Management of the failing haemodialysis access (AV fistula or graft) – online course
Please note that this course is no longer CME accredited, but we are working on a new accredited version.
Authors: K. Pyra and D. Vorwerk
Reviewers: M. Deutschmann, F. Fanelli, M. Hoffmann, C. Nice, D. Tsetis and M. Tsitskari
This course corresponds to chapter 220.127.116.11.6 Haemodialysis Access in the European Curriculum and Syllabus for IR.
In 1966, Ciminio and Brescia were the first to perform subcutaneous, arteriovenous anastomosis that allowed repeated puncturing, a concept which is still being used today.
Long durability, efficient flow rates and lack of adverse events such as infection, thrombosis, stenosis, aneurysms or ischaemia characterise the “perfect” vascular haemodialysis access. Unfortunately, none of the currently employed techniques meet the above criteria. Placing the arteriovenous fistula at the wrist level allows preservation of proximal vessels for the sake of future vascular access.
Poorly functioning fistulas are characterised by changes in the nature of thrill, pulsation and altered bruit at auscultation. Doppler ultrasonography is, alongside clinical examination, the basic method of assessing arteriovenous fistulas. Early occlusion of the arteriovenous fistula is mainly caused by operator error or pre-existing venous stenosis.
For six weeks after surgery the fistula matures, meaning it acquires the ability to be used clinically as a dialysis vascular access. In some cases additional endovascular treatments are required to make it efficient.
Thrombosis is the most frequent late complication. In the majority of patients it occurs as a result of stenosis. Stenoses should be treated if the fistula diameter is reduced by >50% and accompanied with clinical criteria or a reduction in measured dialysis adequacy. In stenosis, balloon angioplasty is associated with a certain degree of failure and may require the use of various additional techniques or instrumentation for patency restoration. Cutting or drug-eluting balloons, catheter-directed thrombolysis, thromboaspiration and mechanical thrombectomy are some of the examples.
Many scientific publications exist that indicate that minimally invasive endovascular procedures provide good and durable results for haemodialysis fistula treatment.
- To become familiar with the anatomy, location, morphology and preferred order of fistula creation.
- To understand pathophysiology of arteriovenous access failure and become familiar with the clinical presentation and signs of complicated, failing or failed haemodialysis.
- To understand the modern approach to diagnostic work-up and management of the failing haemodialisis access.
- To become familiar with indications and contraindications for treatment.
- To achieve technical competence of venous, arterial and anastomotic stenosis and occlusion management related to fistulae.
- To become familiar with possible complications and methods for their repair.
- To understand the differences between primary, primary-assisted and secondary patency and become familiar with the published literature relating to these different outcome points.
This course covers a basic level of IR knowledge and is designed for trainees, students or young consultants aiming to acquire essential knowledge or prepare for the EBIR exam. Thereby, it is tailored to the European Curriculum and Syllabus for IR and corresponds to chapter 18.104.22.168.6 Haemodialysis Access.
The format of the course is easy to use and interactive by including texts, graphics, videos and a quiz to support your learning. The course duration is around one hour.
Upon purchase, access to the course is granted for an enrolment period of 90 days.
Release date: November 2018