SURGICAL MANAGEMENT

Vascular access surgery

One important step before starting hemodialysis treatment is having

minor surgery to create a vascular access. The vascular access will be the
lifeline through which will connect to the dialyzer. Dialysis moves blood through
the filter at a high rate. Blood flow is very strong. The machine withdraws and
returns almost a pint of blood to the body every minute. The access will be the
place on the body where the needles will be inserted to allow your blood to flow
from and return to the body at a high rate during dialysis.

Three types of vascular access exist

 an arteriovenous (AV) fistula

 an AV graft

 a catheter

Work closely with a nephrologist and vascular surgeon—a surgeon who

works with blood vessels—to make sure the access is in place in plenty of time.
Healing may take several months. The goal is for your access to be ready for
use when you are ready for dialysis.

FEMORAL CATHETER

The femoral vein lies within the femoral triangle in the inguinal-femoral
area. The superior border of the triangle is formed by the inguinal ligament, the
medial border by the adductor longus, and the lateral border by the sartorius.
The apex of the triangle is formed by the sartorius crossing the adductor longus.
The roof of the triangle is composed of the skin, subcutaneous tissue, the
cribriform fascia, and the fascia lata. The concave floor is formed by the
underlying adductor longus, adductor brevis, pectineus, and iliopsoas.
 Femoral triangle anatomy.

The neurovascular bundle consists of the femoral vein, artery, and

nerve, which lie within the triangle in that order from medial to lateral. The
femoral sheath encloses the femoral artery and vein, and the nerve lies outside
the sheath. The femoral canal is a space within the femoral sheath and medial
to the femoral vein.
The femoral artery lies at the midinguinal point, which is midway between
the pubic symphysis and the anterior superior iliac spine. The surface anatomy
of the femoral vein is identified for venipuncture by palpating the point of
maximal pulsation of the femoral artery immediately below the level of the
inguinal ligament and marking a point approximately 0.5 cm medial to this
pulsation.
Distally in the leg, the femoral vein lies almost posterior to the artery.
This is important because arterial puncture is more likely in the sites distal to
the inguinal ligament.
Many clinical situations necessitate placement of central venous
catheters. The choice of site is dictated by the specific advantages and
disadvantages of each access method in the clinical situation being considered.
The femoral site is advantageous in patients who are critically ill because the
femoral area is relatively free of other monitoring and airway access devices. If
a bedridden patient requires central venous access, the femoral site allows
relatively free movement of arms and neck without impeding the access line. In
patients with severe coagulopathy or profound respiratory failure, femoral
access precludes the risks of a development of
a hemothorax or pneumothorax, both of which are potential complications of
supraclavicular venous access.
The disadvantage of the femoral site is that it presents a field that is
potentially contaminated because of its proximity to the perineal area. However,
this disadvantage is disputed by many investigators, who point out that the
incidence of CRBSIs at the femoral access site is not significantly different from
e incidence at the supraclavicular access site. ]
The following are generally accepted indications for femoral venous catheter
placement:
 Emergency venous access during cardiopulmonary resuscitation (CPR),
in that it provides a rapid and reliable route for the administration of drugs
to the central circulation of the patient in cardiac arrest
 In hypotensive trauma patients, emergency access via the femoral route
is recommended by some traumatologists immediately after two
peripheral venous catheters are established; if peripheral access cannot
be established expeditiously, femoral venous access is established
immediately; femoral venous catheter placement is preferred to
supraclavicular central venous access in patients with suspected superior
vena caval injuries
 Urgent or emergency hemodialysis access
 Hemoperfusion access in patients with severe drug overdose
 Central venous pressure monitoring
Absolute contraindications for femoral central venous access include the
following:
 Venous injury (known or suspected) at the level of the femoral veins or
proximally (ie, iliac veins or inferior vena cava)
 Known or suspected thrombosis of the femoral or iliac veins on the
proposed side of venous cannulation
  Ambulatory patient (because ambulation increases the risk of catheter
fracture and migration)
Relative contraindications for femoral central venous access include the
following:
 Presence of bleeding disorders (innate or iatrogenic from the use of
anticoagulants or thrombolytics)
 Distortion of anatomy due to local injury or deformity
 Previous long-term venous catheterization (which increases the risk of
venous thrombosis)
 Absence of a clearly palpable femoral artery
 History of vasculitis
 Previous injection of sclerosis agents
 Previous radiation therapy

AV FISTULA

The best type of long-term access is an AV fistula. A surgeon connects

an artery to a vein, usually in your arm, to create an AV fistula. An artery is a
blood vessel that carries blood away from your heart. A vein is a blood vessel
that carries blood back toward your heart. When the surgeon connects an artery
to a vein, the vein grows wider and thicker, making it easier to place the needles
for dialysis. The AV fistula also has a large diameter that allows your blood to
flow out and back into your body quickly. The goal is to allow high blood flow
so that the largest amount of blood can pass through the dialyzer.
 The AV fistula is a blood vessel made wider and stronger by a surgeon
to handle the needles that allow blood to flow out to and return from a dialysis
machine.

The AV fistula is considered the best option because it

 provides highest blood flow for dialysis

 is less likely to become infected or clot

 lasts longer

Most people can go home after outpatient surgery. You will get
local anesthesia to numb the area where the vascular surgeon creates the AV
fistula. Depending on your situation, you may get general anesthesia and not
be awake during the procedure.
AVGRAFT

If problems with your veins prevent you from having an AV fistula, you may
need an AV graft instead. To create an AV graft, your surgeon uses a man-
made tube to connect an artery to a vein. You can use an AV graft for dialysis
soon after surgery. However, you’re more likely to have problems with infection
and blood clots. Repeated blood clots can block the flow of blood through the
graft and make it hard or impossible to have dialysis.

An AV graft uses a synthetic tube to connect an artery and a vein for

hemodialysis.

IJ CATHETER

Indications for the posterior approach to the IJV are the same as for any of
the indications for a central line. They include the following:
 Fluid resuscitation requiring a large-bore IV line for medical or trauma
resuscitation
 Need for a multilumen IV line
 Lack of peripheral access
 Measurement of CVP
 Access via the superior vena cava (SVC) to the right ventricle for passage
of a venous pacemaker
 Access to the pulmonary artery via the right ventricle for passage of a
Swan-Ganz catheter
 Access to a large vein for temporary renal dialysis
 Access to a large vein for administration of hypertonic solutions (eg, for
total parenteral nutrition)
No absolute contraindications exist for placement of a central line in the IJV
via the posterior approach.
Relative contraindications revolve around mechanical problems of access to
the neck. Skin infection, abscess, trauma, scarring, or mass along the side of
the neck would make cannulation of the IJV difficult and hazardous. In addition,
obesity may obscure landmarks and increase the risk of complications.
A coagulopathy, regardless of etiology, is a relative contraindication even
though the IJV, unlike the subclavian vein, is compressible. The compressibility
of the IJV allows it to be used for central line placement in a patient with a
clotting disorder.
The ability to turn the head away from the side where the line is being placed,
though not essential, is helpful with the posterior approach to the IJV. In patients
with limited neck mobility (eg, trauma patients who do not have the cervical
spine cleared), the posterior approach can be quite difficult. [2]
Finally, cooperation of the patient is essential because the lung and carotid
artery are nearby and the risk of injury is excessive if the patient moves during
the procedure.
One of the more common, and feared, complications of central line
placement in the IJV is injury to the lung resulting in pneumothorax or tension
pneumothorax. This is particularly true if the cupula of the lung is above the
clavicle, as it can be inadvertently punctured, causing a pneumothorax.
Any shortness of breath following or during the procedure warrants immediate
investigation with chest radiography. Air embolism can occur if the catheter is
allowed to be open to the air; to prevent air aspiration, the practitioner should
keep his or her finger over the hub when the guide wire is removed or a syringe
is attached or removed.
A hematoma at the site of insertion can occur, particularly if the carotid
artery is punctured. Loss or breakage of the guide wire has been described,
and control of the wire must be maintained at all times. If any resistance is
encountered during withdrawal of the wire through the needle, remove the
needle and the wire as a single unit to avoid breakage of the wire against the
bevel of the needle. Laceration of a vessel or nerve has been described with
IJV central line placement.
PERMANENT CATHETER

A permanent catheter or permcath is a long, flexible tube that is inserted

into a vein most commonly in the neck (internal jugular vein) and less commonly
in the groin (femoral vein). This type of ventral venous catheter is tunneled
under the skin for a few centimeters usually on the chest before it enters the
neck vein. This is done when the catheter is going to be in place for long term
(ie. greater than two weeks). If the catheter is not being left in long term than a
Vascath can be placed which is a nontunneled central venous catheter that
directly enters the neck or groin vein without having to be tunneled under the
skin. The reason for the tunneling of the permcath is that it had been shown
that catheters that are tunneled under the skin before entering the vein have a
lower risk of becoming infected or colonized by bacteria. This is partly
accomplished by tunneling under the skin and because the permcath has a cuff,
which is not visible and is in the tunnel under the skin allowing the subcutaneous
tissue to grow into the cuff essentially creating a barrier for bacteria. This cuff
once in place is also responsible for keeping the catheter stable so that it does
not easily slide out as well as protecting it from infections.

These tunneled central venous catheters can be left in place for as long
as one year and provides permanent access in patients. However, despite
being considered permanent the longer they are in place the greater the risk
that they will eventually become infected. This is why most physicians will try
to use these catheters as a bridge for finding other means of even more
permanent dialysis such as an arteriovenous fistula or graft.

Permcaths although they appear to be one tube actually have two hollow
bores. One part of the tube is responsible for carrying the blood to the dialysis
machine and the other one carries it back from the machine to the body.
 Permcath, better known as the dialysis catheter or hemodialysis catheter is
used in a variety of cases. Here are a few indications;

 Regular hemodialysis to treat kidney failure- permcath avoids multiple

catheter insertions and serves as a permanent catheter for dialysis.
 Route for plasmapheresis.
 Frequent blood sampling
 Administration of drugs and fluids during long-term treatment
 Administration of caustic medications (chemotherapy) that may harm
peripheral veins
 A route for TPN and blood products in special cases

There are a number of complications that may arise due to placement of this
permanent catheter for dialysis. However, a professional could avoid most of
these by following proper protocol and aseptic techniques. These complications
are;

 Arterial puncture (less likely under ultrasound guidance)

 Pneumothorax
 Haemothorax
 Pain
 Cardiac arrhythmias
 Air embolism
 Bleeding
 Cardiac tamponadE

With a permcath inserted, you have to be extra careful and avoid vigorous
activities like swimming. Make sure that the dressing over the sites is always
clean and dry. A small shower is always preferred to a bath in which the
dressing soaks. The dressing should always be dry and secure, so that it holds
the catheter in position firmly and the risk of infection is reduced.
Other than this make sure you abide by your surgeon’s instructions and go
through the guidelines thoroughly. If you feel pain, swelling, redness or any
other unusual symptom, contact the doctor immediately.