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| > ![](medi     | **DEPARTMENT OF VETERANS AFFAIRS**                  |
| a/image1.png){ |                                                     |
| width="0.86805 | **Veterans Health Administration**                  |
| 55555555556in" |                                                     |
| > he           | **Washington DC 20420**                             |
| ight="0.825694 |                                                     |
| 4444444444in"} |                                                     |
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**IL 10-2001-003**

In Reply Refer To: 111B

February 21, 2001

UNDER SECRETARY FOR HEALTH'S INFORMATION LETTER

HEMODIALYSIS ACCESS VIA AV-FISTULA

1\. The literature supports the use of autogenous arterio-venous (AV)
fistula for hemodialysis as compared to prosthetic graft. Autogenous AV
fistula is associated with lower morbidity and longer survival. Various
studies have demonstrated that the 2-year patency rate of a
*e*-Polytetrafluoroethylene (*e*-PTFE) graft is only 30 to 40 percent,
and these grafts have a useful life one-third to one-tenth that of
autogenous AV fistula. In addition, a large proportion of
hospitalization costs encountered in patients with end-stage renal
disease (ESRD) has been associated with complications of hemodialysis
access. Since autogenous AV accesses have a much lower complication
rate, the Veterans Health Administration should move towards at least 50
percent autogenous AV fistulas in patients requiring hemodialysis as
supported by the Dialysis Outcomes Quality Initiative (DOQI) guidelines.
Therefore, a meeting of vascular surgeons was held in Washington, DC,
(see Att. B) to formulate the following recommendations in dealing with
hemodialysis accesses:

#  a. [Access.]{.underline} Autogenous AV access is the preferred form of AV access for hemodialysis. Ideally, placement of an autogenous AV access should occur about 12 weeks (at a creatinine clearance of 25ml/min for diabetics and 15ml/min for non-diabetics) in advance of the need for renal replacement therapy. It is recommended that under no circumstances autogenous access be used before 8-12 weeks. Even then, the treating physician should clear it for use after inspecting the access. The prosthetic access should not be used for 4 weeks; however, 2 weeks may be adequate if the treating physician inspects the graft and deems it ready for use. Within 3-7 days of the operation, the access site needs to be assessed to ensure the absence of any immediate complication. A surgeon needs to conduct a follow-up assessment within 14-28 days to sign-off the patient or verify that the site is ready for use.

\(1\) **Anatomical options:**

\(a\) Autogenous.

\(b\) Non-dominant upper extremity preferred over dominant (upper
extremity).

\(c\) Upper extremity location starting distally and working proximally:

[1]{.underline}. Snuff box fistula.

[2]{.underline}. Forearm radio cephalic AV-fistula.

[3]{.underline}. Forearm vein transposition.

[4]{.underline}. Forearm graft may be considered.

[5]{.underline}. Upper arm brachiocephalic AV-fistula.

[6]{.underline}. Upper arm basilic vein transposition.

[7]{.underline}. Upper arm graft may be considered.

\(d\) At the end of AV access placement surgery, there must be a
palpable thrill or audible bruit over the arterial anastomosis, and
basic evaluation for pulses in the wrist should be carried out.

\(2\) **Evaluation of Upper Extremity for autogenous AV access
options:**

\(a\) Arterial:

[1]{.underline}. Blood pressure in both arms.

[2]{.underline}. Pulse exam.

[3]{.underline}. Continuous wave Doppler exam with palmar arch signal.

\(b\) Venous:

[1]{.underline}. Careful history of central venous access.

[2]{.underline}. Upper extremity symptoms or previous fractures.

[3]{.underline}. Exam should include application of tourniquet to upper
extremity to evaluate superficial veins.

[4]{.underline}. Tap test to outline course and continuity of suitable
veins.

[5]{.underline}. Evaluate collaterals and skip segments of veins
suggesting problems.

[6]{.underline}. Previous venous punctures

\(c\) Refer to Vascular Laboratory for evaluation for the following:

[1]{.underline}. Central venous catheters with symptoms of concern.

[2]{.underline}. Abnormal findings of the upper extremities or patients
with multiple catheters.

[3]{.underline}. Access failures without technical reasons.

[4]{.underline}. Patients who only had one catheter with normal venous
examination may be deferred from Vascular Laboratory examination
depending on judgement of the surgeon.

b\. **[Stenosis]{.underline}**

\(1\) If there is a problem with stenosis, imaging study and dilatation
of the stenosis and/or an operative repair needs to be performed.

\(2\) If there is no identifiable technical problem in the graft or
anastomosis of the thrombosed access then it is suggested that a work-up
for hypercoagulable state and/or proximal venous and arterial system be
carried out.

c\. **[Pseudoaneurysm]{.underline}**

\(1\) If there is presence of complication or potential for complication
(such as thinning of skin over the pseudoaneurysm), then repair is
indicated.

\(2\) [Preventive Suggestion:]{.underline} Puncture the fistula at
different sites along its course to prevent localized weakness of the
wall.

d\. **[Infections.]{.underline}** Early cellulitis can be treated with
antibiotics.

\(1\) [Localized infection.]{.underline} If the infected part of the
graft is isolated to a localized area of the body of the graft without
involvement of an anastomosis, then try to replace only that part of the
graft by bypassing it.

\(2\) [Generalized infection.]{.underline} If the whole graft is
infected including one or both anastomoses and/or the patient is
systemically ill or septic, the entire graft needs to be removed and a
central access placed. Once the infection is cleared, a new access is
then created.

e\. **[Steal Syndrome.]{.underline}** Evaluate the proximal arterial
inflow for presence of significant stenosis. If none is found, then
procedures aimed at decreasing the amount of blood flow through the
access need to be considered.

f\. **[Indications For Temporary Dialysis Access]{.underline}**

\(1\) [Non-tunneled Temporary Catheters.]{.underline} Non-tunneled
catheters will be used strictly for emergencies when dialysis is
required right away and there is no time for interventional radiology or
surgery. The site may be internal jugular, subclavian, or femoral as
determined by the vascular surgeon. However, the subclavian site should
be avoided to prevent proximal venous stenosis or occlusion precluding
future placement of AV access in the affected limb. These catheters
should be avoided as much as possible.

\(2\) [Tunneled Catheters.]{.underline} Tunneled catheters can be used
as a "bridge" until a permanent AV access is placed. Under no
circumstances should tunneled catheters be considered a permanent AV
access for dialysis except in patients with very short expected survival
or those with tendency towards infections. ***NOTE:** Tunneled catheters
with implantable dialysis ports may need to be considered.*

\(3\) Optimally, no more than 10 percent of patients in a VA Dialysis
Unit should have dialysis delivered via a tunneled catheter (not to
include patients with limited life span or with infection). Permanent
access is desired as soon as possible. Patients with these catheters
need to be evaluated frequently for creation of a permanent AV access.

\(4\) Fifty percent of patients that present with thrombosed, but
salvageable AV access, need to be declotted on an urgent basis.
Autogenous AV accesses need to be declotted as soon as possible,
preferably within 24 hours. Thrombosed non-autogenous AV accesses need
to be declotted as soon as possible or at least within 3 days of
presentation. Central lines need to be avoided whenever possible.

g\. **[Standardized Record-Keeping]{.underline}**

\(1\) At each medical center a standard template needs to be developed
containing universally collected information to assist in the early
identification of problems that may indicate deteriorating or failing
accesses.

\(2\) At each dialysis visit the minimum recorded data needs to include:

[1]{.underline}. History,

[2]{.underline}. Physical exam,

[3]{.underline}. Appearance of access site,

[4]{.underline}. Character of pulse,

[5]{.underline}. Static and dynamic venous pressures,

[6]{.underline}. Standardized rates,

[7]{.underline}. Flow rates,

[8]{.underline}. Arterial pressure or venous pressure, and

[9]{.underline}. Any special concerns that may be a predictor of a
possible problem, such as excessive bleeding and/or declining blood flow
rate, even if adequate on that day.

\(3\) If any of the preceding is of concern in three consecutive visits,
it needs to be considered a "red flag," and the patient is to be
referred immediately to vascular surgery staff or the vascular surgical
coordinator for further evaluation. ***NOTE:*** *The coordinator needs
to be a specific individual, preferably a dialysis nurse that will be
responsible for follow-up and evaluation of problems with access.*

\(4\) Inpatients with a possible proximal venous problem, need to have a
venogram performed in consultation with vascular surgery staff and
reviewed with interventional radiologists. ***NOTE:** If the facility
has the capability to conduct a Duplex scan, this study needs to be
performed for non-invasive diagnostic purposes.* Vascular surgery staff,
in conjunction with radiology staff, need to discuss options and make a
decision.

\(5\) If a patient is referred for vascular surgery, then a vascular
surgeon needs to conduct a minimum of one follow-up visit. After the
creation of AV fistula or revision by a vascular surgeon or
interventional radiologist, a minimum of one follow-up visit needs to be
made with the vascular surgeon.

h\. **[Hemodialysis Access Coordinator and Clinic]{.underline}**

\(1\) Coordinators are essential to the success of the dialysis program.
The coordinator would be responsible for multi-disciplinary care. The
continuity of this care is essential since other disciplines and staff
rotations must be considered. A permanent coordinator is preferred;
otherwise, a member of the current staff is assigned to perform these
tasks. This person would also be charged with maintaining a registry of
patients and data that can be entered into a computer for analysis at a
later date.

\(2\) A dedicated dialysis access clinic needs to be established (based
on the volume of the patients with chronic renal failure or
hemodialysis) that includes interdisciplinary staff, a vascular surgeon,
access coordinator, interventional radiologist, if available, and a
nephrologist. This will facilitate timely referral to vascular surgery
and placement of an AV fistula or an AV graft for adequate dialysis
access. A dedicated clinic could provide such information as history on
the patient, date of access creation, type of access, pictures and other
pertinent information prior to placement of an AV access.

2\. Attachment A contains pertinent references.

3\. Questions regarding this information letter may be referred to T. G.
Patel, M.D., Acute Care Strategic Healthcare Group, Veterans Health
Administration at 202-273-8530.

  ------------------------------- ---------------------------------------
                                  Dennis Smith for

                                  Thomas L. Garthwaite, M.D.

                                  Under Secretary for Health
  ------------------------------- ---------------------------------------

  --------------- ------- ------------------------------------------------
  DISTRIBUTION:   CO:     E-mailed 2/22/2001

                  FLD:    VISN, MA, DO, OC, OCRO, and 200 -- E-mailed
                          2/22/2001
  --------------- ------- ------------------------------------------------

**ATTACHMENT A**

## REFERENCES

1\. National Kidney Foundation. "Dialysis Outcomes Quality Initiative:
Clinical Practice Guidelines for Vascular Access," New York; National
Kidney Foundation, 1997.

2\. Feldman, HI, Held, PJ, Hutchinson, JT, et al. "Hemodialysis Vascular
Access Morbidity in the United States," [Kidney
International]{.underline} [(Kidney Int.)]{.underline}
43;1091-1096:1993.

3\. Hakim, R, Himmelfarb, J. "Hemodialysis Access Failure; a Call to
Action," [Kidney Int.]{.underline} 54:1029-1040:1998.

4\. Veterans Health Administration Clinical Practice Guidelines for the
Management of Chronic Renal Disease and Pre-ESRD in the Primary Care
Setting.

**ATTACHMENT B**

**VASCULAR MEETING ATTENDEES AND CONSULTANTS**

**SEPTEMBER 13, 2000**

Dr. Joseph Rapp

Chairman, Vascular Committee

Chief, Vascular Surgery

VA Medical Center

4150 Clement Street

San Francisco, CA 94121

Dr. Fred N. Littooy

Attending Surgeon

VA Medical Center

Hines, IL 60141

Dr. Mohammed Moursi

Chief, Vascular Surgery Service

VA Medical Center

Little Rock, AR 72205

Dr. Dennis Baker

Chief, Vascular Surgery Service

VA Medical Center (Wadsworth)

Los Angeles, CA 90073

Dr. Anton Sidawy

Chief, Surgical Service (112)

VA Medical Center

50 Irving Street, NW

Washington, DC 20422

Dr. Faris Hakki

Washington Hospital Center

P. O. Box South #408

Washington, DC 20020

Dr. Erik Owens

VA SDHS (112)

3350 Lajolla Village Dr.

San Diego, CA 92161

Dr. Alex O. Aquino

Washington Hospital Center

110 Irving Street, NW \# 3B1

Washington, DC 20020

Dr. Charles E. Palant

VA Medical Center

50 Irving Street, NW #4B200

Washington, DC 20422

Dr. Andres Guerrero

Surgery Department

VA Medical Center

10 Calle Casia

San Juan, PR 00921

Denis Carnigan, RN

(Dialysis Unit)

VA Medical Center

50 Irving Street, NW

Washington, DC 20422

Dr. Ralph DePalma

National Director of Surgery

VHA Headquarters

810 Vermont Avenue, NW

Washington, DC 20420

Dr. Gerald McDonald

Senior Consultant in Surgery

VHA Headquarters

810 Vermont Avenue, NW

Washington, DC 20420

Dr. Thakor G. Patel

Acting Chief Consultant, Acute Care

Strategic Healthcare Group

VHA Headquarters

810 Vermont Avenue, NW

Washington, DC 20420

Dr. Ted Kohler

Professor, Surgery (112V)

Chief, Peripheral Vascular Surgery

Seattle VAMC

Campus Box 358280

Seattle, WA 98108