Vascular access (VA) for hemodialysis (HD) is the lifeline of a patient. Arteriovenous fistula (AVF) is the gold standard of VA, but there are challenging situations when providing long-term VA becomes challenging, in the presence of central vein stenosis (CVS), which is common in patients on hemodialysis, but its exact prevalence is not known. It would be ideal to have proper venous mapping with imaging modality to be able to plan central venous access. This prior venous mapping will help to plan the target vein and delineate venous path to be able to place HD catheter in the best position or resolve the VA-related problems. However, digital subtraction angiography remains the gold standard of the procedure, during which the target vein is accessed via ultrasound guidance, and subsequent passage of wire is done under fluoroscopic guidance. Venous angiography and, if indicated, angioplasty are performed. For complete chronically occluded thrombotic veins, recanalization needs to be attempted. Stenting is reserved for a select group of patients. There are advances in endovascular techniques to deal with CVS, and it needs a multidisciplinary team approach to tackle the complex issues of VA-related central venous disease (CVD).
Part of the book: Cardiac Diseases
Vascular access (VA) is the life line for hemodialysis (HD) but also Achilles’ heel. VA consists of HD catheters, arterio-venous fistula and arterio-venous grafts. From the earlier ‘Fistula First’ initiative, we later moved to ‘Fistula First, catheter last’ approach and have now realized that we need to follow the recommendation for End Stage Kidney Disease (ESKD) patients, given by Kidney Disease Outcome Quality Initiative (KDOQI). It says, “Patient First: ESKD Life-Plan” to attain the “right access, in the right patient, at the right time, for the right reasons”. However, this applies to the creation of VA. It is essential to monitor and do VA surveillance to maintain the VA, as it can malfunction. When the VA malfunctions, it needs intervention. Depending upon the type of VA, the intervention varies. It could be endovascular or surgical. These issues will be highlighted in this chapter.
Part of the book: Chronic Kidney Disease