Nonthrombotic complications of arteriovenous hemodialysis access
- Mark Little, FRCP, PhD
Mark Little, FRCP, PhD
- Professor of Nephrology
- Trinity College Dublin
- Karen Woo, MD
Karen Woo, MD
- Associate Professor
- UCLA Division of Vascular Surgery
- Section Editors
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
- Steve J Schwab, MD
Steve J Schwab, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- University of Tennessee Health Science Center
Loss of hemodialysis arteriovenous (AV) vascular access, which may be the end result of a number of complications, is a major problem in maintenance hemodialysis. The most common complication is thrombosis of the fistula or graft, which is discussed elsewhere (see "Hemodialysis arteriovenous graft dysfunction and failure"), but other problems such as seroma, extremity swelling, aneurysm/pseudoaneurysm formation, neuropathy, extremity ischemia, heart failure, and infection can also occur. These complications are reviewed here.
UPPER VERSUS LOWER EXTREMITY ACCESS
The complications of arteriovenous (AV) hemodialysis access in the lower extremity mirror those of the upper extremity for autogenous and prosthetic access. However, in the literature, complications are almost exclusively reviewed with respect to patients with upper extremity AV access, predominantly due to the infrequency of lower extremity access, which is reserved for patients who have exhausted their upper extremity sites [1-3]. Important differences pertaining to the development of complications between the lower versus upper extremity include the following :
●The lower extremities are more often affected by peripheral occlusive disease. Although symptomatic steal may affect the upper and lower extremity equally, the need for upper extremity amputation is uncommon, whereas lower extremity tissue loss and major amputation as a complication of lower extremity hemodialysis access is not infrequent.
●The proximity of the lower extremity access to the lower gastrointestinal tract likely predisposes these sites to a higher incidence of infectious complications. Body habitus also affects the ability to maintain an adequate state of basic hygiene in the region of the access.
●Cannulation may be more difficult in lower extremity access and predisposes to hematoma and aneurysm formation when "easier" sites are repeatedly accessed.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Korzets A, Ori Y, Baytner S, et al. The femoral artery-femoral vein polytetrafluoroethylene graft: a 14-year retrospective study. Nephrol Dial Transplant 1998; 13:1215.
- Vogel KM, Martino MA, O'Brien SP, Kerstein MD. Complications of lower extremity arteriovenous grafts in patients with end-stage renal disease. South Med J 2000; 93:593.
- Geenen IL, Nyilas L, Stephen MS, et al. Prosthetic lower extremity hemodialysis access grafts have satisfactory patency despite a high incidence of infection. J Vasc Surg 2010; 52:1546.
- Carsten CG 3rd. Lower extremity arteriovenous hemodialysis access: an important adjunct in select patients. Semin Vasc Surg 2011; 24:102.
- Dauria DM, Dyk P, Garvin P. Incidence and management of seroma after arteriovenous graft placement. J Am Coll Surg 2006; 203:506.
- Eid A, Lyass S. Acute perigraft seroma simulating anastomotic bleeding of a PTFE graft applied as an arteriovenous shunt for hemodialysis. Ann Vasc Surg 1996; 10:290.
- Chen JC, Kamal DM, Jastrzebski J, Taylor DC. Venovenostomy for outflow venous obstruction in patients with upper extremity autogenous hemodialysis arteriovenous access. Ann Vasc Surg 2005; 19:629.
- Woo K, Cook PR, Garg J, et al. Midterm results of a novel technique to salvage autogenous dialysis access in aneurysmal arteriovenous fistulas. J Vasc Surg 2010; 51:921.
- Pasklinsky G, Meisner RJ, Labropoulos N, et al. Management of true aneurysms of hemodialysis access fistulas. J Vasc Surg 2011; 53:1291.
- Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
- NKF-DOQI Clinical Practice Guidelines for Vascular Access. V. Management of complications: Optimal approaches for treating complications. Am J Kidney Dis 2001; 37(Suppl 1):S163.
- Jindal K, Chan CT, Deziel C, et al. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol 2006; 17:S1.
- Witz M, Werner M, Bernheim J, et al. Ultrasound-guided compression repair of pseudoaneurysms complicating a forearm dialysis arteriovenous fistula. Nephrol Dial Transplant 2000; 15:1453.
- Clark TW, Abraham RJ. Thrombin injection for treatment of brachial artery pseudoaneurysm at the site of a hemodialysis fistula: report of two patients. Cardiovasc Intervent Radiol 2000; 23:396.
- Palder SB, Kirkman RL, Whittemore AD, et al. Vascular access for hemodialysis. Patency rates and results of revision. Ann Surg 1985; 202:235.
- Miles AM. Vascular steal syndrome and ischaemic monomelic neuropathy: two variants of upper limb ischaemia after haemodialysis vascular access surgery. Nephrol Dial Transplant 1999; 14:297.
- Gilbert MS, Robinson A, Baez A, et al. Carpal tunnel syndrome in patients who are receiving long-term renal hemodialysis. J Bone Joint Surg Am 1988; 70:1145.
- Reyal Y, Robinson C, Salama A, Levy JB. Neurological complications from brachial arteriovenous fistulae. Nephrol Dial Transplant 2004; 19:1923.
- Thermann F, Kornhuber M. Ischemic monomelic neuropathy: a rare but important complication after hemodialysis access placement--a review. J Vasc Access 2011; 12:113.
- Leon C, Asif A. Arteriovenous access and hand pain: the distal hypoperfusion ischemic syndrome. Clin J Am Soc Nephrol 2007; 2:175.
- Papasavas PK, Reifsnyder T, Birdas TJ, et al. Prediction of arteriovenous access steal syndrome utilizing digital pressure measurements. Vasc Endovascular Surg 2003; 37:179.
- Tordoir JH, Dammers R, van der Sande FM. Upper extremity ischemia and hemodialysis vascular access. Eur J Vasc Endovasc Surg 2004; 27:1.
- Lazarides MK, Staramos DN, Kopadis G, et al. Onset of arterial 'steal' following proximal angioaccess: immediate and delayed types. Nephrol Dial Transplant 2003; 18:2387.
- Asif A, Leon C, Merrill D, et al. Arterial steal syndrome: a modest proposal for an old paradigm. Am J Kidney Dis 2006; 48:88.
- Yilmaz C, Ozcan K, Erkan N. Dialysis access-associated steal syndrome presenting as bidirectional flow at duplex Doppler ultrasound. AJR Am J Roentgenol 2009; 193:W568.
- Moghazy KM. Value of color Doppler sonography in the assessment of hemodialysis access dysfunction. Saudi J Kidney Dis Transpl 2009; 20:35.
- Malik J, Slavikova M, Maskova J. Dialysis access-associated steal syndrome: the role of ultrasonography. J Nephrol 2003; 16:903.
- Tordoir JH, Van Der Sande FM, De Haan MW. Current topics on vascular access for hemodialysis. Minerva Urol Nefrol 2004; 56:223.
- Aimaq R, Katz SG. Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation. J Vasc Surg 2013; 57:1073.
- Wixon CL, Hughes JD, Mills JL. Understanding strategies for the treatment of ischemic steal syndrome after hemodialysis access. J Am Coll Surg 2000; 191:301.
- Berman SS, Gentile AT, Glickman MH, et al. Distal revascularization-interval ligation for limb salvage and maintenance of dialysis access in ischemic steal syndrome. J Vasc Surg 1997; 26:393.
- Knox RC, Berman SS, Hughes JD, et al. Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access. J Vasc Surg 2002; 36:250.
- Diehl L, Johansen K, Watson J. Operative management of distal ischemia complicating upper extremity dialysis access. Am J Surg 2003; 186:17.
- Schanzer H, Eisenberg D. Management of steal syndrome resulting from dialysis access. Semin Vasc Surg 2004; 17:45.
- Leake AE, Winger DG, Leers SA, et al. Management and outcomes of dialysis access-associated steal syndrome. J Vasc Surg 2015; 61:754.
- Scali ST, Chang CK, Raghinaru D, et al. Prediction of graft patency and mortality after distal revascularization and interval ligation for hemodialysis access-related hand ischemia. J Vasc Surg 2013; 57:451.
- Zanow J, Kruger U, Scholz H. Proximalization of the arterial inflow: a new technique to treat access-related ischemia. J Vasc Surg 2006; 43:1216.
- Goel N, Miller GA, Jotwani MC, et al. Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) for treatment of dialysis access-associated steal syndrome. Kidney Int 2006; 70:765.
- Miller GA, Goel N, Friedman A, et al. The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome. Kidney Int 2010; 77:359.
- Misskey J, Yang C, MacDonald S, et al. A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia. J Vasc Surg 2016; 63:1574.
- Crowley SD, Butterly DW, Peter RH, Schwab SJ. Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis 2002; 40:852.
- Gaudino M, Serricchio M, Luciani N, et al. Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula. Circulation 2003; 107:2653.
- Feldman L, Tkacheva I, Efrati S, et al. Effect of arteriovenous hemodialysis shunt location on cardiac events in patients having coronary artery bypass graft using an internal thoracic artery. Ther Apher Dial 2014; 18:450.
- Cuthbert GA, Kirmani BH, Muir AD. Should dialysis-dependent patients with upper limb arterio-venous fistulae undergoing coronary artery bypass grafting avoid having ipsilateral in situ mammary artery grafts? Interact Cardiovasc Thorac Surg 2014; 18:655.
- Kato H, Ikawa S, Hayashi A, Yokoyama K. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003; 75:270.
- Centers for Disease Control and Prevention (CDC). Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients--United States, 2005. MMWR Morb Mortal Wkly Rep 2007; 56:197.
- Fysaraki M, Samonis G, Valachis A, et al. Incidence, clinical, microbiological features and outcome of bloodstream infections in patients undergoing hemodialysis. Int J Med Sci 2013; 10:1632.
- Nguyen DB, Lessa FC, Belflower R, et al. Invasive methicillin-resistant Staphylococcus aureus infections among patients on chronic dialysis in the United States, 2005-2011. Clin Infect Dis 2013; 57:1393.
- D'Amato-Palumbo S, Kaplan AA, Feinn RS, Lalla RV. Retrospective study of microorganisms associated with vascular access infections in hemodialysis patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:56.
- Crowley L, Wilson J, Guy R, et al. Chapter 12 Epidemiology of Staphylococcus aureus bacteraemia amongst patients receiving dialysis for established renal failure in England in 2009 to 2011: a joint report from the Health Protection Agency and the UK Renal Registry. Nephron Clin Pract 2012; 120 Suppl 1:c233.
- Anderson JE, Chang AS, Anstadt MP. Polytetrafluoroethylene hemoaccess site infections. ASAIO J 2000; 46:S18.
- Laupland KB, Conly JM. Treatment of Staphylococcus aureus colonization and prophylaxis for infection with topical intranasal mupirocin: an evidence-based review. Clin Infect Dis 2003; 37:933.
- Ayus JC, Sheikh-Hamad D. Silent infection in clotted hemodialysis access grafts. J Am Soc Nephrol 1998; 9:1314.
- Nassar GM, Ayus JC. Clotted arteriovenous grafts: a silent source of infection. Semin Dial 2000; 13:1.
- Nassar GM, Ayus JC. Infectious complications of old nonfunctioning arteriovenous grafts in renal transplant recipients: a case series. Am J Kidney Dis 2002; 40:832.
- Bosman PJ, Blankestijn PJ, van der Graaf Y, et al. A comparison between PTFE and denatured homologous vein grafts for haemodialysis access: a prospective randomised multicentre trial. The SMASH Study Group. Study of Graft Materials in Access for Haemodialysis. Eur J Vasc Endovasc Surg 1998; 16:126.
- McKenna PJ, Leadbetter MG. Salvage of chronically exposed Gore-Tex vascular access grafts in the hemodialysis patient. Plast Reconstr Surg 1988; 82:1046.
- Kovalik EC, Raymond JR, Albers FJ, et al. A clustering of epidural abscesses in chronic hemodialysis patients: risks of salvaging access catheters in cases of infection. J Am Soc Nephrol 1996; 7:2264.
- Blum C, Baker M. Venous congestion of the breast mimicking inflammatory breast cancer: case report and review of literature. Breast J 2008; 14:97.
- Oskrochi Y, Razi K, Stebbing J, Crane J. Angiosarcoma and Dialysis-related Arteriovenous Fistulae: A Comprehensive Review. Eur J Vasc Endovasc Surg 2016; 51:127.
- Makhdoomi K, Mivefroshan A, Abbasi F, et al. Angiosarcoma at dialysis fistula site in a patient on continuous ambulatory peritoneal dialysis. Iran J Kidney Dis 2015; 9:154.
- Andre J, Parsikia A, Minimo C, et al. Soft tissue sarcoma at a dialysis access site in a transplant recipient. Exp Clin Transplant 2012; 10:410.
- Kahveci A, Asicioglu E, Arikan H, et al. Malign epithelioid tumor at the site of an arteriovenous fistula in a dialysis patient. J Vasc Access 2011; 12:391.