Blood Vessel Access Options for Dialysis Patients

What is hemodialysis and hemodialysis access?

Hemodialysis (dialysis) is a treatment for patients with kidney problems that has been prescribed by a kidney specialist (nephrologist). Hemodialysis is the process of using a machine to send the patient's blood through a filter, which is called a dialyzer and to undergo hemodialysis treatment this requires what is called vascular access hemodialysis.

The access to hemodialysis functions as a pathway for withdrawing and returning patient blood during the procedure of hemodialysis. There are several types of access that can be used, including: ArterioVenous (AV) shunt or fistula (AVF) and AVGraft (AVG) as permanent access, while the catheter hemodialysis or commonly called CDL (Double Lumen Catheter) which is for temporary access (3 months / 1 year) .

What is AV Shunt?

AV Shunt or Arterio-Venous shunt (AV Fistula / Cimino) is the result of an action to connect the veins and arteries in the wrist or elbow area which aims to increase venous blood flow to make it easier to undergo hemodialysis. Making an AV shunt is carried out by a surgeon who has the competence to operate blood vessels. The AV shunt causes extra pressure and extra blood to flow into the vein, causing it to grow bigger and stronger (thicker). Without this AV shunt, hemodialysis will be difficult to do. AV shunt is highly recommended because in addition to providing good blood flow for the hemodialysis process, it can function for a long time and even permanently compared to other types of access and there is less chance of infection or causing a blood clot (thrombus) than other types.

Before making the AV Shunt, the surgeon will do a mapping of the blood vessels (Artery and Vein Mapping) which is done using Doppler Vascular Ultrasound (USG). By carefully evaluating the vessels preoperatively, surgeons can optimally perform AV shunts in their patients with measurable success. AV shunt generally requires 6 – 8 weeks to mature (maturation), or it can be used for hemodialysis.

What is an arteriovenous graft?

AV graft is an artificial (synthetic) vascular tube made to replace a blood vessel. Unlike the AV shunt, this tool/material (Polytetrafuoroethylene(PTFE)/Dacron) takes 2 to 3 weeks before it can be used.

What is a venous catheter (hemodialysis catheter/ CDL)?

A venous catheter or often called a double lumen is a pipe/hose/catheter that is inserted into a blood vessel (vein) in the neck (jugular) or groin (femoral), usually only for temporary/short term (short term-3 months) hemodialysis. There are also catheters that can be used for the long term (Long term-1 year), called Long term/tunneling HD Catheter, with certain indications which are of course more selective.

Making this access can be carried out by a specialist who is competent in this procedure, which functions only temporarily (temporary access/temporary access) while planning to make an AV shunt as permanent access. This temporary access is not ideal if it is permanent, because it can cause various complications such as a blood clot (thrombus) that clogs the access, infection and long term the vein where the catheter is placed will experience narrowing of the vein so that it cannot be used for hemodialysis access.

However, if the patient really needs to start (indicated) direct or urgent hemodialysis , the venous catheter will work for several weeks or months until the surgeon can operate for permanent access, namely AV shunt or AV graft which requires a certain amount of time to be used.

Tips for choosing Hemodialysis Access

Although based on the guidelines NKF-DOQI & PERNEFRI have been regulated and recommended, ideally, access to hemodialysis that is feasible for each patient is different, because in Indonesia the patient's problems also vary in clinical condition, severity when first coming to see a specialist kidney. There are some patients who can be immediately advised for AV Shunt, but there are also some who are advised to have a CDL installed first. Only then were consulted for a further access, some have had an AV Shunt manufacturing operation once, or several times.

The key to successful selection depends on patient factors (steadiness, knowledge & insight, anatomy of blood vessels, presence or absence of comorbidities, etc.), doctors-paramedics (good clinical examination, preoperative ultrasound mapping, history of punctures) as well as cooperation & cooperation factors. good communication between patient-doctor-paramedic.