Section 12 Vascular Access for Hemodialysis - American ...

Section 12
Vascular Access
for Hemodialysis
Lesley C. Dinwiddie, MSN, RN, FNP, CNN

Section 12. Vascular Access for Hemodialysis
About the Author
Lesley C. Dinwiddie, MSN, RN, FNP, CNN, Section Editor and Author, is
a Nephrology Nurse Consultant at Vascular Access Education and
Research in Cary, North Carolina, and the Executive Director for the
Institute of Excellence, Education and Research (ICEER).
736
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Section 12
Vascular Access for
Hemodialysis
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
Historical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739
Chapter
58 Patient Evaluation for Long-term Access Selection . . . . . . . . . . . . . . . . . 740
59 Vascular Access Type and Site of Placement . . . . . . . . . . . . . . . . . . . . . . . 741
60 Nursing Process in the Routine Care of Vascular Access . . . . . . . . . . . . 752
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 737

Section 12. Vascular Access for Hemodialysis
Section
12
Vascular Access for Hemodialysis
Purpose
The purpose of this section is to provide an overview of the commonly used
types of vascular access for hemodialysis as well as the nursing process necessary
to assure the following patient outcomes (Burrows-Hudson & Prowant, 2005):
1. The patient’s vascular access will provide a blood flow rate adequate to
achieve the dialysis prescription.
2. The patient’s vascular access will have a long use-life and be free of
complications.
3. The patient will demonstrate knowledge regarding his/her vascular access.
Objectives
Upon completion of this section, the learner will be able to:
1. List the preferential order for vascular access according to the 2006 KDOQI
guidelines and compare the indications, locations, advantages, and
disadvantages of the arteriovenous fistula (AVF); the arteriovenous graft
(AVG); and the central venous catheter (CVC) and catheter/port devices.
2. State the steps for assessment for each type of access.
3. List the possible causes and diagnoses of complications.
4. Describe routine planning for management of the vascular access, implementation
(including cannulation), and interventions for complications.
5. Define the ongoing evaluation by the vascular access team through
continuous quality improvement (CQI) and:
a. Patient education.
b. Staff education.
c. Data collection and analyses.
Introduction
Vascular access is essential to hemodialysis (HD) therapy. Positive patient
outcomes for hemodialysis are highly dependent on complication-free
vascular access. The type of vascular access needed to achieve such outcomes
depends upon the diagnosis and prognosis as well as the anatomic and
physiologic potential and limitations of the patient. The ideal blood flow
through a patient’s fistula or graft is a flow sufficient to achieve prescribed blood
flow rates through the dialyzer without compromising cardiac output or flow to
the extremity distal to the access. While creation/placement of vascular access is
primarily the purview of physicians, the routine maintenance, preservation, and
patient education is the responsibility of the nephrology nurse.
738
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Historical Perspectives
Historical Perspectives
1960 Scribner and Quinton developed the first
permanent access for chronic hemodialytic
therapy. It consisted of Teflon tubes, one placed
in an artery and one in a vein, which exited
through the skin and were joined by a Teflon
loop by means of swedge locks. (The detailed
information on external AV shunts that has
appeared in previous editions of the Core
Curriculum has been archived to Historical
Documents on the ANNA Web site,
www.annanurse.org.)
1961 Shaldon described a technique for cannulation
of femoral veins.
1962 Siliconized rubber used for external shunt loop
and Teflon used for vessel tips. A curved loop
connected the two cannulas forming the shunt,
which was specifically made for each patient.
Siliconized rubber segments had steps and bends
formed in them to make them more comfortable
for patients, and to extend the life of the shunt
by bringing it back up to the limb and away
from the joint (reverse-winged shunt).
1966 Brescia and Cimino developed the internal
arteriovenous (AV) fistula for repeated
venipunctures for maintenance hemodialysis.
1966 Ramirez developed the straight-winged shunt
for better stabilization and easier declotting.
1966 Buselmeier shunt developed.
1972 Allen-Brown shunt developed.
1974 Bovine carotid artery graft used for circulatory
access.
1975 Gore-tex® graft became commercially available
for use as AV access for hemodialysis.
1977 Umbilical cord vein used for AV graft.
1977 Expanded polytetrafluoroethylene (ePTFE) used
as AV conduit for hemodialysis.
1979 Uldall developed a catheter that allowed repeated
cannulation of subclavian vein for temporary
access for hemodialysis; introduced the concept
of subclavian vein as temporary access to avoid
destruction of peripheral vessels that later may
be needed for creation of permanent vascular
access. This led to the development of subclavian
and jugular vein catheters that could be used as
permanent circulatory access for hemodialysis
when peripheral vasculature was inadequate to
support creation and patency of either an AV
fistula or an AV graft.
1980 Button needle-free vascular access for hemodialysis
developed.
1980 Interventional radiology procedures for the
(circa) treatment of underlying anatomic stenotic
lesions emerged.
1980 Urokinase used for thrombolysis of AV access,
(circa) especially catheters.
1983 The tunneled, cuffed catheter for long-term
hemodialysis access introduced.
1997 National Kidney Foundation/Dialysis Outcome
Quality Initiative (NKF-DOQI) Clinical Practice
Guidelines published.
1998 Trials began for subcutaneous port/catheter
devices for hemodialysis.
1999 Clinical Performance Measures (CPMs) based
on the NKF-DOQI guidelines were introduced.
1999 Centers dedicated to vascular access were
established with many using interventional
nephrologists.
1999 Urokinase was removed from the market. Other
lytics came to the forefront, most notably tissue
plasminogen activator (tPA), to fill the need to
lyse clot in thrombosed accesses.
2001 The DOQI guidelines were revised and renamed
the Kidney Disease Outcomes Quality Initiative
(KDOQI). The most significant change in these
Vascular Access guidelines was in the section on
Monitoring and Surveillance.
2003 The National Vascular Access Improvement
Initiative (NVAII) began because the AVF
growth and the catheter reduction goals in the
KDOQI guidelines were not being realized. It
soon came to be known as the Fistula First
Program and in March 2005, this program was
elevated by CMS to breakthrough initiative
status and is now known as the Fistula First
Breakthrough Initiative (FFBI).
2006 The KDOQI guidelines for Vascular Access were
revised with major format changes. There are
now eight clinical practice guidelines (CPG) and
a section for clinical practice recommendations
(CPR) with specific recommendations for
pediatrics. The CPGs are evidence-based. The
CPRs are supported by a combination of weaker
evidence and expert opinion. Four topics were
intensively reviewed and revised for this iteration
and all others updated. While the goal for longterm
catheter reduction (< 10%) is unchanged,
the goal for AVFs, incident and prevalent, is now
65% (NKF KDOQI, 2006, CPG 8). It is to be
noted that the KDOQI guidelines are not
standards of care.
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 739

Section 12. Vascular Access for Hemodialysis
Chapter 58
Patient Evaluation for
Long-term Access Selection
This chapter is based on NKF KDOQI, 2006, CPG 1.
I. Patient history. To optimize the choice of access
type and placement, the following factors must be
assessed.
A. Dominant arm.
B. Exercise capacity and current arm strength
training (Leaf et al., 2003; Oder et al., 2003).
C. History of:
1. Previous vascular catheters, peripheral or central.
2. Previous vascular surgery for access.
3. Needle phobia.
4. Pacemaker or internal defibrillator.
5. Other arm, neck, breast, chest surgery, or trauma.
6. Any cardiovascular disease including stroke.
7. Diabetes mellitus.
8. Coagulopathies.
9. Other life-threatening comorbidities (e.g.,
malignancies).
D. Current anticoagulation therapy.
E. Kidney replacement therapy (KRT) modality plan.
1. Scheduled transplant from a living donor.
2. Potential candidate for peritoneal dialysis.
3. Undergoing a trial of hemodialysis to help
decide between KRT or palliative care option.
II. Physical examination.
A. Examine skin for scarring.
B. Check arterial blood supply in all extremities,
noting:
1. Character of peripheral pulses.
2. Color of digits.
3. Temperature of hands and feet.
4. Presence of lesions.
5. Deficits in function.
C. Perform Allen test (see Table 12.1).
D. Listen to apical pulse for rate and rhythm.
E. Measure bilateral upper arm blood pressures to
detect differences in arterial flow.
F. Examine venous drainage in all extremities.
1. Compare both arms for:
a. Presence and degree of edema.
b. Differences in size (evidence of venous
and/or lymphatic obstruction).
c. Patency of veins noting compressibility and
mobility of superficial veins in arms.
d. Note degree of change in superficial vessels
with application of tourniquet.
2. Compare both legs for:
a. Presence and degree of edema.
Standards of Nursing Care for Vascular Access
The nephrology nurse:
A. Assesses the patient and collects comprehensive data pertinent to the
maturation or routine management of the access for HD therapy.
B. Analyzes the assessment findings and/or data to determine normalcy of the
access or the presence of pathology.
C. Identifies expected individual patient outcomes.
D. Develops a plan of care to attain the patient outcomes.
E. Implements the plan by:
1. Coordinating the delivery of care and assuring appropriate documentation.
2. Providing patient education including self-management.
F. Evaluates the status of the patient’s progress in attaining the stated outcomes
individually and as part of the vascular access team using the CQI process.
740
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Chapter 58. Patient Evaluation for Long-term Access Selection • Chapter 59. Vascular Access Type and Site of Placement
Table 12.1
Allen Test
III. Diagnostic evaluation.
1. Patient clenches the fist of one hand to produce
pallor in the hand.
2. Clinician occludes arterial flow by compressing both
radial and ulnar arteries.
3. Patient opens clenched fist.
4. Clinician releases pressure on the ulnar artery and
counts the seconds required for color to return to the
hand. More than 3 seconds indicates decreased ulnar
arterial supply to the hand if the radial artery is used
for the vascular access.
5. Repeat the procedure, but release pressure on radial
artery this time to assess radial arterial flow to hand.
6. Repeat procedure with opposite hand.
b. Difference in size (evidence of lymphatic
and/or venous obstruction).
c. Presence of varicosities.
3. Look for swelling and presence of collateral
veins in chest wall and neck indicating central
venous obstruction.
A. Duplex ultrasound mapping of the upper
extremity arteries and veins for all patients.
B. Central vein evaluation in the patient known
to have:
1. Previous catheter, pacemaker, and/or internal
defibrillator.
2. Edema or unilateral enlargement in the
extremity of choice.
3. Collateral veins above the planned access site.
4. Evidence of any surgery or trauma to the neck,
chest, breast, or arm involving the planned
access vessels.
C. Central venography can be accomplished with
dilute contrast, CO 2 , magnetic resonance imaging
(MRI), duplex ultrasound to avoid nephrotoxicity
and preserve residual kidney function. However,
gadolinium-based contrast agents for MRI should
not be used in patients with CKD stage 4 or 5 due
to risk of nephrogenic systemic fibrosis (NSF)
(FDA, 2007).
Chapter 59
Vascular Access Type and Site of Placement
This chapter is based on NKF KDOQI, 2006, CPG 2.
Vascular access should be placed distally and in the
upper extremities whenever possible. Because AVF
provides the access with the longest patency rates and
need for fewest interventions (Huber et al., 2003;
NKF, 2006; Pisoni et al, 2002) options for AVF
creation should be considered first, followed by
prosthetic grafts, if AVF creation is not possible.
Catheters should be avoided for HD and used only
when the previous options are not possible, are
contraindicated by the patient’s condition, or the
access for hemodialysis is short-term.
I. Arteriovenous fistulae (AVF).
A. Definition. A surgically created opening between
an artery anastomosed to a juxtapositional
(nearby) vein allowing the high pressure arterial
blood to flow into the vein causing engorgement,
enlargement, and wall thickening. This process is
known as arterialization or maturation of the vein
and is necessary to provide a vessel with adequate
flow for hemodialysis and sufficiently strong to
effectively cannulate. The outflow vessel should be
naturally superficial or surgically superficialized.
The artery and the anastomosis site should never
be cannulated. A variety of surgical anasomotic
techniques are used to create the fistula and are
illustrated in Figure 12.1.
B. Anatomic locations. The sites for creation of an
AVF are limited only by the patient’s suitable
vasculature and the skill and creativity of the
clinicians creating and caring for it.
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 741

Section 12. Vascular Access for Hemodialysis
Figure 12.1. Examples of various configurations for AV fistula anastomoses: (a) normal artery-vein
relationship, (b) end-to-end anastomosis, (c) end-vein to side-artery anastomosis, (d) side-to-side
anastomosis, (e) side-vein to end-artery anastomosis, (f) side-to-side converted to end-to-end anastomosis.
C. Placement in order of priority.
1. A wrist (radial-cephalic) primary fistula (see
Figure 12.2).
2. An elbow (brachial-cephalic) primary fistula.
3. An upper arm (brachial-basilic) fistula with
vein transposition.
vein
artery
Figure 12.2. Preferred site for fistula.
Actual site may vary depending on patient.
Used with permission from Arrow International Inc.
D. Classification of AVFs. The traditional AVF (such
as the radial-cephalic or brachial-cephalic) is
created with just the construction of the AV
anastomosis — a one-step procedure, sometimes
known as a primary fistula. With the increased
impetus to give priority to AVF creation, more
innovative surgical techniques are being used to
superficialize the outflow vein such as transposition
(surgically dissecting out and tunneling in a
superficial, accessible area of limb) of the vein or
surgical removal of the tissue between the skin
and the vein (Roberts, 2005). AVFs with vein
transposition are frequently created with two
separate procedures to allow for arterialization of
the vein prior to superficialization.
E. Indication for AVF creation. A fistula should be
placed at least 6 months prior to the anticipated
start of hemodialysis treatments. This timing
allows for access evaluation and additional time
for revision to ensure a working, fully functional
fistula is available at initiation of dialysis (NKF
KDOQI, 2006, CPG 1). Patients should be
considered for construction of a fistula after
failure of every dialysis AV access. In the patient
performing PD, who is manifesting signs of
modality failure, the decision to create a backup
fistula should be individualized by periodically
reassessing need (NKF KDOQI, 2006, CPG 2).
742
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Chapter 59. Vascular Access Type and Site of Placement
F. Advantages of AVF accesses.
1. Have the lowest rate of thrombosis and require
the fewest interventions, providing longer
survival of the access (Huber et al., 2003; Pisoni
et al., 2002).
2. Have lower rates of infection than grafts
(which, in turn, are less prone to infection than
percutaneous catheters and subcutaneous port
catheter systems).
3. Cost of implantation and access maintenance
are the lowest long-term.
4. Are associated with increased survival (Dhingra
et al., 2001) and lower hospitalization rates.
5. Avoid the complications associated with the
venous anastomosis in AVGs.
6. Avoid potential for allergic response to
synthetic materials.
7. Outflow veins are autogenous tissue which seals
and heals after cannulation. Synthetic grafts
only seal by means of a fibrin plug.
8. Can utilize the buttonhole cannulation technique.
G. Disadvantages of AVF accesses.
1. The vein may fail to enlarge or increase wall
thickness (i.e., fail to mature). This may be caused
by inadequate inflow or the presence of collateral
or accessory veins that divert both volume and
pressure from the intended outflow vein.
2. AVFs have comparatively long maturation
times. Weeks to months must elapse following
creation of these fistulae before they can be
used. If the access has not been created several
weeks in advance of the anticipated need for
dialysis, an alternative method of vascular
access must be used while the fistula matures.
3. In some individuals, the vein may be more
difficult to cannulate than an AVG.
4. AVF creation and cannulation require different
skill sets than for AVGs. Proficiency in one type
of access does not assure proficiency in the other.
5. Thrombosed AVF may be more difficult in
which to restore flow.
6. The enlarged vein may be visible, especially in
the forearm and perceived as cosmetically
unattractive by some individuals.
7. A hypertrophied outflow vein may significantly
increase cardiac output (in turn increasing
cardiopulmonary recirculation), and myocardial
load and may cause steal syndrome in patients
with compromised peripheral vasculature.
H. Complications of AVFs (KDOQI, 2006, CPG 5).
1. Nonmaturing outflow vein and early failure.
Primary nondevelopment of the outflow vein
may be secondary to:
a. Insufficient vasculature caused by poor
arterial flow and/or small vein size.
Signs and symptoms.
(1) Minimal increase in vein size and bruit
limited to anastomosis area.
(2) Absence of palpable thrill and bruit by
auscultation along the outflow vein.
b. Treatment is surgical revision if possible.
2. Disturbances in flow dynamics that are usually
caused by venous stenosis (abnormal narrowing
of the lumen of the vessel as a result of injury to
the wall causing intimal hyperplasia). Related
problems include:
a. Venous hypertension: engorgement of vessels
distal to anastomosis when resistance to flow
is greater in proximal veins due to venous
stenosis (Schanzer, 2002).
b. Sore thumb syndrome: engorgement of
thumb veins with sometimes painful
throbbing or pulsating of distal veins and
edema of thumb that may extend to entire
hand; cyanotic nail bed with potential for
serous oozing if obstruction of venous
capillary drainage continues (White, 2006).
c. Increased venous return can cause arm,
breast, neck, chest, and face swelling if
stenosis develops in the central vessels.
3. Accessory veins: arterial flow through multiple
outflow veins prevents the arterialization of a
single outflow vein and therefore the development
of a functional fistula; thrill and bruit are
present but appropriate vein development is
absent. To detect the presence of an accessory
vein, occlude the main outflow vein with finger
pressure sequentially along the vein. Note the
character of the flow with the occlusion. If there
is no accessory, the flow will become an
augmented pulse. If an accessory vein is present
between the anastomosis and the occlusion
point, the thrill will continue.
4. Medical diagnostics and treatment.
a. Doppler ultrasound or fistulogram/venogram
to measure flow and detect stenosis.
Treatment for hemodynamically significant
stenosis is balloon angioplasty.
b. Treatment for venous hypertension is arm
elevation above the level of the heart.
c. Treatment for accessory veins is surgical
ligation or percutaneous coil ablation (coils
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 743

Section 12. Vascular Access for Hemodialysis
are injected into the veins and expand to
block and clot the veins) if no stenosis is
detected in main outflow vein.
d. Infection occurring within 3 weeks of surgery
is generally considered perioperative infection
and is usually prevented by prophylactic
antibiotics at the time of surgery.
5. Late failure.
a. Thrombosis.
(1) Causes. Items (a) through (d) are
applicable for AVG also.
(a) Stenosis of main outflow vein
without collateral circulation and/or
(b) Significant hypotension due to
volume depletion.
(c) Hypercoagulable states.
(d) Prolonged occlusive compression of
access vessel vein from a pressure
dressing, tight clothing or jewelry
(anything that leaves an impression is
too tight), supporting heavy objects
such as a basket handle or a sleeping
head. (Lifting heavy objects with the
hands once the suture line is well
healed [> 10 days postoperatively]
will not damage the AVF.)
(2) Signs and symptoms of impending
thrombosis. Items (b) through (h) are
applicable for AVG as well.
(a) The vein is distended and does not
soften when the arm is elevated
overhead.
(b) Significantly decreased intra-access
blood flow (400–500 mL/min for
AVF and < 600 mL/min for AVG )
(NKF KDOQI, 2006, CPG 4).
(c) Increased static venous pressures and
standardized dynamic venous
pressures with a ratio:
[1] >0.5 for AVG venous segment
and for AVG arterial segment
ratio > 0.75.
[2] >0.35 for AVF venous segment
and > 0.43 for AVF arterial segment
(NKF KDOQI, 2006, CPG 4).
(d) Changes in the quality of the bruit.
(e) Pulsation rather than thrill.
(f) Difficulty cannulating or pain with
cannulation.
(g) Evacuation of clots even with needle
properly inserted into the center of
the vessel.
(h) Increased viscosity of intra-access
flow as evidenced by:
[1] Difficulty maintaining
extracorporeal blood flow at
prescribed rate without increase
in venous pressure and decrease
in arterial pressure.
[2] Access recirculation causing
unexplained decrease in Kt/V and
URR – this is a late sign.
[3] Black blood syndrome that occurs
when the same blood is being
recirculated through the dialyzer
and becomes deoxygenated as
well as hemoconcentrated.
Lightening of blood color in the
arterial line when saline is
introduced into the venous line
confirms recirculation. This is a
very late sign and constitutes an
emergency requiring same day
intervention.
(3) Predominant signs of thrombosis in AVF
and AVG are the absence of thrill and
bruit along the access vessel. There may
be a strong pulse in the artery at the
inflow anastomosis. Do not cannulate
vessel to confirm. Needle holes in a
thrombosed access complicate or prevent
lytic administration.
(4) Treatment for AVF and AVG.
(a) Urgent referral to an interventionalist
or surgeon to:
[1] Prevent thrombosis by detecting
and treating stenosis or
[2] Perform thrombectomy by lysing
with a thrombolytic such as tPA
(tissue plasminogen activator)
to soften or resolve clot. This is
frequently used before mechanical
thrombectomy and can be
followed by correction of causative
stenoses if indicated with
angioplasty or surgical revision.
(b) Access monitoring and surveillance
postprocedure to assure normal flow
and pressure parameters.
(c) Anticoagulation for proven
hypercoagulable states.
(d) Targeted ultrafiltration to patient
tolerance.
(e) Patient and staff education about
prevention of:
[1] Prolonged occlusive pressure.
[2] Hypovolemic hypotension.
744
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Chapter 59. Vascular Access Type and Site of Placement
b. Infection (for both AVF and AVG).
(1) Causes.
(a) Poor patient hygiene (Kaplowitz et
al., 1988).
(b) Inadequate skin cleansing for
cannulation.
(c) Not using aseptic technique for
cannulation (Schanzer, 2002).
(d) Seeding from another infected site in
the body.
(2) Signs and symptoms.
(a) Inflammation.
(b) Pain.
(c) Skin break with drainage along the
course of the vessel.
(d) Fever.
(3) Intervention and treatment.
(a) Culture of any exudates.
(b) IV broad spectrum or organism
sensitive antibiotics.
(c) Surgical takedown of AVF if evidence
of septic emboli. Surgical resection
and removal of affected portion or all
of graft.
(4) Nursing management note: Cannulation
of an access with an infected segment
should be done only with a physician
order if dialysis is extremely urgent. The
infected area must be avoided.
c. High output cardiac failure (seen in AVF and
progresses with AVF maturation).
(1) Cause. Creation or development of an
AVF that shunts more blood through the
fistula to the detriment of the peripheral
circulation causing tissue hypoxemia and
a compensatory increase in cardiac
output (Guyton & Hall, 2006). This
condition can include the development
of left ventricular hypertrophy, highoutput
cardiac failure, exacerbation of
coronary ischemia, and the possible
contribution to the development of
central vein stenosis (MacRae et al.,
2006) and is aggravated by a preexisting
anemia and/or cardiovascular disease.
(2) Signs and symptoms that occur at or
near dry weight:
(a) Tachycardia.
(b) Shortness of breath.
(c) Pulmonary crackles.
(d) Cyanosis of lips and nail beds.
(e) Pulmonary edema.
(f) Peripheral edema.
(g) Jugular vein distension (if patent).
(h) Confusion.
(3) Potential complications.
(a) Pulmonary edema.
(b) Angina.
(c) Cardiac dysrhythmias.
(4) Diagnosis is by:
(a) Branham’s sign: a decreasing pulse
rate when the vein is compressed.
(b) Echocardiography with and without
AVF compression.
(5) Treatment.
(a) Surgical reduction of flow with a
banding procedure or surgical ligation.
(b) Correct anemia.
(c) Review cardiac pharmacotherapy.
(d) To reduce interdialytic symptoms, the
AVF and outflow vein can be wrapped
with an elastic bandage to reduce
cardiac output. This requires a physician’s
or APN’s order. The nurse or
patient must be able to comfortably
slide an index finger under the bandage
to be sure the AVF is not occluded.
II. Arteriovenous grafts (AVG).
A. Definition. A synthetic or, less frequently, biologic
conduit implanted subcutaneously and interposed
between an artery and a vein. Needles are inserted
into the graft (never into the anastomoses) to
remove and return blood during hemodialysis.
The average graft diameter is 6 mm.
B. Types. Synthetic grafts are usually made of
expanded polytetrafluoroethylene (ePTFE/Teflon)
and may be tapered for the arterial anastomosis or
contain ringed segments to prevent kinking at the
apex of the loop. Tapering and external reinforcement
have not been shown to significantly
improve AVG outcomes (NKF KDOQI, 2006,
CPG 2). The composite/polyurethane graft has a
temporary advantage over ePTFE. Because of its
self-sealing property, it can be cannulated within
hours of placement. Biologic grafts are sometimes
autogenous vein or cryopreserved human vein but
most frequently are from treated bovine vessels.
The latter have been shown to provide functional
access for patients who have failed PTFE.
C. Indications. Patients who do not have vasculature
suitable for AVF or who have a failed AVF in the
location of the planned AVG.
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 745

Section 12. Vascular Access for Hemodialysis
4. Can be placed in many areas of the body
including the upper surface of the thighs and
the anterior chest wall.
5. Can be placed in a variety of shapes to facilitate
cannulation.
6. Are easier for the surgeon to handle, implant,
and construct the vascular anastomoses.
7. Are comparatively easier to repair either
surgically or endovascularly (gaining entry
through the vascular system rather than
through an incision).
vein
artery
Figure 12.3. Forearm loop graft. Actual site
may vary depending on patient.
Used with permission from Arrow International Inc.
D. Anatomic locations, configurations, and
placement priority (NKF KDOQI, 2006 CPG 2)
(see Figure 12.3).
1. A forearm loop graft is preferable to a straight
configuration.
2. Upper arm graft – either an arc (preferred) or a
loop.
3. Chest wall or “necklace” prosthetic graft or
lower-extremity fistula (rare) or graft; (all arm
sites should be exhausted). “Femoral placement
of access has been associated with proximal
venous stenosis, which may be problematic later
in patients receiving kidney transplantation”
(NKF, 2006).
E. Advantages of AVGs.
1. Have a large surface area available for
cannulation.
2. Are technically easier to cannulate than new AVFs.
3. Lag time from insertion to maturation is short.
For ePTFE grafts, it is recommended that not
less than 14 days should elapse prior to
cannulation to allow healing and incorporation
of the surrounding tissue into the graft. Ideally
3–6 weeks are recommended to allow healing of
incision and resolution of pain and swelling.
F. Disadvantages of AVGs.
1. Are associated with an increased incidence of
thrombosis and infection over an AVF.
2. Patients have a higher mortality risk than
patients dialyzed with fistulae. Those without
diabetes have a relative risk (RR) = 1.47, and
those with diabetes have a RR = 2.47 (Dhingra
et al., 2001).
3. Have shorter patency rates than AVF (a primary
patency in grafts at 18 months of 33%
compared with fistulae at 51% and a secondary
patency rate of 55% as compared with 77% in
fistulae) (Huber et al., 2003).
4. Cannulation sites seal but do not heal.
5. Have the potential for an allergic response to
nonautogenous material, especially PTFE.
6. May cause steal syndrome in patients with
compromised peripheral vasculature.
G. Complications of AVGs (NKF KDOQI, 2006,
CPG 6).
1. Extremity edema.
a. Causes. Venous hypertension secondary to
increased cardiac output and exacerbated by
presence of one or more stenotic lesions in
the proximal and central vessels.
b. Treatment. If newly postoperative, arm
should be elevated above the level of the
heart whenever the patient is sitting or lying
down. If swelling persists beyond 2–3 weeks,
imaging to detect pathologic stenosis is
indicated and corrected with angioplasty and
maybe even stenting for a long, recoiling
(returns after angioplasty) stenosis.
2. Steal syndrome, usually early post-AVG
placement, is ischemia of the extremity distal to
the arterial anastomosis (may be seen late in
AVF with hypertrophied upper arm with flows
> 1.5 L/min).
a. Caused by diverting significant volume of
blood away from the peripheral circulation.
746
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Chapter 59. Vascular Access Type and Site of Placement
b. Complicated by patients, usually elderly,
with:
(1) Peripheral vascular disease.
(2) Diabetes.
(3) History of multiple access surgeries in
same extremity.
c. Signs and symptoms (that may increase
intradialytically).
(1) Pain distal to anastomosis.
(2) Cold, pale hand.
(3) Impaired hand movement and strength.
(4) Paresthesias: numbness, tingling (pins
and needles) which increases
intradialytically.
(5) Poor capillary refill of affected nail beds
(> 2 secs).
(6) May progress to ulcerated, necrotic
fingertips.
d. Diagnosis, based on physical examination,
can be confirmed with ultrasound to
measure arterial flow to fingertips
(plethysmyography/PPGs).
e. Treatment.
(1) Surgical reperfusion of the hand using
the DRIL (distal revascularizationinterval
ligation) procedure (Diehl et al.,
2003; Knox et al., 2002) while
maintaining flow through AVG.
(2) Banding of inflow to AVF to reduce flow.
(3) Severe ischemia not amenable to surgical
revision may require urgent ligation of
the access.
(4) Symptoms of mild ischemia may be
improved with the wearing of a glove,
keeping the hand dependent as much as
possible, exercise, and massage.
3. Graft degeneration and pseudoaneurysms in
AVG and aneurysms in AVF outflow vein.
a. Causes.
(1) AVG. Repeated cannulation in same area
of graft leading to extravasation (bleeding)
into the incorporating tissue and creating
a pseudoaneurysm. The expansion of the
pseudoaneurysm can cause stretching of
the overlying subcutaneous tissue and
combined with the scar tissue of multiple
cannulations can lead to compromise of
the microcirculation. This causes tissue
breakdown and puts the patient at risk for
graft rupture.
(2) AVF. Repeated cannulation in same area
of vein leading to weakening and
subsequent ballooning of the vein wall.
What is the difference between an aneurysm and a
pseudoaneurysm?
■ An aneurysm is an abnormal blood-filled dilation of a
blood vessel wall (most commonly in arteries) resulting
from disease or repeated injury of the vessel wall.
■ A pseudoaneurysm is a vascular abnormality that
resembles an aneurysm, but the outpouching is not
limited by a true vessel wall, but rather by external
fibrous tissue.
Adapted from the glossary (NKF, 2006).
b. Signs (2–4 apply to both AVF and AVG).
(1) Sudden appearance of an irregular,
pulsatile mass on the surface of the AVG.
(2) Increase in size of the pseudoaneurysm
or aneurysm from increased pressure
in vessel.
(3) Thinning of the overlying skin over the
vessel giving a shiny appearance.
(4) Poor healing of needle sites.
c. Treatment.
(1) Never cannulate into a pseudoaneurysm
or a large aneurysm. It causes further
vessel degeneration and can be difficult
to locate the center of the underlying
vessel flow.
(2) A rapidly, progressing pseudoaneurysm
or aneurysm is one that is more than
twice the diameter of the vessel and must
be surgically repaired or a covered stent
placed. Those with skin degeneration
should be surgically repaired as they put
the patient at risk for infection and access
rupture that is a life-threatening emergency.
Cannulation through a stent is an
off-label use of the device and should
never be done without a physician’s order.
4. Traumatic AVF.
a. Caused by needle passing through the vessel
during cannulation and creating an abnormal
fistula track between the vessel and an underlying
artery. Blood from the artery shunts
into the vessel, thereby disturbing the existing
flow pattern (White, 2006).
b. Signs.
(1) Abnormal presence of a strong pulsation
in area of vessel not previously observed.
May be more pronounced than at the
arterial anastomosis.
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 747

Section 12. Vascular Access for Hemodialysis
Vascular Access Terminology for Physical Examination
■ Proximal: that portion of the access used for “arterial
needle.” In both a graft and AVF, this is the part of the
access vessel that is closest to the arterial anastomosis.
■ Distal: that portion of the access that is used for the
“venous needle” and leads to the draining veins of the
central venous system.
Adapted from the glossary (NKF, 2006).
(2) Sudden increase in venous pressure not
present during previous dialysis session is
possible.
c. Treatment is referral to an interventionalist
for evaluation and/or to a surgeon for
possible repair.
5. Thrombosis, impending and actual.
a. Causes.
(1) Stenosis at the anastomoses, intragraft,
the outflow vein or the central veins.
Though the venous anastomosis is the
most common site of stenosis, inflow
stenosis at the arterial anastomosis can be
as high as 20 to 25%. Stenosis is the cause
of 90% of thrombosed grafts (NKF
KDOQI, 2006, CPG 6).
(2) In the absence of stenosis, causes as for AVF.
b. Signs of impending thrombosis (same as for
AVF), plus:
(1) Increasing static pressures proximal to
the stenosis; can lead to extended time to
hemostasis postdialysis and appearance
of new pseudoaneurysms.
(2) Decreasing flow through the graft to
< than 600 mL/min.
(3) Abnormal coagulation studies indicating
a hypercoagulable state (LeSar et al.,
1999; O’Shea et al., 2003).
c. Treatment for preventing impending
thrombosis.
(1) Angiography with selective angioplasty of
those stenoses that cause > 50% decrease
in vessel lumen diameter and reduction
in access flow with increased intra-access
pressure.
(2) Anticoagulation or antiplatelet therapy
for hypercoagulable state.
(3) Signs and treatment of thrombosis is as
for AVF.
6. Infection (see complications of AVF).
III. Central venous catheters (CVC)/port
catheter systems.
Catheters and ports are essential tools for providing
urgent and, in some cases, long-term vascular access.
Prevention and early treatment of complications
should greatly reduce associated morbidity and
mortality (NKF KDOQI, 2006, CPG 7).
A. Definition. A synthetic, relatively large (10–22 Fr.
outer diameter in adults) tube placed into a highflowing
central vein. Because hemodialysis
removes and returns blood at the same time, the
catheter either has two side-by-side chambers or
lumens (called a dual lumen catheter) or two
single lumen catheters (called twin catheters). The
end of the catheter that enters the patient’s
bloodstream is the “tip” and has holes for blood
entry or exit. The other end, the “tail,” is outside
the body with the two lumens separated (see
Figure 12.4). Each lumen has a threaded hub on
the tail for attaching to the bloodlines. The exit
site is where the catheter comes out through the
skin. The port catheter system has one or two
metal ports under the skin that are attached to
single lumen catheters. These are accessed each
treatment by cannulas.
Tunnel tract
Portion of the catheter that
is tunneled
under the skin
Cuff
Small fibrous band
that holds the
catheter in place
under the skin
Exit site
Where the catheter exits
the body
Tips
Placed in right
atrium of the heart
Figure 12.4. Central venous catheter.
Used with permission from Arrow International Inc.
748
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Chapter 59. Vascular Access Type and Site of Placement
B. Types. Catheters need to be made of rigid, semirigid
material, or be structurally reinforced to
prevent collapse of the lumen. Catheter lengths
vary with the size of the patient and the site of
placement.
1. Nontunneled, noncuffed acute catheters for
short-term use (see Figure 12.5). These should
stay in no longer than a week, and the patient
should not be discharged from hospital with
this type of catheter. The tips should be in the
superior vena cava (NKF KDOQI, 2006, CPG 2.)
2. Tunneled, cuffed catheters (see Figure 12.6) and
port catheter systems are for long-term use only
in the patient who:
a. Is not suitable for an AVF or AVG access.
b. Has an AVF or AVG planned.
c. Has an AVF or AVG waiting to mature.
d. Is waiting for a scheduled live donor
transplant.
3. The tips of the catheter should be in the right
mid-atrium with the arterial port medial (for
neck and chest placements) (NKF KDOQI,
2006, CPG 2) (see Figure 12.4). The fibrous
cuff, positioned about 1 cm from exit site inside
the tunnel, is designed to incorporate the
tunnel tissue thereby creating a barrier to
organism entry as well preventing catheter
dislodgment. In chest and neck placements, the
exit site is usually a few centimeters below the
clavicle. To determine whether the catheter is
inserted into the internal jugular (IJ) or the
subclavian vein, see Table 12.2.
C. Anatomic locations. Catheters or port/catheter
devices should not be placed on the same side as a
slowly maturing long-term access (NKF KDOQI,
2006, CPG 2). Catheters are always inserted into
veins.
1. Right internal (or external) jugular vein is the
preferred site because this site offers a more
direct route to the right atrium than the leftsided
great veins (see Figure 12.4). Catheter
insertion and maintenance in the right internal
jugular vein are associated with a lower risk of
complications compared to other potential
catheter insertion sites.
Figure 12.5. Nontunneled, noncuffed acute catheters for
short-term use.
Used with permission from Arrow International Inc.
Table 12.2
How to Differentiate Between an IJ
and a Subclavian Catheter Placement
Inspection
pediatric
adult
split
lumens
twin,
single
lumen
■ Where is the exit site — above or below the clavicle?
■ Can you see the outline of the catheter in a tunnel?
■ Can you see the tunneled catheter crossing the
clavicle?
Figure 12.6. Cuffed catheters. The pencil is shown as a
size comparison.
Palpation
■ With a gloved hand, feel the skin above the exit site.
Can you feel the catheter in a tunnel?
■ Trace the tunnel till you can no longer feel the
catheter. If it crosses the clavicle, it’s jugular. If not, it’s
probably subclavian.
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 749

Section 12. Vascular Access for Hemodialysis
2. Left internal jugular vein catheter placement
potentially puts the left arm’s vasculature in
jeopardy for a long-term access on the same
side. It may also be associated with poorer
blood flow rates and higher rates of stenosis
and thrombosis than the RIJ due to the
increased length.
3. Femoral placement is associated with the
highest infection rates and the catheter tip must
be in the inferior vena cava to avoid regional
recirculation (see Figure 12.7). Placement of a
femoral catheter in a transplant candidate
should be avoided because of potential damage
to blood vessels needed for the transplant.
4. Subclavian veins on either side must be strictly
avoided due to risk of stenosis, which can
permanently exclude the possibility of upper
extremity long-term AVF or AVG (NKF
KDOQI, 2006, CPG 2). They should be used
only when all access sites are exhausted in the
ipsilateral (same side) arm. Subclavian
placement puts patient at greater risk for
pneumothorax and/or hemothorax during
insertion.
5. When all the above sites are exhausted, catheters
may be inserted into the inferior vena cava using
the translumbar or transhepatic approach.
D. Advantages of catheters/ports.
1. Are universally applicable – anyone can have one.
2. Can be inserted into multiple sites relatively
easily.
3. Require no maturation time. They can be used
immediately (after tip position is confirmed by
fluoroscopy or chest x-ray).
4. Cause no changes in cardiac output or
myocardial load.
5. Can provide access over a period of months,
permitting AVF maturation in patients who
require immediate hemodialysis.
6. Percutaneous catheters only.
a. Skin puncture not required for repeated
vascular access for hemodialysis.
b. Lower initial cost and replacement costs.
Exit site
Venous
Arterial
E. Disadvantages.
1. High morbidity due to thrombosis and infection
(Oliver et al., 2004; Pastan et al., 2003). Patients
receiving catheters have a relative risk (RR) of
death (RR = 2.3 for patients with diabetes and
1.83 for those without) greater than those with
an AVF (Dhingra et al., 2001).
2. Risk of permanent central venous stenosis or
occlusion.
3. Percutaneous catheters only.
a. Discomfort and cosmetic disadvantage of an
external appliance.
b. Safety concern with inadvertent dislodgment
of external appliance as well as need for
protection of exit site.
c. Shorter expected use-life than other access
types.
d. Overall lower blood flow rates, requiring
longer dialysis times.
4. Frequent episodes of occluded catheters due to
thrombosis or fibrin sheaths may require use of
a lytic agent or an interventional procedure to
replace the catheter and possibly disrupt a
sheath. These episodes may lead to reduced
dialysis adequacy (lower BFRs and shortened or
missed treatments) that is associated with
increased morbidity and mortality.
Figure 12.7. Femoral vein central venous catheter.
750
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008

Chapter 59. Vascular Access Type and Site of Placement
F. Complications.
1. Immediate/early.
a. All catheters should be placed using imaging
such fluoroscopy or ultrasound (NKF
KDOQI, 2006, CPG 2) to assure correct
tip placement and minimize complications
such as:
(1) Carotid or femoral artery puncture.
(2) Pneumothorax.
(3) Hemothorax.
(4) Cardiac dysrhythmias.
(5) Tissue perforation (e.g., brachial plexus,
trachea, superior vena cava, myocardium).
(6) Poor flow from malpositioned tip.
b. Operating room conditions and practice
must be used for placement to prevent
infection.
2. Late complications.
a. Infection. Local and systemic.
(1) Causes.
(a) Not using aseptic technique and
appropriate cleansing for accessing
catheter.
(b) Poor patient hygiene.
(c) Inadequate skin cleansing at dressing
change.
(2) Signs and symptoms.
(a) Inflammation and pain around exit
site and in tunnel.
(b) Drainage at exit site or from tunnel.
(c) Erosion of skin over catheter.
(d) Fever and/or chills.
(3) Treatment (NKF KDOQI, 2006, CPG 7).
(a) IV broad spectrum or organism
sensitive antibiotics for all infections
except localized exit site where topical
and/or oral antibiotics may be used.
(b) Catheter exchange within 72 hours of
initiating antibiotic therapy with
follow-up cultures 1 week after
antibiotic therapy.
(c) Antibiotic lock therapy may be used
instead of catheter exchange in cases
where the patient is clinically stable
and/or the catheter is reinfected with
the same organism and catheter sites
are limited (NKF KDOQI, 2006,
CPR 7) (see Section 5, Table 5.6, for
sample protocol).
(d) Port pocket infections are treated
with systemic antibiotics and pocket
irrigation.
b. Catheter dysfunction (BFR < 300 mL/min).
Exceptions are for pediatric patients and
small adults. Dysfunction for these categories
is defined by a significant reduction in
baseline flows.
(1) Causes.
(a) Mechanical. Line and catheter
kinking, holes or cracks in catheter,
drug precipitation.
(b) Patient position.
(c) Partial or complete occlusion due to
intraluminal or mural thrombus or
fibrin sheath.
(2) Signs.
(a) Inability to withdraw anticoagulant
lock or blood.
(b) Inability to maintain consistent
BFR > 300 mL/min at an arterial
< -250 mm/Hg. Arterial prepump
pressure monitoring is mandatory.
(c) Presence of leak from catheter.
(3) Treatment. See algorithm in Nursing
Process interventions (see Figure 12.8).
c. Superior vena cava syndrome. Catheter
insertion and long-term placement can cause
endothelial injury, inflammation, stenosis,
and occlusion of any vein. When this occurs
in the superior vena cava, it has lifethreatening
implications and constitutes an
emergency to be reported to the physician. It
can have slow or rapid onset.
(1) Signs and symptoms.
(a) Swelling of the chest/breast, arms,
neck, and face with periorbital edema.
(b) Visible collateral veins on chest wall
and jugular vein distension (if patent).
(c) CNS disturbances such as vision
changes, dizziness, confusion, pain.
(d) Dyspnea (difficulty breathing) and/or
dysphagia (difficulty swallowing).
(2) Treatment.
(a) Removal of any obstruction
including an indwelling catheter.
(b) Lysing of thrombus with a
thrombolytic infusion.
(c) Angioplasty of identified stenoses.
Stents could be placed for recoiling
stenoses.
(Figure 12.8 on next page)
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008 751

Section 12. Vascular Access for Hemodialysis
Nursing Assessment: Decision to Use a Thrombolytic
Sluggish flow or inability to withdraw blood or
infuse fluid through the catheter
Check for mechanical
obstruction
Occlusion
remains
Suspect
thrombus
Thrombolytic therapy?
Obstruction
corrected
Flow restored
• BFR < 300 mL/min
• URR < 65%
• Kt/V < 1.2
• AP > -250 mm Hg
• VP > 200 mm Hg
• Kink in line
• Catheter migration
• Patient position
• Catheter integrity
• BFR < 300 mL/min
• URR < 65%
• Kt/V < 1.2
• AP > -250 mm Hg
• VP > 200 mm Hg
YES!
Figure 12.8. Algorithm for catheter dysfunction.
Source: Dinwiddie, L.C. (2004). Managing catheter dysfunction for better patient outcomes:
A team approach. Nephrology Nursing Journal, 31(6), 653-660.
Needle phobia
Needle phobia has been defined
as a formal medical condition and
is included in the American Psychiatric
Association’s Diagnostic
and Statistical Manual of Mental
Disorders, 4th edition (DSM-IV)
within the diagnostic category of
Blood-Injection-Injury. Needle
phobia is evidenced by a vasovagal
reflex (frequently inherited) that
causes shock with needle puncture.
With repeated needle exposure,
those with vasovagal shock
reflex tend to develop a fear of
needles. According to the DSM-IV,
a phobia is defined by the
presence of fear and by avoidance
behavior. While a dislike or mild
fear of needles is very common,
needle phobia can be more
rigorously defined by objective
clinical findings in addition to
subjective symptoms.
Source: Hamilton, J.G. (1995). Needle
phobia: A neglected diagnosis. Journal
of Family Practice, 41(5), 437, 512.
Chapter 60
Nursing Process in the Routine Care
of Vascular Access
I. Assessment of all accesses, mature or maturing.
A. Assess patient’s subjective response to the vascular
access, e.g. function, body image, self-concept,
fears, need for local anesthesia. Many patients who
suffer from needlephobia will require some form
of local anesthetic. A cream containing lidocaine
2.5%/prilocaine 2.5% is the best choice. The
patient self-administers the cream prior to coming
to dialysis. He/she will need to be instructed on
needle sites at the previous treatment time. This
cream is expensive and can have systemic effects if
too much is absorbed (AstraZeneca, 2005).
Therefore it should not be applied all over the
vessel. If the patient does not have cream, lidocaine
injection or ethyl chloride spray can be used.
Lidocaine injections put the cannulator at twice
the risk of needle accident and are thought to
facilitate scarring as is ethyl chloride. Patients
should be assessed frequently to determine if the
local anesthetic can be discontinued.
B. Solicit access complaints from patient and
evaluate prior to initiation of treatment.
752
Core Curriculum for Nephrology Nursing, Fifth Edition © American Nephrology Nurses’ Association 2008