RBT Roundtable: Vascular Access

What steps can be taken by nephrologists and/or primary care physicians to ensure better vascular access care?

U.S. Vascular: Educating the patient and their significant other is the first step to ensuring better vascular access care. Ensuring dialysis centers are monitoring access monthly is being mandated by CMS according to the new rules posted in October 2008. V tag 550 (5) states the interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors and whether the patient is a potential candidate for arteriovenous fistula placement. And V tag 551 states The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of symptoms of stenosis. While the physicians are responsible for overseeing the care given to the patients, the dialysis staff has the more direct hands on care given to the patients. Ensuring the staff is following the federal regulations will be the step physicians must take to ensure better vascular access care.

Dees: Steps to ensure better access care include early diagnosis, vein mapping and early fistula creation. Cannulation techniques are essential to fistula maturation and longevity as is patient education. The newer surveillance and monitoring tools that are available, such as Vasc-Alert, will earlier identify the troublesome access and indicate a need for early intervention as opposed to thrombosed accesses. Routine fistulagrams in addition to surveillance, patient education and staff in servicing will ensure the transition from clotted accesses to early intervention thus reducing the trauma and more extensive procedures.

Kraus: Education is key. PCPs need to understand early referral of a pre-ESRD patients to a nephrologists is important. (CKD programs are making a difference.) Many patients present uremic and then a temporary catheter is placed. Educating the patients on AVF, AVG and catheters along with caring for their access after placement are all fundamentals that need to be in practice everyday.

Urbanes: Our primary care colleagues and nephrologists are absolutely crucial in our efforts to assure that our patients have the optimum vascular access. This begins with preservation of venous access sites in any patient identified with CKD. While the traditional teaching of avoiding blood pressures and venipuncture in the non-dominant arm remains applicable, the new and emerging menace we face is the proliferation of the use of PICCs and other long-term venous access catheters/ports. That these catheters can cause venous thrombosis and/or stenosis in as brief a period as two weeks should temper the zeal with which these implements are used in CKD patients. While we do educate our patients and their caregivers on the importance of vein preservation, it is also imperative that our other medical colleagues similarly advocate for the same proscription whenever possible. Secondly, early referral to a surgeon who has shown an interest and proficiency in vascular access has been shown to increase the success rate of AVF creation. This should be accompanied by pre-operative vascular mapping in order to assess for vessel patency and caliber and to assure contiguity with proximal venous structures free of obstruction or other pathology that would preclude successful fistula creation.

Sam: Nephrologists and other primary care physicians aid the access care patient significantly primarily by their action at two time points: prior to access placement, and once a functioning access has been achieved. Prior to access placement, it is vital to eliminate or significantly minimize the length of time that a patient relies on a catheter for dialysis. Thus, early autogenous access creation is the Holy Grail of vascular access care. It is well established that early access construction is associated with a lower risk of death and sepsis. Also, pre-dialysis nephrology referral is associated with a shorter duration of catheter use after the initiation of dialysis and with a greater likelihood of autogenous access placement—a superior conduit compared to nonautogenous access. Once an access is established, nephrologists must be vigilant that the dialysis units are properly caring for the access by using vigilant sterile techniques when cannulating the access, taking care to rotate the needles to various sites on the access with each dialysis session avoid psuedoaneurysm formation, and not applying excess occlusion pressure once the needles are removed.