Planning and Protecting Vascular Access Sites in the Future Hemodialysis Patient

Abstract

The patient with incipient renal failure has usually undergone repeated phlebotomy, intravenous catheter insertion, or invasive monitoring through veins and arteries of the upper extremity. When finally evaluated for hemodialysis angioaccess, the patient may be found to have numerous sclerotic or thrombosed veins, inflamed catheter entry sites, resolving hematomas, or radial artery occlusion. These complications are common. In 50% of the patients referred to me for access, their anatomy has become unsatisfactory for construction of long-term dialysis access. Therefore, at the earliest sign of renal failure, the primary-care physician must consider the special problems of future hemoaccess. Precautions should be taken to keep monitoring and phlebotomy procedures away from the primary-access vessels, generally the radial artery and cephalic veins. Although short-term access may be provided through external shunts (Scribner type) from the radial artery to a forearm vein, the preferred access is the subcutaneous Brescia-Cimino radiocephalic arteriovenous fistula. This high-flow