and call the preferred surgeon to
insert a permanent vascular access as soon as the patient is diagnosed "ESRD". I
have expressed my concern to the VP of nursing in our facility to look into
these issues, as this could also be a revenue-generating action for the
hospital. We need to advocate that a new ESRD patient released from us should be
discharged with a maturing access. This also makes a happier and healthier
patient, and also a happier outpatient dialysis center! My exact words were "we
should act responsibly to these patients we send home by making sure that they
have a permanent access, and if we do this early, we can create a better access
with a fistula than waiting later and the patient may just be suitable for a
graft."
A: I’m delighted that you have become such a great advocate for patients
obtaining a permanent vascular access in your hospital setting. You are exactly
on the right track, because we’ve found that when access evaluation for the
patient is "missed" during their primary hospitalization, it takes approximately
5-6 months (sometimes as much as 9-10 months, depending on insurance) to get the
patient back to complete the surgery and get a functioning fistula. That time
lag obviously opens the patient up to all the risks of infection and other
complications associated with catheters during the interim. There are a number
of resources on the Fistula First website (tools) available to assist you. I
would also recommend consulting with your local ESRD Network, since they have
many resources and are in the process of teaming up with local Quality
Improvement Organizations and hospitals to encourage the adoption of Fistula
First best practices. (V. Peters, RN)
Change Concept #4
Q: What criteria should we use to evaluate a surgeon doing vascular access?
A: It is important that the vascular access surgeon be willing to participate as a member of a
multidisciplinary vascular access team and possess not only the skills and judgment required for this highly specialized and demanding area of surgery, but also the ability to perform the entire repertory of AV fistula procedures, including vein transpositions. The surgeon treating a hemodialysis patient should also
possess a caring attitude and the willingness to be available and devote the time and attention needed to provide the patient with the best evaluation and optimal surgery in a timely manner and based on a long-term plan. In the absence of a medical contra-indication, the surgeon should be dedicated to providing a native AV fistula as the optimal access for every patient, where feasible.
In addition, the vascular access multidisciplinary team should collect data and evaluate the access surgeon by their outcomes at least every quarter. Questions that need to be answered are: what percentage of access procedures are autogenous (native) AV fistulae, are the minimal
K/DOQI standards being met, and are the outcomes of those procedures good? Surgeons doing access should be expected to meet minimal performance standards.
See the following related information:
Surgeon Questionnaire
Change Concept #5
Q: What are vein transposition AV fistulae and how successful are they?
A: When suitable superficial veins are not available for AV fistula construction, there are usually deeper veins that are suitable. These veins and their suitability can be identified by vessel mapping and then surgically repositioned (transposed) to a superficial location suitable for cannulation. Transposition can also be done for veins that may be superficial enough but not positioned for safe cannulation.
In general, the success rates of vein transposition AV fistulae are similar to those of the conventional simple direct AV fistulae. What is critically important is that vein transpositions have expanded the AV fistula opportunities and options for patients who would otherwise receive an AV graft or catheter if only the more conventional constructions were employed. Adding transposition AV fistulae to the options, armamentarium is estimated to enable 80 to 90 percent of new patients to be candidates for an AV fistula.
For information on a video training series for surgeons,
click here.
Q: Do vein transposition AV fistulae require a longer maturation period or special care?
A: In some cases the maturation period is longer - three months or more - because some of the deep veins used for transpositions are initially more delicate and thin-walled. Cannulation technique and protocol is the same as for conventional AV fistulae (see
Cannulation of New Fistula Policy and Procedure).
Q: Dr. Spergel, I attended a Fistula First (surgical) conference about two
years ago. I placed a proximal radial AV fistula in a morbidly obese lady who
weighed over 300 pounds. There was essentially no cephalic system in this
patient’s forearm or upper arm. The fistula has developed nicely into the
Basilic vein. The median antecubital vein is usable only from the deep
communicating branch and then to the basilic vein cephalad. There is nothing
usable other than that in the forearm. A transposed basilic vein seems to be my
only option for a fistula. I am concerned about losing considerable length on
that vein bringing it out to the surface and then back down again to the
brachial artery in this extremely fat arm. I did check with Dr. Jennings
inquiring whether or not he had ever utilized an extension of saphenous vein to
the median antecubital vein to gain some length for this type of fistula. He
replied that he had not, but that you had done that. We do have the capacity to
do buttonhole cannulation in some patients but I am still concerned about
leaving this lady with a very short length of access on the surface. I would
appreciate feedback from you as to what your experience has been with the
addition of saphenous vein.
A: I have used vein segments to extend a short basilic vein. I try to use the
saphenous as a last resort, only because I have found (like others) that this is
not a reliably durable vein. The saphenous either works great for a long period
or fails fairly quickly – with no reliable way to predict the outcome, assuming
DU (diagnostic ultrasound) exam is normal. I study the arm with DU to see if a
suitable, distensible brachial vein is present, which is often the case if the
patient has had a forearm access with flow into the brachial. This vein is often
overlooked as a viable option that I found functions well. Even a small brachial
will dilate adequately if it is not diseased and dilates with a tourniquet. If
this is not the case, and there is not an available nearby vein that can be
used, I will use the saphenous. Even if the saphenous fails, it may only be
segmental, permitting salvage by PTA or surgical revision. Also, if revision is
required some time following AVF construction, the entire "composite" fistula
will have elongated, thereby providing additional length for a longer fistula.
Hope this provides some useful information. (Lawrence Spergel, MD)
Q: What is the minimal size of the radial artery you use for wrist RCF (radiocephalic
fistula)? What about brachial?
A: Recommended minimum diameter is 2.0 mm in adults for artery, 2.5 mm for vein,
based on Silva’s ultrasound studies regardless of location of vessel. I
sometimes use smaller diameter vessel if it is healthy and also use smaller
vessels in the pediatric (patient) group. (L. Spergel, MD)
Q: When a secondary AVF is created due to a failing graft, are the grafts
routinely tied off at that point or left patent for continued use as the AVF
matures? We have a couple of clinics ask recently which they are to use, the
graft or fistula. I have advised them to call the surgeon and ask the plan, but
want to know what is routinely done.
A: It depends on how the secondary AVF is created, so they need to discuss each
case with the surgeon. If the outflow vein is used, the graft is almost always
ligated and hopefully the new AVF is usable immediately, since it should be
mature from being the outflow vein for a long period during graft use. Some
surgeons keep the graft "alive" by attaching it to another vein at the time that
the outflow vein is disconnected and made into an AVF. If the new AVF is at a
remote site, then the old graft can usually be used until the new AVF is ready.
(L. Spergel, MD)
Q: As an access procedure absolute "last choice", have you any experience
using a synthetic graft from the axillary artery tunneled over to the distal
superior vena cava (SVC)? This area is relatively easy to expose via a costal
cartilage excision approach, but I can’t find this in the literature – some
references have used the atrial appendage as the outflow but not the SVC. Any
advice about these issues would be greatly appreciated.
A: I have not come across the specific surgical approach you describe in the
literature either, although I am familiar anecdotally with the same or similar
procedures utilizing the vena cava when the subclavian or internal jugular were
not available. As you know, one often has to be creative, but as long as there
is an adequate inflow and outflow, it usually works. I would mention a couple of
cautionary comments when getting into the chest and involving the vena cava and
atrium, which deal with the consequences of infection. When prosthetic is used,
obviously the (infection) rate goes up, just related to the multiple
cannulations. Then, if the graft thromboses repeatedly, the risk increases
further. If that infection progresses quickly, that entire graft may have to be
removed, which could make for a difficult situation. Also, if the graft is too
long, as is sometimes the case with creative and "exotic" accesses, the flow
will be reduced and may cause the graft to fail. Certainly, if this is used as
you say, as a last resort, then the patient has to accept the risks for the
benefit obtained – and I wouldn’t hesitate to do it. Other options, if you have
not yet considered them, are: the PRA AVF as described by Dr. Jennings, who
co-produced the surgical DVD series with me; transposition of the femoral vein;
and a simple posterior (or anterior) tibial artery saphenous vein AVF. The added
benefit with these procedures is that they are autogenous. Finally, I don’t know
if you received the surgical DVD program. If not, your ESRD Network can send it
to you at no cost, or you can go to the link on the Fistula First website to
view it as streaming video or slides. (L. Spergel, MD)
Q: I attended a symposium, and was very impressed at the fact that it takes
to little time to convert a graft to a fistula and be used right away, avoiding
the use of a catheter. I had sent one of our patients back to his surgeon for
fistula evaluation when he had the thrombosed AVG with successful PTA, and I
noticed a huge vein in his upper arm. I was told by the surgeon that "nothing
could be done". Do you know of any vascular surgeons in (county area) doing this
procedure?
A: Unfortunately, I do not know the surgeons in your area. With regard to your
second question, most recommend waiting at least 2 weeks for the anastomosis to
heal before doing anything. Some recommend waiting 4 weeks, that the AVF be
evaluated and undergo PTA or surgery if a significant stenosis or other lesion
is identified. Hope this helps. (L. Spergel, MD) For information on local
surgeons, contact your local ESRD Network. They can put you in touch with some
high-AVF facilities in your area, and you can find out which surgeons they use
to get good results. (V. Peters, RN)
Q: I attended one of the Fistula First (surgeon) programs earlier this year.
My patient has a good median cubital vein flowing in to a good basilica vein
that stays superficial (within 1 cm of skin surface) up to the axilla. He has a
2-3 mm median antecubital vein but no substantial cephalic vein in arm or
forearm. My plan is to do a PRA fistula to side of the median cubital vein in
continuity with the median antecubital vein. Although the Basilic vein is
superficial in the arm, my concern is for the safety and convenience of
accessing it in this medial location. I asked one of the experienced dialysis
nurses if she thought this might be a problem, and she felt it would be fine,
but I still have a concern. What do you think about this plan?
A: Thank you for your query; I agree with your concern. Although the vein
appears to be superficial, we all know that it runs deep to the fascia after a
short distance from the antecubital fossa. The cannulator, especially if
inexperienced (as opposed to your experienced consultant) may get fooled and
then find a deeper stick is needed – only to strike the brachial artery, with an
ensuing potential disaster. However, having stated that, there are 2
circumstances where I have not transposed the vein: 1) Where the vein is easily
visible and palpable (as in this case) and it is agreed that only an experienced
AVF cannulator will be doing the cannulation. Then, if problems ensue, you can
always do the second stage transposition, or 2) Where the segment of vein above
the fossa is prominent and the "buttonhole technique" is to be used. In this
situation, only a short cannulation segment is needed, since the same two
cannulation sites will be established and used (no need for a longer cannulation
segment, since no rotation of sites). If your nurse is comfortable with either
option above, you could give it a try. Just be sure to stay as distal as
possible with your anastomosis in order to have ample vein to transpose should
you decide later to transpose. The good news is that if you need to transpose
later, the vein will be quite mature and elongated, giving you more vein length
than you would have had if you did a 1-stage BVT. If any questions, let me know.
You might refer your nurse to the Fistula First website for information on
"buttonhole" and other cannulation issues. (L. Spergel, MD)
Q: As part of the FFBI, you have suggested that a "full range of appropriate
surgical approaches to AVF evaluation and placement" be considered. Does this
mean you do not encourage the use of non-standard techniques? Is it considered
standard technique to raise the brachiocephalic vein closer to the skin through
the use of suction-assisted lipectomy? I am not familiar with this technique as
it relates to vascular surgery procedures (I have seen it used in cosmetic
surgery procedures only), can you suggest any references or reading materials
that might be of help?
A: First, the intent of "a full range of appropriate surgical approaches" is to
recommend that surgeons doing access be familiar with the various AVF procedures
beyond the older, simpler procedures that limited AVF options. The newer
procedures include the transpositions and others – all of which have been
established as viable AVF options by clinical trials and reporting in
peer-reviewed publications. With respect to newer AVF procedures, such as
experimental procedures that have not yet been established in the manner above,
Fistula First neither endorses nor rejects these as AVF options – until such
time as evidence supports one position or the other. The specific procedure to
which you refer is fairly new and is currently being used by some surgeons, in
lieu of a surgical transposition, to bring the skin close to the vein (AVF) by
removing the intervening fat layer to allow for safe and easy cannulation. It is
the equivalent of a vein transposition, whereby the vein is surgically moved to
a superficial position. It certainly appears to be a viable concept, in that it
would obviate the need for a more involved surgical procedure to move the vein.
Hopefully, clinical trails will support the use and standardization of this
procedure. Until then, Fistula First would have no position on this procedure,
one way or the other. Fistula First does not discourage the trial and use of any
AVF procedure; in fact, quite the contrary. For example, all of the newer
transpositions were at some time "non-standard", but with trials and reporting
that provided evidence and outcomes that justified their use, they became
standard options that could be recommended. Simply stated, Fistula First does
not dictate practice, but will make recommendations when certain scientific
criteria are met. (L. Spergel, MD)
Q: I know the AVF rates in other parts of the world are much higher than the
U.S. I had someone ask me why, and I did not feel sure of my answer, so I told
that person I would ask the expert! Can you help me out?
A: I have studied this issue extensively, and there are a number of reasons and
explanations. But the root cause for the high rate in other countries is that
when we became a "graft culture" beginning in the mid-1970’s when PTFE grafts
came on the scene, other countries could not and would not pay the high price
for grafts. In addition, their hemodialysis patients were selected based on
suitability of vessels as well as other factors. But in this country, the good
news is that everything is paid for an obtainable if it is ordered for the
benefit of the patient. In this case, it turned out not to be such good news,
since we had no idea of the problems we were going to face with grafts (and
catheters). Since grafts were so easy to obtain in any size and length, and easy
to place, surgeons didn’t have to rely on the patient’s vessels, which were
often poor – and often failed or did not mature. Unfortunately, no one knew
about the problems associated with grafts, the most common of which is intimal
hyperplasia, responsible for stenosis and eventual failure of the access. Now
that we have learned these lessons about problems associated with grafts (and
catheters), it is extremely difficult to change practitioner behavior and
practice to establish a "fistula culture" after 30 years of using grafts. Our
surgeons have not yet learned to perform all of the AVF procedures that are
skillfully performed on a regular basis in other developed countries. And
nephrologists have not had the proper education about AVF’s as well. That is
where Fistula First comes in. Through education and training and raising
awareness about the problem, we are (beginning to) see a gradual transition from
grafts to fistulas over the coming generations of practitioners. This will take
time. (L. Spergel, MD)
Q: At a vascular society meeting here, one of the surgeons asked if there
were any studied or published reports on AVF’s with slower maturation having
less steal than AVG’s? If you are aware of any studies, I’d appreciate some
direction.
A: No studies, and there would not really be a need for one, since any condition
that causes a non-maturing AVF (i.e. diseased artery with poor inflow, a
diseased AVF vein, etc.) will result in low flow and thereby reduce the chance
or severity of steal. Since AVFs will remain patent at very low flows, and AVGs
will not, there is more chance that a higher percentage of new AVFs will have
less steal (and ischemia) than AVG’s, since 20-30% of AVFs will fall into the
category of "failed" or "failing to mature". Grafts have a large diameter and
therefore do not have to "mature" (increase diameter and thickness) and
therefore do not have this failure-to-mature/low flow problem. But remember, an
AVF with the same low flow as an AVG will produce the same degree of steal and
ischemia, as it is a high access flow which "steals" blood flow from the distal
extremity, regardless of whether the access is a fistula or graft. (L. Spergel,
MD)
Change Concept #6
Q: What is meant by a "secondary" AV fistula?
A: In the context of the
NVAII initiative, this is an AV fistula placed in a patient whose initial access was a graft. Staff should consider every graft patient a candidate for an AV fistula and should evaluate each patient for an AV fistula before the graft fails. In this way, a plan will be in place for providing the patient with an AV fistula when the graft begins to fail. This avoids the need for a catheter or missing an AV fistula opportunity when the graft fails and there is urgency for an immediate usable access.
See the following related Change:
Secondary AVF Placement in Patients with AV Grafts
Q: How soon can a secondary AV fistula be cannulated?
A: If the secondary AV fistula uses the outflow vein from an existing graft, it usually can be cannulated immediately. However, to confirm that the outflow vein can be used immediately if converted to an AV fistula, staff should test the outflow vein before converting (sacrificing) the graft by attempting cannulation of the outflow vein while the graft is still being used.
If the secondary AV fistula uses a new vein, then the maturation period will be the same as for any new AV fistula: a minimum of 6 weeks, with a recommended waiting period of 8 to 12 weeks.
See the following related Change:
Secondary AVF Placement in Patients with AV Grafts
Change Concept #7 Q: We have many patients with permanent catheters because of exhausted permanent access sites. Is an AV fistula still an option for these patients?
A: In most cases, yes. In fact, studies have shown that when patients considered to have exhausted permanent access sites are re-evaluated and undergo vessel mapping, at least two-thirds are found to be candidates for an AV fistula. Vessel mapping is critical in identifying these AV fistula candidates.
See the following related Change:
AVF Placement in Patients with Catheters Where Indicated
Q: Why is it so important to remove a central venous catheter as soon as possible?
A: Complications, including infection, catheter failure, thrombosis, inadequate dialysis, and central venous stenosis and occlusion, occur frequently with catheters - and the complication rate rises sharply with duration of use. Studies have also reported that catheter use is associated with an increased mortality risk.
See the following related information:
Reducing Central Venous Catheter Infections Cause and Effect Diagram
Change Concept #8 Q: We started buttonhole this year and
it seems very successful for a number of patients. Now we wonder if there is any
experience on buttonhole protocol for grafts or in PTFE grafts? We would be very
grateful to have some more information on this topic.
A: Regarding your question on use of buttonhole cannulation technique on
grafts, please be aware that buttonhole (constant site cannulation) is NOT
recommended for use in PTFE or any artificial graft material. Continuous use of
the same spot on those vascular access materials can result in damage to the
graft, and hematomas and/or other complications for the patient. Use rotating
sites for cannulation on those materials. Buttonhole is ideal for native tissue
in an AV fistula, since the tissue develops a more usable "track" after repeated
use with less damage to the vessel. (Remember, live tissue can repair itself.)
Hopefully you have found the articles on buttonhole and other cannulation-related
tools in the Tools section of the Fistula First website. (V. Peters, RN)
Q: I am a nephrologists. You recently fielded a question about using
buttonhole technique in patients with limited space for needle insertion in
their AV graft and with recent stent-grafts placed in those areas. I have not
found any literature on the use of buttonhole in AVG, but it sounds good to me
from a theoretical perspective (with a single hole in the AVG, the graft should
not degrade or develop pseudoaneurysms). Please let me know your experience or
any references in the literature regarding this issue.
A: There are no studies or reports on the use with AVGs of which I am aware, but
there are those who plan to try this technique with grafts. At this time, I
would strongly advise against use with AVGs, at least with synthetic grafts
(i.e. PTFE). The issue of concern is hemorrhage. The safety of establishing a
short permanent track to and through vein is based on the ability of a vein to
develop a flat and for the vein wall to be able to close upon itself, thereby
filling in the vein defect until the next cannulation. There is some histologic
evidence from explants to support this. This does not happen with PTFE, and the
concern is that the fibrin plug, which fills in the PTFE defect, which does not
close upon itself, could blow out – especially in the presence of infection or
simply hypertension. The Vectra graft is a different animal, as it is made to be
self-sealing. This might present an even more problematic scenario, as the blunt
buttonhole needle could not be used, since the defect in the thick-walled
conduit would close upon itself, possibly tightly. Thus, every cannulation would
require a sharp needle, which would likely destroy the graft wall, as with
"one-site-itis", with eventual hemorrhage through an established track. The
answer to your question would require a study, but I would not recommend its use
without any supportive evidence, as there is for autogenous use. Thanks for your
interest, and stay tuned. (L. Spergel, MD)
Q: What is your opinion, or what is known about buttonhole in either bovine
or impra grafts? One of our surgeons is pushing it and we are holding off at
this point…
A: I am not aware of any published data on the use of buttonhole with bovine
grafts. The use with PTFE has been avoided and not recommended because of the
concern about establishing a permanent track to and through the graft where only
a clot plugs the hole after cannulation – which could likely blow out and result
in hemorrhage. Studies need to be done on this with synthetic grafts, but I
would not recommend being the first on the block to try this, considering the
potential life-threatening consequences. Finally, I would also hold off on
bovine or other biologic graft materials for now, since when these grafts are
treated, sterilized and then used for cannulation, they have a history of
disrupting and especially of getting infected and having to be removed. Since
same-site cannulation involves some degree of contamination with the scab that
forms each time that has to be removed, the risk of infection is significant for
a graft, whether PTFE or bovine, but especially bovine. As you know, native vein
is more resistant to infection. Hope this helps. As buttonhole is used more in
this country, all of these questions will be answered. For now, I would be
conservative, and limit use to native vein. (L. Spergel, MD)
Q: I am a nurse clinician working in the dialysis unit of a
hospital. I have been a dialysis nurse for 8 years now in both chronic and acute
settings. I browsed the net for resources regarding cannulation technique,
however there has been NO mention of studies about wet-stick versus dry-stick
cannulation technique. Facility policies differ from each other, though a few
would advocate both, but a lot of clinics force employees to follow just one,
though no evidence I have encountered so far show the advantage of one over the
other. Please refer me to appropriate resources so I can initiate efforts to
investigate this concern. I believe that there are advantages and disadvantages
to either approach, however, should we as staff use the technique we are used to
and comfortable with for the best interest of our patients and the safety and
longevity of their lifelines as well?
A: If you are looking for clinical research on cannulation techniques, the sad
answer is the research has not been done. What you currently use as your basis
for cannulation policy and procedures is tradition and theory. The "wet" needles
were used when dialysis first started. The tradition was stopped due to cost of
the extra syringe, needle and alcohol prep. Many other countries still use "wet"
needles. The procedure is now part of the 2006 KDOQI Vascular Access guidelines
because the committee agreed that if saline is used to flush the needles
(especially with new AV fistulas) it is safer to the vascular access than a
(possible) infiltration with blood. In case of infiltration, saline is more
easily absorbed by the tissue and poses a lesser risk of infection (blood in a
hematoma can lead to infection). The idea is also to check the needles for not
just a blood return (as done with "dry" needle when just bleed-back to the hub)
is not good enough to identify if the needle is in the vessel or not. The danger
of not checking a venous needle carefully is just starting the blood pump can
and has lead to a severe infiltration and can also lead to loss of the AVF. The
saline flush is not harmful to the vessel in any way. (Deborah Brouwer, RN)
Q: We have adopted the Fistula First recommendations regarding cannulation of
new fistulas in our hemodialysis units. The nurses are questioning why week one
recommends the arterial be accessed for needle placement if there is a catheter
present, rather than venous. The obvious answer is less trauma if infiltration
occurs. Is there literature out there to back that up? I’ve looked and haven’t
come up with anything yet.
A: In response to your query about literature on arterial vs. venous for AVF
needle placement when a catheter is present, the 2000 KDOQI guidelines (vascular
access guideline #9), originally stated "use of an AV fistula can begin with
placement of the arterial needle only, with return flow accomplished by means of
a catheter". The most current version of KDOQI (2006, Guideline #3, under
"cannulation tips") states "The combined use of the new fistula and bridge
vascular access (e.g. TCC [tunneled cuffed catheter] as a return for blood) may
be necessary until the fistula is well developed." There is general agreement
that pump speeds in the (venous) return lines may be too strong for the
developing AVF, and therefore the arterial line is the best connection for the
AVF, at least temporarily. (V. Peters, RN)
Q: I have a question I am struggling to learn more about, and was hoping you
could shed some light, since I have heard two sides of the coin. Can you give me
feedback regarding use of clamps at the end of dialysis, as opposed to direct
pressure to stop the site from bleeding?
A: Clamp usage varies greatly around the country, but the experts all agree that
NO clamps should be used on NEW or surgically revised AV fistulas. The
preference is to not use clamps at all. (If the patient or family member can be
taught to hold the insertion sites after dialysis needles are removed, that is
always the best option.) However, in some cases, clamp usage cannot be avoided.
In that case, there are some guidelines: use only ONE clamp at a time; make sure
the clamp is adjustable so it doesn’t put pressure on the vessel; check for a
"thrill" or pulsation above the clamp to make sure the vessel is not being
occluded by the clamp; and never leave clamps on over 20 minutes. There is a
specific clamp policy available on the Fistula First website, under Tools,
Change Concept #8. (V. Peters, RN)
Q: Do you have any literature to support the practice of inserting a needle
into a fistula bevel-down? I have a nurse who attended a seminar and was told
this is a method that should be used to minimize arterial spasm during dialysis.
All of my teaching tells me this is not an acceptable practice, however a lot of
stuff I learned many years ago may no longer be considered best practice. Any
information you can provide will be most appreciated.
A: The issue with the AVF "sucking up against the wall" (and causing spasm) is a
very different issue – that is addressed with the use of a back-eye needle.
Bevel-down needle insertion has been thought to create a cleaner cut/flap in the
AVG or AVF with needle insertion; however, the bevel- down has not been studied
in any clinical trials. It is not recommended, since the needled are
manufactured for a bevel-up vessel insertion. Do you know who the speaker was
that provided that information? It might have been a misunderstanding. No
references are available to support bevel-down cannulation. (D. Brouwer, RN)
Change Concept #9 Q: If a new AVF does not appear to be maturing and cannot be used successfully, what do we do and when?
A: We recommend that four weeks after the operation, patients have mandatory visits with the surgeon, nephrologist and the rest of the team. At that time, the AVF is not ready to use but most problems can be assessed by physical exam. The most common problems are stenosis or sclerosis near the connection with the artery.
If there is any question about whether the AVF is maturing properly, the patient should be referred to a diagnostic study (preferably Doppler ultrasound) or given an appointment for another assessment in two weeks. At that point, the team will decide either to wait, revise the AVF, or make a new AVF.
See the following related information:
Fistula Preservation, Development, and Maintenance Policy and Procedure
VAMP Vascular Access Monitoring and Surveillance Flow Chart
Q: What monitoring and surveillance methods work best for AV fistulae?
A: The
K/DOQI has established recommendations and guidelines for monitoring and surveillance:
Monitoring, which K/DOQI defines as physical examination techniques to detect access dysfunction, has been shown in many studies to be able to identify the majority of patients with AV fistula dysfunction.
Surveillance involves the use of a variety of tests to detect access dysfunction. Intra-access blood flow measurement over time is the best surveillance method available for assessing AV fistula function and detecting dysfunction.
Two other methods offer significant value for AV fistula surveillance:
- Pre-pump arterial pressure, which is measured on almost all dialysis machines, indicates the ease or difficulty with which the blood pump is able to draw blood from the access (inflow). A significant restriction of inflow will cause an excessively negative pre-pump arterial pressure. Since most causes of AV fistula dysfunction are inflow problems, an excessively negative pre-pump arterial pressure is often the earliest indication of such a problem.
- Access recirculation measurement. An AV fistula may remain patent but not provide enough blood flow to meet the prescribed blood pump flow rate, resulting in underdialysis. If there is any question about adequacy of blood flow for dialysis, or if there is difficulty dialyzing the patient at the prescribed pump rate, a recirculation study will determine if the AV fistula blood flow is not sufficient to meet the prescribed blood pump flow rate.
Note: While physicians commonly use venous pressure measurement to detect access dysfunction, it is of very limited value in AV fistula surveillance. This is because most of the flow-limiting problems in AV fistulae are on the arterial of the venous needle (and often the arterial needle as well) and therefore are not detectable by pressure measurements made at the venous (or arterial) needle, which can only detect an outflow obstruction downstream of the measuring needle(s). In addition, the fistula has tributaries that can dissipate pressure in the presence of an outflow
obstruction. Finally, access pressure measurements are not likely to identify centrally located venous obstructions.
See the
Pre-ESRD AV Fistula Planning Algorithm, a monitoring and surveillance algorithm with recommended criteria.
Change Concept #10
Q: Our facility is understaffed. What are some creative ways that we can provide AV fistula education for our patients?
A: Many resources are available for patients and their families such as the
Patient Resource List and
Staff Resource List. The National Kidney Foundation’s
Kidney Learning System is also an excellent resource.
Switching to an AV fistula (AVF) can require a change in attitude on the part of patients and staff, and everyone needs to understand the associated benefits. You may want to invite current fistula patients, who have made a positive adjustment to treatment, to share their stories about why and how they chose to have an AV fistula. They could also share their feelings about their perceived and actual improved outcomes. This patient-to-patient discussion could be done in either a group or one-on-one setting, or by pairing up patients with and without AVF. It’s important to remember
that patients should not be giving health care/medical advice!
See the following related information:
Education for Care Givers and Patients
Q: Some patients refuse to have an AV fistula because they don’t like the look of a bulging fistula. How do we deal with such body image issues?
A: The issue of body image is a very real concern that may dictate a patient’s decision regardless of the health benefits of an AV fistula, and despite the education and support that health care professionals offer. Every patient has the right to make an informed decision; it is the responsibility of the caregivers to ensure that the patient's decision is an informed one.
See the following related information:
Education for Care Givers and Patients
Q: How can health care professionals convince patients to have an AV fistula and accept the long maturation period, and possibly one or more catheters as well?
A: Patients can’t simply be "convinced." Health care professionals should discuss the outcome benefits associated with having an AV fistula (e.g., decreased infection rate, improved blood flow which increases adequacy of dialysis, decreased incidence of clotting) and make sure patients understand these benefits. Determining each patient’s actual concerns is also important. For example, a woman may be more concerned than a man about body image with an AV fistula. Once the patient’s
concerns are known, they can be addressed to help the patient cope with specific challenges which may include body image, the long maturation process, and the potential need for one or more catheters.
See the following related information:
Education for Care Givers and Patients
Q: What are the most effective ways to teach a patient about access options and the superiority of an AVF - and who should provide this education?
A: All members of the health care team have a professional obligation for patient teaching. However, to optimize effectiveness and avoid duplication of effort it can be beneficial to plan a comprehensive patient teaching approach that clarifies responsibilities and involves a multidisciplinary perspective. This should be part of the organization’s vascular access management plan.
See the following related information:
Routine CQI Review of Vascular Access
Education for Care Givers and Patients
Q: How do we assist in providing education and resources for surgeons and interventionalists?
A: A dual approach to education can be helpful: provide evidence-based information on the benefits of AV fistulae to the surgeons and interventionalists, as well as "empower" patients to share their preferences with the surgeons and interventionalists involved in their individual treatment. The
literature and
resources available on this website can be helpful. For example, the
National Kidney Foundation launched a
best practice newsletter in July 2004 that highlights clinical protocols that are successful in improving outcomes, including a theme issue on vascular access.
Change Concept #11
Q: Which specific AV fistula-related outcomes are important to track and report for the facility, nephrologists, surgeons, and interventionalists?
A: In addition to the facility performance measures listed above, the following performance outcomes for specialists (surgeons, nephrologists, and interventionalists) should be tracked and reported to everyone on the team on a regular basis:
- For surgeons, track the AV fistula placement rate (compared to
K/DOQI standards) as well as success and patency rates.
- For nephrologists, track the distribution of access types their patients receive, with a focus on the AV fistula rate and the percentage of new patients starting dialysis with only a catheter.
- For interventionalists, measure the success rate of interventions and track patency rates for their procedures.
Q: Over time we have had an increase of our older fistulas being revised
and resulting in a graft segment insertion, which makes the access a combination
of the two. I would then change their access to a graft instead of a fistula. I
was told that if any part of the fistula had a graft, then it should be counted
as a graft. I am finding this difficult to keep up with due to the fact that we
don’t always see the surgical records, especially if done in a hospital. From
the clinical view, staff members are puzzled, because it appears to be a fistula
(the majority of it is), but is recorded as a graft. It would help our facility
fistula count, but I also want to ensure that we are all doing the same thing. I
would like direction on this matter.
A: This issue of a "combination" access was discussed at length, by the ESRD
Network community, when it came up. I’ll give you Dr. Spergel’s direct quotation
on the subject: "The Fistula First recommendation would be that if, following
the AVF revision with graft material, the AVF vein continues to be cannulated
(which means that most of the access is still AVF and used as such), that it
could continue to be classified as an AVF. However, if any part of the new graft
component is cannulated, it should be classified as a graft. Other variations
would simply have to be part of those rare outliers that would be subject to the
judgment of the individual center or surgeon". From the quality management
perspective, I would also add that your organization should keep an eye out for
any patterns developing around this issue. Specifically, if the clinical and
facility staff start running into these combination accesses more frequently,
there may be some surgeon practice patterns that need to be investigated. Notice
that Dr. Spergel calls these "rare outliers", and I conclude from that statement
that these AVF "patches" should be last-ditch efforts to maintain an AVF, not a
first-line approach to AVF repair. (V. Peters)
Q: My question concerns incident and prevalent data. I have seen the KDOQI
(2000) goals of 50% incident and 40% prevalent AVF rates, but the Fistula First
data shows a higher prevalent than incident rate. What seems odd to me is that
in talking with some doctors, they think that the incident number has to be
higher than the prevalent number in order to continue to increase the prevalent
number. However, right now your incident number is quite a bit below your
prevalent number. How would it work that you could achieve your prevalent number
without achieving your incident number?
A: Your observations are certainly valid, and the "conventional wisdom" of our
local doctors matched your doctors: that the incidence rate should drive the
prevalence rate, and not vice-versa. However, the project data shows
differently. One reason for this is the definition of "incident" in this data
collection set: Incident patients are defined as from start of ESRD at the
chronic facility until 30 days after. Some organizations define incidence
differently, or have a longer timeframe (3+ months), but our definition only
encompasses patients who have literally "come in the door" with an AVF already
in place and ready to use, and there are not many of those. The higher
prevalence rate seems to be the result of the ESRD Networks and dialysis
facility efforts to convert existing accesses (catheters and grafts) into AVF’s
once the patient gets to the facility, often within 4-6 months after arrival.
Improving incident AVF rates will depend on engaging institutions and
practitioners on the CKD/pre-ESRD side of the equation, and that is something
the larger FFBI has begun to address. The original KDOQI recommendations for
incidence/prevalence refer in a general manner to the new patient’s first
permanent access – regardless of when it is placed – and not to the true
CMS/dashboard definition of incidence, which, as already mentioned, refers to
the access that the new patient shows up with at the clinic to start dialysis.
Since so many patients present to the clinic with a catheter to start their
dialysis and then get referred for a permanent access, the true incident rate of
AVFs and AVGs is far less by CMS data collection and measurement definitions
than the rate if measured 90 days later, for example, when most patients are now
dialyzing with their first new permanent access. This is also a reason the new
KDOQI guidelines (2006) removed AVF incidence from their recommendations, and
focus on an overall prevalent rate of 65%. (V. Peters, RN)
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