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Wave 2: Module 4: Carotid, Vascular access and Venous – Week 3 – Case 1
A 67-year-old patient has been developing chronic kidney disease over the past several years.
He is currently under the care of a renal physician.
His most recent blood work shows an eGFR of 12 mL/min/1.73m².
The patient has now been referred to you, the vascular surgeon, for assessment and planning of long-term renal access.
Questions for Students
1. CKD Staging:
• Indicate the levels of chronic kidney disease (CKD) based on eGFR.
2. Timing of Access:
• When is it advisable to consider planning and creation of renal access for a patient with CKD?
3. Assessment:
• How would you assess this patient before considering surgical intervention?
4. Consent & Planning:
• How would you obtain informed consent from this patient?
• How would you plan him for surgical intervention?
1. stage 5 CKD
2. 16 to 24 weeks before the expected date of dialysis
3. Cardiac assessment, clinical and doppler assessment of the veins and arteries
4. consent for AVF/G creation with its possible failure and complications
i will prefer regional anesthesia, also prophylactic Antibiotics if AVG is planned
Questions for Students
1.CKD Staging:Indicate the levels of chronic kidney disease (CKD) based on eGFR.
- Stage 1 of CKD (eGFR of 90 or greater)
- Stage 2 of CKD (eGFR between 60 and 89)
- Stage 3 of CKD (eGFR between 30 and 59)
- Stage 4 of CKD (eGFR between 15 and 29)
- Stage 5 of CKD (eGFR less than 15)
2. Timing of Access: at stage 4 of CKD
3. Assessment:
• How would you assess this patient before considering surgical intervention?
general assessment :
life expectancy :more or less than 2 years
sex : female have less veins diameter
chronic diseases : DM affect distal AVF maturation
cardiac condition : exclude low cardiac output
other condition : vasculitis , obesity
vascular assessment
U/S duplex assessment to identify vein diameter , patency and depth from skin
from distal to proximal
and to exclude any central venous stenosis or occlusion
4. Consent & Planning:
• How would you obtain informed consent from this patient?
after confirming patient capacity to make a informed consent
i will describe the purpose and concept of the procedure whether it is AVF AVG or Permanent catheter and every procedure short and long term complications .
. How would you plan him for surgical intervention?
labs investigation
cardiac assessment
arterio venous duplex of the limb
choose site of intervention and preoperative marking
A1:
CKD staging considered according to eGFR and albumin creat ratio
Stages built on eGFR n > 90
1- >90 with high protei in urine
2: 60-90 mild
3a: 45-60 moderate
3b: 30-45 moderate to severe
4: 15-30 severe with planning fordialysis or transplant
5: less than 15 ESRD for dialysis or transplant
A2:
Stage 4 should be prepared for dialysis access or transplant surgery
A3:
Clinical assessment includind history
USS venous and arterial for access vesseles depth diameter patency
Venogram if CVO. is expected
A4:
The ptn should be informed about the plan includinf CVC AVF or AVG options and the procedure complications including infection hematoma ischemia thrombosis and aneurysm. how to take care of it after surgery and the time taken to be mature and ready to be used
Type of anesthesia LA or preferably regional
Ptn should be assessed for cardiac function
Post op anti platelets is recommended
Antibiotic pre procedure
Arm use instructions
Stage 5
PT should be educated on heamidialysis and prepared for avf creation
Physical exam of arterial and venous system fore avf selection considering
Duplex us assessment
Informed consent should be obtained from the patient after benefits Risk and complications possibilities declaration
Full lab assessment echo preoperative fitness surgery to be done under local or regional Vs general anathesia
Q1) CKD Staging:
STAGE 1 : kidney damage with normal or elevated GFR (more than 90 ml/min/1.73 m2)
STAGE 2 :kidney damage with mild decrease GFR ( 60-89 ml/min/1.73 m2)
STAGE 3 : moderate decrease GFR (30-59 ml/min/1.73 m2 )
STAGE 4: severe decrease GFR ( 15-29 ml/min/1.73 m2 )
STAGE 5: End stage renal disease GFR less than 15 or on dialysis
Q2) Timing of Access:
AV access should be constructed 16-24 weeks before need for dialysis
Q3) Assessment:
- planning will be in access clinic with nurse coordinator.
- Fistula should be as distally as possible, non-dominant hand, upper limb before lower limb, autogenous AVF better than AVG
- Proper clinical and USS assessment essential for planning ( rule of 6 s)
- Duplex scan and venography may be needed
Q4) Informed Consent
- Patient diagnosed as advanced stage 5 CKD (eGFR 12) so need long-term dialysis access needed.
- Patient has many options as AV fistula (preferred), AV graft, central venous catheter (temporary).
- Benefits of AVF are reliable access, best long-term patency, lower infection risk.
- Risks of AVF are bleeding, infection, thrombosis, non-maturation, steal syndrome, aneurysm.
- Alternatives for AVF are peritoneal dialysis, central venous catheter.
- Patient understanding and written consent essential.
Q5) Plan:
- History & examination: dominant hand, pulses, vein quality, comorbidities, previous access.
- Duplex ultrasound mapping of arteries and veins.
- Site selection: distal first (radiocephalic → brachiocephalic → brachiobasilic), non-dominant arm.
- Optimise comorbidities and preserve veins (no cannulation in access arm).
- Multidisciplinary discussion with renal team.
- Patient education: fistula care, maturation time (6–12 weeks)