Av Shunt Mabi Xx
-
Upload
ethan-amal -
Category
Documents
-
view
221 -
download
0
Transcript of Av Shunt Mabi Xx
-
7/25/2019 Av Shunt Mabi Xx
1/33
A-V SHUNT FOR
HEMODIALYSIS
HEROE SOEBROTO, DR., SPB, SPBTKV(K)THORACIC, CARDIAC, & VASCULAR SURGERYDIVISION/DEPARTMENT OF SURGERY
SOETOMO GENERAL HOSPITAL FACULTY OF MEDICINEAIRLANGGA UNIVERSITY SURABAYA20!
-
7/25/2019 Av Shunt Mabi Xx
2/33
INTRODUCTION
Vascular access for hemodialysis :
- central vein cannulation double lumcatheter
- device implantation Port-a-Cath
- surgical AV Shunt (Brescia-Cimino
AV Shunt : surgical procedure to create aanastomosis bet!een an artery and a vefor hemodialysis access
-
7/25/2019 Av Shunt Mabi Xx
3/33
INTRODUCTION
"heoretical Basis
AV Shunt !or# e$ectively forhemodialysis because they:
%ave high volume &o! rates
'se native blood vessels !hich !hencompared to synthetic graftsare lessli#ely to develop stenosesand fail)
https://en.wikipedia.org/wiki/Volume_flow_ratehttps://en.wikipedia.org/wiki/Stenosishttps://en.wikipedia.org/wiki/Stenosishttps://en.wikipedia.org/wiki/Volume_flow_rate -
7/25/2019 Av Shunt Mabi Xx
4/33
ANATOMY
-
7/25/2019 Av Shunt Mabi Xx
5/33
ANATOMY
-
7/25/2019 Av Shunt Mabi Xx
6/33
GENERAL PRINCIPL
OFAV SHUNT
-
7/25/2019 Av Shunt Mabi Xx
7/33
GENERAL PRINCIPLES
*) "he arm vessels is more preferable ratherthan the leg vessels) +on-dominant arm
,rst)
) Access site should be placed as distally sthat pro.imal sites !ill be available forsubse/uent procedures)
0) 1nade/uate or atherosclerotic arteriesshould be avoided and a long section ofpatent vein is re/uired to accommodatemultiple cannulation site)
-
7/25/2019 Av Shunt Mabi Xx
8/33
GENERAL PRINCIPLES
2) "he chosen site should allo! for ease of access focannulation and should be positioned so that paticomfort is assured during hemodialysis)
3) "echnical precision and gentle tissue handling ismandatory)
4) A temporary access procedure such as :
5ight internal 6ugular Subclavian or femoral catheter
7.ternal shunt
Peritoneal catheter
are re/uired during the time that AV shunt needeto mature)
-
7/25/2019 Av Shunt Mabi Xx
9/33
GENERALPRINCIPLES
8) Anticoagulation is not routinely needed durinsurgery e.cept for graft thrombectomy andrevision procedures or patients !ho do nothave the usual hypocoagulable state ofchronic renal failure)
9) Prophylactic antibiotics are used for all casesinvolving insertion of prosthetic material)
) 1deal vascular access for hemodialysis ;1 5ule of 4s :
- access &o! rate ? 4@@ mmin
- access depth 4 mm belo! s#in
-
7/25/2019 Av Shunt Mabi Xx
10/33
PATIENTS PREPARATION
Dlomerular ,ltration rate (DE5 0@mmin*)80m must be educated for
any renal replacement therapy includingdouble lumen catheter AV Shunt orrenal transplantation
"he vessels of arm !hich !ill be used foAV Shunt should be preserved byavoidance of:V"#$%#'"I#*+"#- '*##*$#I#+*-$+" #$$# $#"-
-
7/25/2019 Av Shunt Mabi Xx
11/33
PATIENTS PREPARATION
Anamnesis :
- history of disease such as diabetesmellitus hypertension stro#e
- history of intravenous line use
Physical e.amination :
1 vein /uality consistency siFe (minG mm infection
1 artery patent palmar arch Allentest
-
7/25/2019 Av Shunt Mabi Xx
12/33
-
7/25/2019 Av Shunt Mabi Xx
13/33
VASCULAR ULTRASONOGRAPHY
Preoperative vasc!ar !traso"#:
- 1n addition to clinical assessment improves AVE outcome
in terms of patency- 1mproves maturation and use of AVE for dialysis
I"traoperative e$a%i"atio"&
- Con,rm pre-op studies
- Assess the impact of ,stula &o! on the artery in&o!- Assess the &o! in the ,stula vein
Eva!atio" o' VA&
- Heasurement of access &o!
-
-
7/25/2019 Av Shunt Mabi Xx
14/33
PROCEDURE CHOICES IN VASCULAR ACCESS SURGERY
Eirst choice:5adiocephalic direct AV ,stula
Brescia-Cimino (!rist
Snu$-bo. (base of the thumb
Second choice:Eorearm AV graft bridge ,stula
Straight : radial artery largest
super,cial vein of the cubital fossa oop : brachial artery largest
super,cial vein of the cubital fossaBrachioa.illary graft'pper arm AV ,stula (brachial basilic
-
7/25/2019 Av Shunt Mabi Xx
15/33
PROCEDURE CHOICES
"hird choice:Eorearm AV graft to brachial vein
Straight : radiobrachial oop : brachiobrachial
Eourth choice:Eemorosaphenous graftEemorofemoral graft
=thers:A.illoa.illary graft1lliac-femoral graftHiscellaneous
-
7/25/2019 Av Shunt Mabi Xx
16/33
-
7/25/2019 Av Shunt Mabi Xx
17/33
-
7/25/2019 Av Shunt Mabi Xx
18/33
-
7/25/2019 Av Shunt Mabi Xx
19/33
SURGICAL TECHNIQUES
() Si#e to si#e a"asto%osis&
"echnically is the easiest
anastomosis %ighest ,stula &o!
*) E"# to si#e +arter, to vei"&
HinimiFe turbulence and distal steal Slightly lo!er ,stula &o!
"!isting of the artery duringconstruction
-
7/25/2019 Av Shunt Mabi Xx
20/33
SURGICAL TECHNIUES
.) E"# to si#e +vei" to arter,&
-
7/25/2019 Av Shunt Mabi Xx
21/33
S'5D1CA "7C%+1>'7S
-
7/25/2019 Av Shunt Mabi Xx
22/33
COMPLICATIONS
-
7/25/2019 Av Shunt Mabi Xx
23/33
COMPLICATIONS
Fai!re& "he most fre/uent complication early
failure 5eported incidence: up to 8J Hay be a result of :
"hrombosis: (more in
-
7/25/2019 Av Shunt Mabi Xx
24/33
COMPLICATIONS
"hrombosis is suspected by clinicaevaluation further assessment can bemade by :
Angiogram
'ltrasonography
Surgical thrombectomy is done byma#ing a small venotomy and using afogarty balloon catheter to remove thethrombus
-
7/25/2019 Av Shunt Mabi Xx
25/33
COMPLICATIONS
A"er,s%&
Pseudoaneurysm formation may occuat puncture sites follo!ing dialysis
"he incidence in autogenous ,stula prosthetic grafts
"rue aneurysm are much rare bu
have also been reported in fe!occasions in the vein distal to theanastomosis
"reated !ith resection and either
7nd to end anastomosis
Placement of short segment graft
-
7/25/2019 Av Shunt Mabi Xx
26/33
COMPLICATIONS
I"'ectio"&
1nfection of autogenous ,stula are rarecompared to prosthetic graft
Signs K symptoms :
Eever
7rythema
"enderness
And complications (such as thrombosi
and aneurysm "he most common infecting organism
S*%34'''- *"-
Hanaged by systemic antibiotics drainageand revision as necessary) Prosthetic grafmust be completely e.cised)
-
7/25/2019 Av Shunt Mabi Xx
27/33
COMPLICATIONS
Isc0e%ic c0a"1es& Steal symptoms may occur in around 2J o
patients !ith autogenous ,stula"he incidence is higher in :
-
7/25/2019 Av Shunt Mabi Xx
28/33
COMPLICATIONS
Ve"os 0,perte"sio"&
"he hand distal to the ,stula becomes!ollen and uncomfortable !iththic#ening of the s#in andhyperpigmentation
Venous hypertension may be avoided by
forming an end to end anastomosis =r to ligate the enlarged venou
tributaries causing the hypertension othe distal digits so preserving the ,stula
-
7/25/2019 Av Shunt Mabi Xx
29/33
COMPLICATIONS
Car#iovasc!ar co%p!icatio"&
%igh output cardiac failure is a rarecomplication !hich may occurparticularly in patients displaying acombination of lo! hematocritcardiomyopathy from diabetes and
the presence of high &o! ,stula"reatment usually involves sacri,cingthe ,stula
-
7/25/2019 Av Shunt Mabi Xx
30/33
CARE AFTER A-V SHUNTSURGERY
;eep the arm raised on a pillo! to reduce s!ellin
"he dressing should remain intact and dry at all t
As soon as post operative pain has subsided se.ercises
-
7/25/2019 Av Shunt Mabi Xx
31/33
NOTES
"he use of regional anesthesia may lead to dilaboth the peripheral veins and in&o! arteries maturation
+o bene,t of intraoperative anticoagulation in Patients in 7S5< are li#ely have defects in he
mechanism increase bleeding
Stapled anastomosis is as good as sutured anasto
ength of the anastomosis irrelevant to the ris# related hand ischemia
-
7/25/2019 Av Shunt Mabi Xx
32/33
REFERENCES
*) Loo ; 5o!e V) @*2) %emodialysis Access:
-
7/25/2019 Av Shunt Mabi Xx
33/33
"%A+; ='