The Michigan Vascular Access/MiDRE primer in Vascular Access

Chapter 4 – General evaluation of the dialysis access candidate

Planning prospective hemodialysis options demands a thorough understanding of the dialysis patient’s vascular assets, peripheral arterial status, cardiopulmonary reserve, general health status, other physical risk factors, emotional response to his or her disease, ability to understand the situation and ability to comply with a treatment plan, and last, likely longevity. Failure to appreciate each of these areas may lead to failure or wasted efforts. Venous and arterial evaluation will be addressed in chapters 5 and 6, the indication for formal venography in chapter 7, and the cardiologic evaluation in chapter 8.

In general, one must understand that renal failure is a mortal disease, with a 40% death rate in the first year, and a 20% death rate each year thereafter on the average, influenced heavily by age at onset of ESRD (graph). The enclosed graph demonstrates that an 85-year-old initiating dialysis has a 50% chance of living a year, and approximately 12% chance pf living three years. It follows, therefore, that we consider carefully what we are going to subject our patients to. The potential benefit must exceed the cost.


Factors such as poor cardiac reserve, pulmonary insufficiency, general fragility, morbid obesity, ongoing substance abuse and in particular poor adaptability to a life on dialysis with non-compliance should be taken into account when deciding which dialysis options are reasonable for a given patient.

The initial history and physical examination attempts to round up and encapsulate all the relevant factors and the other conditions that will define the access options open to that patient, and effect the patient’s perioperative management and long term success. The initial evaluation may point to additional studies or information required to reach a final plan.

A sample hypothetical history and physical

MICHIGAN VASCULAR ACCESS, PC
21701 West Eleven Mile Road, Suite 4
Southfield, MI 48076
Telephone: 248-355-1100


Consultation
Patient: James Longface
Birthdate: January 01, 1918
Consult Date: July 13, 2012
Consulting Physician: Marc G. Webb, M.D.
Requesting Physician: Muhammad Green, M.D.
"Dear Dr. Green:

I saw your patient James Longface in my office in consultation".

CHIEF COMPLAINT: Example – "Hemodialysis access needs" or "Complication of dialysis device with complaints of aneurysmal changes, difficulty cannulating, frequent infiltration, prolonged bleeding, aneurysmal changes, elevated venous pressures, etc" (in general, patients come either to be evaluated for a new access, or because of problems with their existing access – see the "Warning signs", chapter #26)

HISTORY OF PRESENT ILLNESS: Our format – "The patient is a (#) year old (Female/Male) seen for evaluation of hemodialysis access needs. He/she is seen at the request of (Doctors name)."

If applicable - "The patient is pre-dialysis with a GFR of xxxxxx"

Usually - "He/she has been on dialysis {for x years} [since date]. He is currently dialyzing at (Dialysis Unit) on a (MWF-TTS) schedule (1st, 2nd, 3rd shift) via a (right/left) xxxxxx. She/he has had * previous long-term accesses: (1) placed xxxx by Dr. Xxxx, abandoned/removed for infection/ligated for steal xxxx , (2) placed xxxx by Dr. Xxxx, abandoned/removed for infection/ligated for steal xxxx , (3) and so forth. The patient has had [right/left/both right and left] sided catheters for xxxx months. He/she is _____ handed.

If with an access - "currently the access is patent - but is immature and unusable", or "the access is inaccessible due to depth", or " the access is functioning poorly", "or is complicated by difficulty cannulating, elevated venous pressures, prolonged bleeding, a painful hand, a swollen arm/hand, frequent infiltration", whatever.

If applicable – "She/he had a kidney transplant in xxxx, now failing * failed in (date)".

Or – "She/he was on CAPD starting (date), abandoned for poor clearance, removed for infection, etc"

Or – "He/she is being evaluated for renal transplant. Or s/he is on a transplant list at (transplant program)"

(the history can be short and straightforward if the patient comes early for an access, with the most recent GFR giving an idea of how close to needing a dialysis access the patient is, or can be very complicated. Since dialysis patients lives frequently become organized around their dialysis schedule, this info is useful in the history and physical. Complicated patients require coordination of care, so inclusion of the dialysis unit and attending nephrologist is helpful.

The total time on dialysis, the time exposed to central catheters, a history of PICC lines and Mediports, the history of transplant, peritoneal dialysis and all previous hemodialysis access attempts and the complications experienced creates a picture of what deficits are likely to exist {central venous stenosis, depleted venous assets or arterial insufficiency} and what options are likely to remain. The presence of a pacemaker is significant, and is usually included in the history of present illness.

A clear and complete description of a problem access should include recent interventions, and a timeline of the problem access if possible.

Considering the dominant arm may be important to the patient when bilateral options exist, but most patients prefer an access in their dominant arm that works to one in their non-dominant arm that doesn’t


PAST SURGICAL HISTORY: Our format - Non access surgery then ****ACCESS HISTORY PRIOR TO MVA: then ****ACCESS HISTORY AFTER REFERRAL TO MVA (xx/xx/20xx):

PAST MEDICAL HISTORY: The usual suspects - Venous insufficiency [459.81], End-stage-renal disease [585.6], Coronary artery disease with prior myocardial infarction [412] s/p CABG [V45.81], Diabetes [250.00] currently taking Insulin [250.01], Obesity, morbid [278.01], Tobacco abuse [305.1], (all patient conditions are listed here, though many are not really relevant – lupus, diabetes, and adrenal insufficiency are, while constipation and hypothyroidism are not, the difference being that the former conditions affect the evaluation and management of dialysis access provision, while the latter do not)

REVIEW OF SYSTEMS: Example – "Patient notes or Patient denies coldness or numbness or pain in both hands/the left hand/the right hand/ fingers of the left hand/ intermittently/constantly/when cold/when on dialysis". This speaks to neuropathy and possible arterial insufficiency, increasing the risk of neurologic complications of further AV access surgery.
  1. CONSTITUTIONAL SYMPTOMS speak to general health status, nutrition, possible presence of infection, overall prognosis
  2. Cardiovascular symptoms point to risk of ischemic heart disease, congestive heart failure, rhythm disturbances, atrial fibrillation, valvular heart disease, endocarditis and so on, with indication for cardiac clearance
  3. Respiratory: a history of asthma [493], bronchitis [491.0], COPD [496] or emphysema [492.0], particularly if oxygen dependant, or shortness of breath if patient continues to smoke, speaks to risk of perioperative pulmonary problems (think aspiration or post-operative respiratory failure) or elevated risk from allergic reactions and in general a poorer prognosis. History of pulmonary embolus alerts to possible need to manage anticoagulation; an interscalene block may complicate borderline respiratory compensation if the phrenic nerve is involved.
  4. Endocrine: brittle diabetes [250.00] or poorly controlled speaks to risk of insulin reaction or hyperglycemia complicating procedure and advisability of getting these patients done early in the schedule.
  5. Neurologic: mild dementia, significant dementia, diabetic neuropathy, multiple sclerosis [340], numbness, paraplegia [344.1], paresthesias, peripheral neuropathy, [356], seizures [345], stroke [436], TIA [435], tingling, weakness – all speak to risk of complications and overall prognosis
  6. Musculoskeletal: •Gastrointestinal: Gynecologic: Lymphatic: •Lymph Nodes: •Skin: •Hematologic: •Immunologic: •Immunizations: •Psychiatric: are all less pertinent, but may still be important
MEDICATIONS: Example – "Aldactone 50 mg 1 by mouth twice daily, Amitriptyline 100 mg 1 by mouth every night, Atorvastatin 20 mg by mouth every day, Buspar 10 mg 1 by mouth twice daily, Ceftin 250 mg 1 by mouth twice daily, Cordarone 200 mg 1 by mouth every day, Diamox 250 mg 1 by mouth twice daily." Review of the med list may reveal conditions not listed in the Past Medical History, for example warfarin leading to atrial fibrillation not mentioned, allopurinol leading to gout not mentioned, and "multivir" indicating undisclosed HIV infection

ALLERGIES: Example – "IVP Dye: anaphylactic shock, anaphylaxis, itching, hives, rash, shortness of breath, nausea and vomiting, palpitations, tachycardia, or …… which causes unknown reaction". Many allergies are not really allergies – many renal patients state that they are allergic to IV contrast, "Because it killed my kidneys". We distinguish between contrast allergies with low risk features, i.e., hives and itching, and allergies with high risk features, i.e., anaphylaxis, laryngeal edema, or skin blistering. In the former, simple pre-operative steroid dosing, with benadryl and an H-2 blocker are usually enough, whereas severely allergic patients should have a 24 hour pre-operative prep and sometimes postoperative steroids or dialysis as well.

SOCIAL HISTORY: Drinking (amount and duration), smoking (amount and duration), recreational drugs (what – how often), history of IV drug abuse (when, what, how long and how recently), marital status, educational history, work history – all provide information about the patient’s health status, risks, social support system, potential for non-compliance, and so on

FAMILY HISTORY: Example – "End-stage renal disease, father, Diabetes [V18.0] mother"

TRANSFUSION: Example – "Patient agrees to accept banked blood in an emergency situation" or "Patient is JEHOVAH'S WITNESS and refuses any blood products". Transfusion is rare in my practice, but this question should be asked.

VITAL SIGNS: BP bilaterally, respirations, heart rate and temperature 98.5 F. Height and weight for calculated BMI – the BMI is an independent risk factor, and reflects how difficult providing AV access may be. Blood pressures should be measured in both arms and a discrepancy noted. Chronic or regular episodic hypotension is known, and can complicate access management.

GENERAL: Example – "The patient is a cooperative, good historian, middle aged male", or "confused, cachectic and uncooperative", whatever. Sometimes this simple description is enough to assess long term prognosis

HEENT: Example – "There is a right IJ tunneled catheter. Sclera are anicteric. The neck is supple. There is no jugular venous distension. There is normal facial symmetry. The patient wears glasses. The head is normo-cephalic and atraumatic. The dentition is good" – clues about overall health, and particularly about the risk for catheter associated central stenosis by evidence of previous catheterization, puffy supraclavicular fossae, or dilated veins on the neck

CHEST: Example – "Respiratory rate and effort normal". Someone who can’t breathe regularly is not a good risk for vascular surgery that will further stress their cardiopulmonary reserve. In addition, the presence of a pacemaker/AICD should be noted as a risk for central venous stenosis, as well as any prominent veins on the chest.

HEART: Example - "Regular rate and rhythm". Or not - irregularity either reflects a rhythm disturbance in the history or an undisclosed condition mandating further investigation.

PULSES: Example – "Pulses are 2+ and symmetrical". Radial and brachial pulses should be assessed carefully, especially in long standing diabetics and after previous access surgery.

EXTREMITIES: Example – "The patient has no visible veins. The patient has brisk capillary refill". All existing accesses should be carefully assessed for geometry, flow, size, skin integrity, depth, existing cannulation patterns and so on. The strength, quality, and duration of the thrill relative to the cardiac cycle should be documented. All scars and access remnants from previous access or other surgical procedures should be carefully documented. Thenar muscle wasting, contractures, peripheral edema, arm swelling and unexplained thrills in the areas of previous access surgery should be carefully looked for.

NEUROLOGIC: Example – "Neurologically intact. Grips are equal. Sensation is intact." Neurologic deficits secondary to stroke, or to previous ischemic insults from AV access either still functioning or previously ligated should be sought and documented. Only a fool would perform another AV access in an extremity recovering from a previous ischemic injury.

SKIN: Example – "No obvious skin abnormalities". Some skin conditions should be noted: psoriasis, keloid formation, skin cancer or precancerous skin lesions, and so on that would influence the site of access placement, or indicate a higher risk for infection. Of particular note is "crepe paper skin" in patients, especially older females with poor tissue integrity, in whom fistulas and grafts will be poorly supported, and in whom difficult cannulation and frequent infiltration can be expected.

DATA REVIEW: Venous Doppler performed during the evaluation for new access will ideally demonstrate the venous anatomy, with size, patency, continuity, and runoff up to the axilla (basilic/brachial veins), or to the clavicle (cephalic). In addition, the arteries can be assessed for size, patency, calcification, depth and course, and anatomic variations (high bifurcation of the brachial artery, found in 15% of the population). Old accesses can be examined for their affects on the venous anatomy

Existing accesses can be assessed from arterial anastomosis to venous anastomosis and beyond; the size, patency, presence of chronic clot, complications (e.g., pseudoaneurysms)


IMPRESSION: Example "#1. End-stage-renal disease [585.6], current catheter dependence. #2. Venous insufficiency [459.81] with (no) adequate vessels for fistulization. #3. Arterial insufficiency with high bifurcation of the brachial artery. #4. Diabetes currently taking insulin. #5. Morbid obesity [278.01]. #6. Tobacco abuse. #7. Candidate for left brachiocephalic fistula, #8. Risk for shunt-induced digital ischemia (female, age>60, diabetes, tobacco abuse). #9. Moderate obesity making vessels too deep - candidate for second stage superficialization. #10. Elevated medical risk for surgery (ASA 4) due to age and co-morbid conditions; #11 Complication of dialysis access with ……." All conditions relevant to the choice of operation or influencing the patient’s perioperative management should be listed without irrelevancies

PLAN: Example: "Recommend proceed with left brachiocephalic fistula with delayed superficialization. Venogram intraoperatively with possible venoplasty. Needs cardiac clearance due to cardiac history. Needs full-service hospital due to ASA 4, multiple co-morbid conditions. Consider referral for weight loss management or bariatric consultation".

The plan is a reminder of what needs to be done to insure a safe procedure – have venograms done, check the heart, regulate the INR, make sure that the patient goes to a facility where appropriate care can be delivered, and so on, and represents a sort of check list for the team.

RISKS: Example: "The three modalities of renal replacement therapy - transplantation, peritoneal dialysis, and hemodialysis - were discussed briefly. The three types of access for hemodialysis - catheter-based systems, AV grafts and fistulas - were discussed, with the risks, benefits, and complications of each". Example - "The indications for fistula creation, along with specific risks of bleeding, infection, neurovascular injury, ischemic steal from the extremity, early thrombosis, failure to develop, and possible requirement for later adjunctive procedures were discussed. Example – "A staged process with more than one surgery required was carefully explained to the patient and family. The indication for intraoperative venogram, with possible venoplasty or stenting was discussed, with the potential complications of bleeding, infection, reaction to intravenous contrast or other medications, rupture of native or prosthetic vessels, and the potential for failure of the procedure to open any occlusion were all discussed with the patient". Example – "The patient information handout "Risks and complications in Access Surgery" given to patient", and/or "The patient information handout "Risks and complications in endovascular procedures" given to patient", and/or "The patient information handout "Digital ischemia secondary to vascular access (steal)" given to patient". The patient has a good understanding of these risks and benefits as well as alternative methods of treatment and wishes to proceed".

Discussion

Discussion of risks" might just as well be called "Education of the patient" or "Establishing appropriate expectations". Depending on the patient’s familiarity with renal failure and hemodialysis, considerable time may be required to bring them up to speed on the problems that face them and the choices they will be making. The educational process in my office begins with the discussion between my office staff (generally a nurse practitioner) and the patient regarding the three modalities of renal replacement therapy, continues with the discussion of the three types of access for hemodialysis (aided by the "scary wall" – see below), continues further after my ultrasound examination with a discussion of what options are available to the given patient based on their vascular assets and other considerations, a recommendation of one or several options, and then a discussion of risks. The risk discussions are codified in several handouts, which include an acknowledgement sheet signed by the patient and placed in the chart.

The "scary wall – every item has an educational point


Recognizing that all this information may be overwhelming to a new patient, we emphasize that my staff is available to answer questions that may arise, and that every patient will have an opportunity to speak with the surgeon one last time before going into the operating room.

The evaluation usually continues past the office visit: venograms and other tests need to be reviewed, a discussion with the nephrologist regarding the choice of procedure or timing may be required, medical issues may need to be clarified, and frequently, cardiac testing. Considerable time may be lost as the chart circles the office, or if the patient procrastinates in the pursuit of cardiac clearance or venograms. A system should be developed to make sure the patient do not fall through the cracks.

The overall purpose of the evaluation is to clarify the patients’ medical status, determine as much as possible what options exist, to explain and discuss those options while educating the patient and family so that they can make an informed decision, and to arrange the intervention in as safe and efficient a manner possible. Because dialysis patients require ongoing periodic re-evaluation and maintenance, establishing a good working relationship early on is helpful to all.

Patients who have multiple intercurrent hospitalizations prior to their surgery, who are unable to find transportation, or who procrastinate and cancel appointments or procedures should be re-evaluated regarding their medical and psychological ability to survive the demands of renal replacement therapy.

Michigan Dialysis Research and Education (MiDRE)
Saint Mary's Mercy Hospital