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HEMODIALYSIS ACCESSKDOQI GUIDELINES
ELEFTHERIOS XENOS, MD, PhD
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Timing of referral to AV access surgeon and timing of
placement of permanent vascular access
Patients with advanced CKD disease (late stage 4, stage 4 CKD (GFR
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Technical remarks
The average maturation time of a new autogenous access is 2
to 4 months
Catheter use at initiation of dialysis is also associated with
higher subsequent mortality
81% of United States ESRD patients initiate dialysis with acatheter, and only 26% have an autogenous or prosthetic AV
access already in place
Mortality is higher among patients who receive dialyses
continuously through a catheter than among those who switch
from a catheter to autogenous or prosthetic permanent access
Referral for initial vascular access placement should ideally
occur approximately 6 months in advance of the anticipated
need for dialysis
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Preoperative evaluation Factors associated with increased difficulty in establishing a functional
AV access : diabetes mellitus, peripheral vascular disease, severecongestive heart failure, advanced age, and female gender
Ultrasound venous mapping is of critical importance in these patients,not only for identifying preferred autogenous access sites but also for
evaluating the depth of venous structures Studies have shown both 1.5 mm and 2.0 mm to be the minimally
acceptable internal arterial diameters for successful autogenous AVaccess, although 2.0 mm seems to be the more commonly accepted limitin adults
The Allen's test confirms a patent palmar arch and is particularlyimportant when an autogenous AV access at the wrist is planned.Bilateral extremity blood pressures should be recorded and found to beequal
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Preoperative evaluation Ultrasound imaging has become the common standard in preparation for
an AV access procedure, ultrasound evaluation increased AV fistula
construction from 14% to 63%
Ultrasound venous mapping, which is performed with and without a
venous pressure tourniquet in place, evaluates vein diameter, patency,
continuity, and distensibility of the planned venous outflow conduit.
Both distensibility and venous diameter have been found to
independently predict autogenous AV access success
Arteriography : individuals with suspected proximal arterial occlusive
lesions where pre-AV access interventional procedures might both
identify and treat the problem site, gaining adequate arterial inflow for
the eventual autogenous AV access
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Operative strategies to optimize the
placement of autogenous
arteriovenous accesses Upper extremity access sites are used first, with the nondominant arm
given preference over the dominant arm only when access opportunities
are equal in both extremities AV accesses are placed as far distally in the upper extremity as possible to
preserve proximal sites for future accesses
When possible, autogenous AV accesses should be considered before
prosthetic arteriovenous accesses are placed. These autogenous access
configurations should include, in order of preference, the use of direct AVanastomosis, venous transpositions, and translocations
Lower extremity and body wall access sites are used only after all upper
extremity access sites have been exhausted
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Autogenous versus prosthetic vascularaccess for hemodialysis: A systematic
review and meta-analysis
M. Hassan Murad, MD, MPH, Mohamed B. Elamin, MBBS, Anton N. Sidawy, MD, MPH, German Malaga, MD,
MSc, Adnan Z. Rizvi, MD, David N. Flynn, BS, Edward T. Casey, MD, Finnian R. McCausland, MD, Martina M.
McGrath, MD, Danny H. Vo, MD, Ziad El-Zoghby, MD, Audra A. Duncan, MD, Michal J. Tracz, MD, Patricia J.
Erwin, MLS and Victor M. Montori, MD, MSc
Journal of Vascular Surgery
Vol 48,page 34-47(November 2008)
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2.1 The order of preference for placement of fistulae in patients with kidney failure
who choose HD as their initial mode of KRT should be (in descending order of
preference):
2.1.1 Preferred: Fistulae. (B)
2.1.1.1 A wrist (radiocephalic) primary fistula. (A)
2.1.1.2 An elbow (brachiocephalic) primary fistula. (A)
2.1.1.3 A transposed brachial basilic vein fistula: (B)
2.1.2 Acceptable: AVG of synthetic or biological material, such as: (B)
2.1.2.1 A forearm loop graft, preferable to a straight configuration.
2.1.2.2 Upper-arm graft.
2.1.2.3 Chest wall or necklace prosthetic graft or lower-extremity fistula or
graft; all upper-arm sites should be exhausted.
2.1.3 Avoid if possible: Long-term catheters. (B)
2.1.3.1 Short-term catheters should be used for acute dialysis and for a
limited duration in hospitalized patients. Noncuffed femoral catheters should
be used in bed-bound patients only. (B)
2.1.3.2 Long-term catheters or dialysis port catheter systems should be usedin conjunction with a plan for permanent access. Catheters capable of rapid
flow rates are preferred. Catheter choice should be based on local experience,
goals for use, and cost. (B)
2.1.3.3 Long-term catheters should not be placed on the same side as a
maturing AV access, if possible. (B)
Special attent ion sh ou ld be paid to considerat ion of avoidin g femo ral catheteraccess in HD pat ients w ho are current or futu re kidney transplant candid ates.
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Brescia-Cimino AVF
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Choice of arteriovenous access when a
patient is not a suitable candidate for
forearm autogenous access
Two studies compared the autogenous upper arm access with a
prosthetic lower arm access (prosthetic looped forearm access).
Placement of autogenous access in the upper arm is associatedwith a significantly lower rate of infections (RR, 0.23; 95% CI, 0.07-
0.83) and nonsignificant trends for better 12-month primary (RR,
0.88; 95% CI, 0.72-1.07) and secondary (RR, 0.81; 95% CI, 0.54-
1.20) patency.
Patency at 24 months was similar between the two accesses. Bothstudies reported the upper arm placement of autogenous access
to be associated with fewer complications and to require fewer
interventions to maintain patency.
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Choice of arteriovenous access when a
patient is not a suitable candidate for
forearm autogenous access For patients who have exhausted all forearm veins on both sides and, according to
vein availability the surgeon should offer both alternatives to patients
Although the upper arm autogenous access may fare better compared with a
forearm prosthetic access, using these two accesses sequentially may lead to
additive benefit: This practice may help to preserve upper arm veins for future
placement of autogenous access, may help to increase the caliber of these veins
and maximize the success of future upper arm autogenous access, and may provide
patients with an additional 1 to 3 years of functional hemodialysis access .
For patients at risk for ischemia, such as when the brachial or lower extremity
arteries are used for inflow, a tapered graft should be considered for use with the
smaller end of the graft placed at the arterial end
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ACCESS CONFIGURATIONS
Upper arm autogenous accesses Autogenous brachial (or proximal radial)cephalic upper arm
direct access
Autogenous brachial (or proximal radial)basilic upper armtransposition
Autogenous brachial (or proximal radial artery)brachial vein
upper arm transposition
Autogenous brachial (proximal radial) arteryaxillary veinupper arm indirect greater saphenous translocation
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ACCESS CONFIGURATIONS
Configurations of prosthetic AV accesses
Prosthetic radialantecubital forearm straight
access
Prosthetic brachialantecubital forearm
looped access
Prosthetic brachialaxillary (vein) upper arm
access
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ACCESS CONFIGURATIONS
Configurations of prosthetic AV accesses Prosthetic femoral arteryfemoral vein lower
extremity looped access
Prosthetic axillaryaxillary (vein) chest access(necklace prosthetic access)
Prosthetic axillaryinternal jugular chest loop
access Prosthetic axillaryfemoral (vein) body wall
access
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The role of monitoring and surveillance in
arteriovenous access management
Monitoring :physical examination indicators such as observation,
palpation, and auscultation of the access,
Surveillance :tests to assess access function.
Clinical monitoring by skilled personnel was shown to have adequatediagnostic accuracy; clinical monitoring has been reported to have
positive predictive value of70% to 90% in prosthetic accesses and a
specificity of90% and a sensitivity of93% in autogenous accesses
Lower incidence of thrombosis may translate into a reduction in access-
related costs and hospitalizations Flow surveillance produced a 32.5% reduction in the overall cost of
access care
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Surveillance of arteriovenous
hemodialysis access: A systematic
review and meta-analysis
Edward T. Casey, DO, M. Hassan Murad, MD, MPH, Adnan Z. Rizvi, MD, Anton N.
Sidawy, MD, MPH, Martina M. McGrath, MD, Mohamed B. Elamin, MBBS, David N.Flynn, BS, Finnian R. McCausland, MD, Danny H. Vo, MD, Ziad El-Zoghby, MD, Audra
A. Duncan, MD, Michal J. Tracz, MD, Patricia J. Erwin, MLS and Victor M. Montori,
MD, MSc
Journal of Vascular SurgeryVol 48, 2008
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The role of monitoring and
surveillance in arteriovenous accessmanagement
We recommend regular clinical monitoring (inspection,
palpation, auscultation, and monitoring for prolongedbleeding after needle withdrawal) to detect access
dysfunction
We suggest access flow monitoring or static dialysis venous
pressures for routine surveillance We suggest performing a Duplex ultrasound (DU) study or
contrast imaging study in accesses that display clinical signs
of dysfunction or abnormal routine surveillance
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The role of monitoring and surveillance in
arteriovenous access management
Four most useful surveillance methods: (1) serial access flow
measurement, (2) serial measurement of static dialysis venous pressure,
(3) prepump arterial pressure, and (4) DU scanning
The KDOQI Guidelines recommend monthly measurement of access
flow. It requires specialized equipment and a trained technician.
Access blood flow measurements. Access blood flow is the best
determinant of access function. As an access develops progressivestenosis, access blood flow falls. Prosthetic access blood flow rate of
25% from the previous
baseline, has a high predictive value for significant stenosis (87% to
100%).
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The role of monitoring and surveillance in
arteriovenous access management
Static venous dialysis pressure. The greatest value is in prosthetic accesses, but is of little orno value as a surveillance tool for autogenous.
Prepump arterial dialysis pressure: New autogenous accesses, which have a high incidence
of failure to mature, almost always have an access flow problem that is on the arterial side
of the venous needle and therefore will be identified by an excessively negative arterial
dialysis pressure (ADP). In addition, most of the flow-restricting lesions in dysfunctionalradialcephalic as well as some other autogenous accesses, are likewise present on the
arterial side of the venous needle and are often identified by increasingly negative ADPs.
Therefore, routinely checking the ADP at every dialysis session is critically important in
evaluating function in autogenous accesses, especially new ones.
Duplex ultrasound imaging. DU imaging can assess the access for both anatomic as well as
flow abnormalities that may represent significant stenosis. This test requires measuring the
peak systolic velocity (PSV) at the graft venous anastomosis and at any other area of visual
stenosis. A ratio ofPSV 2.0 at the stenotic site compared with the PSV immediately
upstream is used to diagnose stenosis, with a positive predictive value of 80% for
significant graft stenosis
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The role of monitoring and surveillance in
arteriovenous access management
Autogenous access :The best, most feasible tools for
identifying dysfunction in autogenous access include (1)
physical examination (monitoring), (2) routine measurementof prepump ADP at every dialysis session, and (3) serial
access blood flow measurements
Prosthetic access function is best and most feasibly followedup by (1) a physical examination (monitoring), (2) serial
access blood flow measurements, and (3) serial static VDP
measurements.
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Management of nonfunctional
arteriovenous access Access too deep
Nonligated side branches
Insufficient arterial inflow:Stenosis at the arterial anastomosis is the
most common reason for inadequate arterial inflow. Arterial anastomoticstenosis usually occurs as a result of a technical error or neointimal hyperplasia.
The next most common location for arterial stenosis is an orificial stenosis of the
subclavian artery
Poor venous outflow :Poor venous outflow can also be caused by early
anastomotic stenoses, which are technical errors, usually manifest as earlythrombosis, but they can also lead to nonfunctionality or failure to mature in
autogenous accesses.
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Management of failed
arteriovenous access Prosthetic accesses have a much higher incidence of
thrombosis and the access-specific stenotic lesion is more
predictably found at the prosthetic venous anastomosis
In autogenous access the stenosis can be located anywhere
along the access vein used for needle puncture, and multiple
stenoses are often present(need for complete access
evaluation)
Prosthetic and autogenous accesses can both have stenoses
along the venous outflow tract, including central veins on
the same side.
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f f i l
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Management of nonfunctional or
failed arteriovenous access It is important to note that once access occlusion occurs,
prolonged patency is unusual
In >90% of cases, prosthetic accesses failure is due to
stenosis of the venous anastomosis, draining vein, or central
vein
Histologic analysis of the venous anastomotic lesion
demonstrates that it is identical to restenotic lesions that
occur in the coronary arteries after coronary angioplasty or
artery-to-artery bypass. The pathophysiology of prostheticaccess failure is largely that of neointimal hyperplasia at the
venous anastomosis.
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Complications of arteriovenous
hemodialysis access: Recognition and
management
Dysfunctional hemostasis
Infection
Noninfectious fluid collections
Pseudo aneurysm
Venous hypertension
Arterial steal syndrome High-output cardiac failure
Neuropathy
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Platelet dysfunction in uremia is common ,the hazard rate
for bleeding in ESRD patients is 0.55 per annum, the hazard
rate increased with antiplatelet therapy to 0.99 per annum
Management of acute bleeding is best treated with 1-
deamino-8-d-arginine vasopressin (DDAVP). Cryoprecipitate
may play an adjunctive role
Bleeding time in von Willebrand disease is often corrected
during pregnancy, and randomized, placebo-controlled trials
have confirmed that estrogen administration shortens the
bleeding time in uremic patients, both women and men
Dysfunctional hemostasis
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Dysfunctional hemostasis
Evidence from randomized, prospective clinical trials shows
no role for clopidogrel or warfarin as an adjunct to patency
of prosthetic or autogenous AV access
Prosthetic access thrombosis was not reduced by 75 mg of
clopidogrel plus 325 mg of acetylsalicylic acid
low dose warfarin (international normalized ratio, 1.4-1.9)
reported no improvement in prosthetic graft function and an
increase in major bleeding events with warfarin
Clopidogrel (75 mg) demonstrated no benefit for autogenousaccess
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Venous hypertension
Flow in the radial artery increases from 30 to 300 mL/min afterconstruction of a radiocephalic AV access, Mean flow using ultrasound-
detected indicator dilution is 645 mL/min for radiocephalic and 1336
mL/min for brachiocephalic autogenous AV accesses.
The most frequent cause of upper extremity venous thrombosis is now
central venous catheters or cardiac devices; the most powerful predictoris the presence of these devices, with an odds ratio of7.3
Approximately 50% of dialysis patients had a history of subclavian
catheterization, and 50% of those exposed had stenoses that were
considered significant
10-year review of pacemaker insertions at one institution found a 71%incidence of significant subclavian vein stenosis; ligation of an ipsilateral
AV access was required in 10 of 14 dialysis patients
defibrillator lead placements found 14 of 30 had >50% subclavian
stenosis
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Venous hypertension
Endovascular options offer a minimally invasive approach
with relatively low risk
durability is only mediocre
repeated intervention is frequently necessary to maintain
the result
Surgical management options include a direct approach to
the site of obstruction, bypass of the obstruction,
construction of the access in another extremity, and
conversion to peritoneal dialysis.
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Infection An increasing international body of data implicates catheter
access as the leading source of these bloodstream infections
81% of United States ESRD patients initiate dialysis with a
catheter, and only 26% have an autogenous or prosthetic AV
access already in place
CDC, recruited 109 centers in 30 states to form the Dialysis
Surveillance Network in the United States. Overall, there
were 3.22 access-related infections per month, of which 1.78
per month were bacteremias. As expected, the rate ratios foraccess-related bacteremia were less with autogenous AV
access (0.48 [95% CI, 0.35-0.65]), or prosthetic graft (1.0
[reference]) than with a cuffed catheter (9.2 [95% CI, 7.7-
10.8]).
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Infection Staphylococcus spp constitute 32% to 53%
Enterococci and coagulase-negative Staphylococcus spp, 20%
to 32
Polymicrobial infections with gram-negative bacteria, 10% to
18
Staphylococcus and Pseudomonas spp may both be highly
destructive and likely to incur anastomotic disruption
0.56% to 5% per year for autogenous AV access
4% to 20% per year for prosthetic AV grafts
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Infection
Total or subtotal AV access excision
Segmental access excision:94% success rate
when 17 patients were treated withsegmental graft excision
Complete AV access preservation
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Noninfectious fluid collections
Most of these complications may be managed with limited
intervention, but each has the potential to result in loss of
access
Hematoma Seroma: Seromas are sterile fluid collections that can
develop around prosthetic AV grafts and almost never
involve autogenous AV accesses
Lymphocele-lymphorrhea
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Pseudo aneurysm
Puncture site pseudoaneurysm
Anastomotic pseudoaneurysm
Diffuse enlargement of an autogenous AVaccess : a unique feature that may develop in
an autogenous AVF
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Steal
Clinical condition caused by arterial
insufficiency distal to a hemodialysis access
Usually associated with reversal of distal flow
Incidence around 3-5%
Can progress to irreversible neuropathy , loss
of function (claw hand), gangrene, digit loss,
limb loss
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Steal
Hand pain
Diminished/altered sensation
Pale, cold hand
Diminished/absent pulses
Weakness
Ischemic monomelic neuropathy
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IMN
The pathognomic feature of ischemic monomelic
neuropathy is the presence of diffuse neurologic
dysfunction usually in the absence of significant
clinical ischemia The hand is usually warm and often a palpable
radial pulse or audible Doppler signal is present.
Dysfunction of multiple upper extremity peripheral
nerves-potential for long term disability
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Revision Using Distal Inflow: A Novel
Approach to Dialysis-associated Steal
syndrome
David J. Minion, MD, Erin Moore, MD, and Eric
Endean, MD, Lexington, Kentucky
Ann Vasc Surg 2005; 19: 625-628
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Venous hypertension
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Venous hypertension
Flow in the radial artery increases from 30 to 300 mL/min after construction of aradiocephalic AV access, Mean flow using ultrasound-detected indicator dilution is
645 mL/min for radiocephalic and 1336 mL/min for brachiocephalic autogenous
AV accesses.
The most frequent cause of upper extremity venous thrombosis is now central
venous catheters or cardiac devices; the most powerful predictor is the presence
of these devices, with an odds ratio of 7.3
Approximately 50% of dialysis patients had a history of subclavian catheterization,
and 50% of those exposed had stenoses that were considered significant
10-year review of pacemaker insertions at one institution found a 71% incidence
of significant subclavian vein obstruction; ligation of an ipsilateral AV access was
required in 10 of 14 dialysis patients
defibrillator lead placements found 14 of 30 had >50% subclavian stenosis
First choice is forearm autogenous
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First choice is forearm autogenous
arteriovenous access Compared with prosthetic access, the autogenous access is associated with a lower incidence
of death and access infection and with a higher primary and secondary patency at 12 and 36
months
Benefit of autogenous access compared with prosthetic access in terms of lowering the
incidence of the three complications of steal, aneurysm, and hematoma is significantly more
in the case of lower arm autogenous access compared with upper arm autogenous access
Gentle flushing of the distal end of the vein with heparinized saline allows for evaluation ofthe caliber and extent of the vein and identification of side branches for ligation through stab
incisions after performing the anastomosis. This encourages flow in the main venous
segment, allowing for faster maturation. Ligation or endovascular coiling of side branches can
also be delayed to a later date and performed only if the autogenous access does not mature
in a timely basis
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A mature autogenous access requires three components: (1) an adequate diameter to permit safecannulation with dialysis needles without infiltration, (2) an adequate access flow rate to permit
achieving an access blood flow of 500 mL/min and (3) it must be sufficiently superficial to permit
recognition of landmarks and accurate, safe cannulation. The access blood flow increases dramatically
within 24 hours of autogenous access placement and reaches most of its maximum flow within 3 to 6
weeks. Similarly, most of the increase in access diameter is achieved within 4 to 8 weeks of autogenous
access placement.
If upon clinical evaluation at 4 to 6 weeks the autogenous access is not clearly maturing adequately,
further investigation is warranted to identify potentially remediable anatomic lesions. These may
include a venous or arterial stenosis, competing veins, large patent branches, or excessive depth from
the skin.27 The assessment may be performed either by DU scanning or by an imaging study. Several
studies have demonstrated that at least 80% of immature autogenous accesses can be salvaged after
correcting one or more underlying lesions
When the vein diameter is 4 mm and the access blood flow is 500 mL/min, there is a 95% likelihood
that the autogenous access will be usable for dialysis. If the vein diameter is
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Conversion of a prosthetic AV access to a
secondary autogenous AV access
Plan and protocol for eventual conversion of forearm
prosthetic access to a secondary autogenous AV access
should be put in place at the presence of any sign of failing
forearm prosthetic AV access, or after the first failure Conversion of the prosthetic access mature outflow vein to
an autogenous access
Identifying a new, remote site for autogenous access
construction in a patient where the prosthetic accessoutflow vein is not deemed suitable
Conversion of prosthetic AV access
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Conversion of prosthetic AV access
outflow vein to an autogenous
access
Forearm AV prosthetic
The outflow vein candidates in the arm are
the cephalic, basilic, and brachial veins
Autogenous alternative that is durable and
usually usable immediately
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