Approach to an Arteriovenous Access with No Thrill, Bruit, or Pulse
The vascular access of the hemodialysis patient remains his anchor to life-sustaining dialysis. Despite advances in technical surveillance, greater knowledge and practice of clinical monitoring, and more widely available expertise in and infrastructure to
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16
Aris Q. Urbanes
16.1
Introduction
The patient with a hemodialysis vascular access that has no palpable thrill or pulse and no audible bruit presents the physician with at least two simultaneously critically important and time-sensitive issues: the resuscitation of the vascular access and the patient’s need for ongoing life-sustaining renal replacement. Although it may intuitively appear that the former necessarily leads to the latter, the decision regarding how best to assure the immediate and more crucial need for ongoing dialysis often flavors how one approaches the vascular access. In this regard, the physician must employ his keen clinical sensibilities and judgment, understand the renal patient’s history and physiology, and judiciously utilize the most appropriate approach to the problems at hand. The management of the clotted dialysis vascular access can be a most challenging but ultimately uniquely rewarding situation that a clinical interventionalist will face.
16.2
Clinical Considerations
In most circumstances, the patient is referred from the dialysis facility where the health-care professionals assessed the vascular access pre-cannulation and deemed it thrombosed. On occasion, however, they may have attempted cannulation and been unsuccessful in obtaining viable blood return from one or both needles. Invariably, there may have been prodromal symptoms or signs that presaged the clotting of the access. It is useful for the clinical interventionalist to be aware of these because it provides a clue as to the culprit lesion/s that one may anticipate during the procedure. It also aids one to know the duration during which renal replacement has been suboptimal or dysfunctional as this helps stratify procedural and sedation risks based on the patient’s A.Q. Urbanes, MD Lifeline Vascular Access, Vernon Hills, IL, USA e-mail: [email protected]
biochemical and fluid disequilibrium. A patient who has been receiving suboptimal dialysis for a week may predictably have more or more severe biochemical derangements than a patient whose dialysis treatments have been uneventful up until the day of access thrombosis. The clotted vascular access is not difficult to clinically diagnose. A color flow Doppler examination will verify the absence of flow through the access, but this is rarely needed. A sometimes confusing clinical finding is a thrill close to the artery-vein anastomosis in an autologous fistula. If the thrill comes, in fact, from the fistula and not transmitted from the artery, then one’s approach might be simplified to a percutaneous angioplasty of a suspected downstream stenosis. Another useful physical finding is whether or not the fistula or the effluent venous drainage of a prosthetic arteriovenous graft is hard or tumescent suggesting extension of clot to this region. A greater length of soft or collapsible fistula portends of a smaller clot burden than a sizeable length of hard or turgid vein. Anticipating the amount and extent of thrombus that one might encounter would be beneficial
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