What are the best dialysis options for a patient with a failed Arteriovenous (AV) graft and no flow?

Dialysis Options for a Patient with a Failed AV Graft

For a patient with a failed arteriovenous (AV) graft with no flow, a tunneled cuffed central venous catheter is the immediate best option, followed by evaluation for a new AV access at a different site based on the patient's ESKD Life-Plan.

Immediate Management

• A tunneled cuffed dialysis catheter should be placed as an interval means for hemodialysis when an AV graft has failed 1
• The catheter should be placed in the internal jugular vein as the first choice, followed by external jugular, femoral, subclavian, and lumbar veins in order of preference 1, 2
• Right-sided placement is generally preferred over left-sided due to more direct venous anatomy, unless there are pathological findings such as central venous stenosis 1, 3
• The catheter should be placed in the extremity opposite to the one anticipated for future AV access creation 1

Evaluation for New Permanent Access

• After immediate dialysis access is secured, the patient should be evaluated for a new permanent access based on their individualized ESKD Life-Plan 1
• Vascular mapping with ultrasound or contrast imaging should be performed to assess potential sites for a new AV access 4
• Central venous assessment should be conducted to rule out central venous stenosis that might affect future access options 1

Options for New Permanent Access (in order of preference)

1. New Arteriovenous Fistula (AVF):

   • First choice if suitable vessels are available 1, 5
   • Requires 1-3 months to mature before use 1
   • Consider secondary AVF utilizing the mature outflow vein of the failed graft when possible 4

2. New Arteriovenous Graft (AVG):

   • Second choice if AVF creation is not feasible 5, 2
   • Standard AVGs can be used 2-4 weeks after placement 6
   • Early cannulation grafts can be used within 24-72 hours if urgent access is needed 6
   • Consider forearm loop graft, upper arm straight graft, or upper arm loop graft in order of preference 5

3. Long-term Tunneled Catheter:

   • Consider for long-term use only when:
     • Patient has limited life expectancy
     • Multiple prior failed AV accesses with no available options
     • Patient has a valid preference after being informed of risks 1, 2

Special Considerations

• If the patient has had multiple access failures, consider evaluation for hypercoagulability 1
• For patients with exhausted conventional access sites, consider complex AV grafts such as femororenal arteriovenous graft 7, 8
• The HeRO (Hemoaccess Reliable Outflow) Vascular Access Device may be considered as a hybrid alternative when central venous stenosis is present 1

Pitfalls to Avoid

• Avoid prolonged catheter dependence as it increases mortality (51%) and severe infection risk (130%) compared to AVF/AVG 2
• Avoid subclavian vein catheterization as it can cause central venous stenosis in up to 50% of cases, limiting future access options 1, 2
• Do not place a new tunneled catheter on the same side as a planned future AV access 2
• Avoid delaying evaluation for a new permanent access, as early planning reduces catheter dependence 5, 4

Monitoring and Follow-up

• Perform quarterly reviews of vascular access functionality, complication risks, and future dialysis access options 1
• Regular monitoring of the new access is essential to detect dysfunction early and prevent thrombosis 5
• For patients with recurrent access failures, consider referral to a multidisciplinary vascular access team 1