The Michigan Vascular Access/MiDRE primer in Vascular Access
Chapter 3 – Venous preservation
Preservation of the veins for dialysis access
When patients are identified as having renal failure of any degree that may eventually require dialysis they are urged to protect their veins. Managing "vascular access for dialysis" successfully is one of the most serious problems for patients requiring dialysis, and problems with venous access are one of the leading causes of death for this population. As will be discussed, of the means for hemodialysis briefly described in the previous chapter, the more preferred are the arteriovenous fistula and the arteriovenous bridge graft. The ability to provide these AV fistulas and grafts depend on the adequacy of the native arteries and veins. Despite long appreciation that IV cannulation and venipuncture damage the veins and make them less useful for creation of dialysis access, continual carelessness destroys options continually. For that reason it is recommended that IV access in renal failure patients be a carefully considered process aiming to preserve needed venous assets.
It has been conclusively demonstrated through years of research that using a patient’s own vein to create an arteriovenous fistula reduces complications and adds longevity for the majority of dialysis patients.
Unfortunately, many patients will not be able to have a fistula because of damage to their veins caused by IV catheterization, PICC lines or frequent blood draws. This can be a major loss, forcing the patient into a less desirable form of access.
For that reason, careful evaluation of the hemodialysis access candidate is mandatory to avoid ill-advised operations doomed to fail due to depleted venous assets. A full discussion of ultrasound evaluation follows (Chapter 5)
In short, the cephalic, basilic and antecubital veins are important assets that can be turned into an AV fistula (the dialysis "lifeline") or else ruined by blood draws, IV catheters or PICC lines. Patients on dialysis, or patients expecting to be on dialysis, are cautioned to avoid having their veins ruined in this way. Health care personnel, particularly nephrologists, should be alert to inappropriately placed IV accesses, and act promptly to have them removed.
The cephalic vein
The cephalic vein runs from the base of the thumb up the up the flat of the forearm to the crook of the elbow (the antecubital fossa) and then up the front of the arm (where we call it the "Rambo" vein – image below). This vein is the most useful vein in the body, and unfortunately the most abused. Using the veins of the back of the hand, back of the wrist, or undersurface of the forearm preserve this important vein. Placing an IV in the bend between the forearm and the arm (the antecubital fossa) is very damaging, and these IVs should not be placed, or should be changed out as soon as possible.
The cephalic vein originates at the base of the thumb, acquires a large dorsal branch from the back of the wrist, has a variable number and configuration of branches in the forearm, including a midforearm lateral branch which rides over the brachioradialis muscle and rejoins the main cephalic vein above the antecubital fossa. Finally, the cephalic vein continues into the arm via a continuation on the anterior arm, the median antecubital leading to the basilic system, and also the deep brachial veins at the antecubital fossa.
Called to see patient for "AV fistula". The antecubital vein was used for IV placement, compromising a previously possible forearm loop graft, antecubital or upper arm fistula. Although these IVs may be placed in the emergency room, where presumably expediency takes precedence over protocol, these inappropriate IVs should be recognized on initial patient assessment by floor nursing or nephrology and replaced promptly.
This patient was seen in the office and found to have a good potential for a left brachiocephalic fistula with delayed superficialization. Unfortunately, she ended up in the hospital shortly afterward and ended up with a cephalic vein PICC line. Goodbye fistula!!!!!
Even when technically patent, a cephalic vein may have scar tissue or chronic thrombus in the lumen preventing it from developing normally as a fistula. In these situations, the fistula may be lost, may develop more slowly than desired, keeping the patient on the catheter longer, or require repeated adjunctive procedures, adding time and costs to the process, increasing the risk of loss, and demoralizing the patient.
Scarring in an otherwise very nice fistula – due to IV
The basilic vein
The basilic vein runs up the medial aspect of the arm and is generally too deep for normal IVs. A branch of the basilic, the median antecubital, runs from the antecubital fossa angling up the medial aspect of the arm to join the basilic vein. This branch is very useful in producing a transposed basilic fistula, and ideally should not be used. Although too deep for a simple IV, the basilic vein is frequently used for a PICC line. Again, prolonged catheterization of the basilic vein frequently renders it unusable, reducing the patient’s fistula options. PICC lines should not be used in renal failure patients without carefully considering their long-term impact on the patient’s dialysis options.
The basilic vein runs up the back of the forearm and then up the medial aspect of the arm, typically with a large branch from the antecubital fossa (the median antecubital), and joining the deep veins in the axilla. Early juncture with the deep veins is common. The vein in the forearm dives below layers of fascia just above the elbow, and is rarely as visible as in this patient.
Characteristic scars from a basilic PICC line
Basilic vein damaged by PICC line
Clotted basilic vein
Central venous catheterization
Central venous catheterization is employed for a multitude of reasons, including IV access in the difficult patient, access for hyperalimentation, central pressure monitoring in critical patients, and for dialysis access. Subclavian catheterization in the renal failure patient leads to a high incidence of subclavian stenosis and thrombosis, and should be avoided unless that extremity has been abandoned as an option for dialysis access. Internal jugular catheterization (right better than left) is considered the best choice for central venous access, but early thrombosis of the internal jugular and later chronic central venous stenosis is well known. Consequently, a central venous catheter should be viewed as a type of ticking time bomb that almost inevitably leads to serious problems and should be removed as soon as possible unless the patient has no other reasonable choice.
This is a double whammy. A left sided pacemaker and left IJ permacath have together thrombosed the left innominant vein. Drainage is by collaterals, and the whole left upper extremity is no longer usable for a dialysis access.
It should be obvious that in order to create a usable fistula, a healthy vein must be available for use. However, there are only so many usable veins in the body, and once these are used up, the options for a fistula dissipate or become much more difficult. Unfortunately, it is the usual case that all medical treatment involves IV access, and anyone who has had significant contact with the medical system has had blood draws, IVs and PICC lines, all contributing to damaged or thrombosed veins.
A vein once thrombosed will not be usable – a lost option. A damaged vein might be usable, but with difficulty – demanding more experience or skill from the surgeon, or secondary maturation procedures that prolong time on the catheter, increase expense, complicate cannulation, and shorten the life of the access.
Although guidelines for venous preservation are included in the DOQI Guidelines, these are inconsistently followed in the ER or in the hospital. Increasing awareness of this problem and enforcing adherence to the guidelines is essential. Vigilance is required of those who have the most immediate contact with patients – the nephrologists – to prevent or limit damage to the venous assets. Early education of the patients is also helpful.
Preservation of the veins is an important strategic goal in the long term management of dialysis access options. Patients should be aware of these issues, as otherwise their options may be destroyed.