Makindo Medical Notes

🩸 Introduction

• 💉 Vascular access is essential for haemodialysis.
• 🔀 Options: dual-lumen central venous catheters (acute use) OR arteriovenous (AV) fistula/graft (chronic use).
• 📌 Dual-lumen catheters (internal jugular > femoral > subclavian): immediate access but 🚨 higher infection/thrombosis risk.
• 📌 Tunnelled lines: long-term use if fistula not possible (e.g. poor vasculature, comorbidity).
• ⭐ AV fistula = gold standard: artery ↔ vein anastomosis → high-flow, durable access. Takes 4–6 weeks to mature.
• 🖐️ First choice = radiocephalic fistula (non-dominant wrist). Other options:
  • 💪 Brachiocephalic fistula (elbow)
  • 🔄 Brachiobasilic fistula (with transposition)
  • 🧪 Synthetic graft (ePTFE) if native vessels unsuitable

⚠️ Complications

• ⏱️ Immediate: bleeding, haematoma, arterial puncture.
• 🕐 Early: infection (esp. catheters), thrombosis, failure to mature (≤30%).
• 🕰️ Late:
  • 🖐️ Steal syndrome: hand ischaemia (pain, pallor, cold, ulcers).
  • 🎈 Aneurysmal varices: repeated needling → rupture risk.
  • ❤️ High-output cardiac failure: rare, high flow shunt.
  • 🩵 Venous hypertension: limb swelling, congestion.
  • 🪤 Central vein stenosis: esp. post-subclavian lines → arm swelling.

🔍 Fistula Maturity

• ✅ Ready after 4–8 weeks if: good size + high flow.
• ✋ Clinical: palpable thrill + audible bruit.
• 🖥️ US flow >600 mL/min = ideal.

🛠️ Clinical Pearls

💡 Key Pearls:
⭐ AV fistula = longest survival, lowest infection.
🚫 Never use fistula arm for BP, bloods, or IV lines.
🚫 Avoid subclavian lines (stenosis risk).
📞 Urgently refer access issues to vascular team.

🔄 Comparison of Vascular Access Options

📍 Central Venous Catheter (CVC)
✔️ Immediate access, no maturation needed.
❌ Infection + thrombosis, poor long-term patency, central stenosis.
➡️ Used for AKI, bridging, or unsuitable for fistula/graft.

📍 Arteriovenous (AV) Fistula
✔️ Best long-term survival, lowest infection, high flow.
❌ 4–8 wks to mature, failure to mature (≤30%), steal syndrome, aneurysm, high-output failure.
➡️ Gold standard for chronic haemodialysis.

📍 AV Graft (Synthetic ePTFE)
✔️ Can use in 2–3 weeks, option if poor veins.
❌ More infection, poorer patency than fistula, frequent re-interventions.
➡️ For patients with poor native vessels (elderly, diabetics).

💡 Quick Rules

📊 Infection risk: CVC > Graft > Fistula
📊 Patency/survival: Fistula > Graft > CVC
👂 Always confirm thrill + bruit before use