Management of the failing haemodialysis access (AV fistula or graft) (2025 – CME) – online course

Description

Authors: D. Vorwerk and R. Hoffmann

Reviewers: A. Gjoreski, R. Graaf, S. Protto, R. Uberoi and F. Wolf

This course corresponds to chapter 2.2.1.3.6 Haemodialysis vascular access in the European Curriculum and Syllabus for Interventional Radiology.

Abstract

In 1966, Ciminio and Brescia were the first to perform subcutaneous, arteriovenous anastomosis that allowed repeated puncturing, a concept still used today. Long durability, efficient flow rates, and lack of adverse events such as infection, thrombosis, stenosis, aneurysms, or ischaemia characterize the “perfect” vascular haemodialysis access. Unfortunately, none of the currently employed techniques meet the above criteria. However, placing the arteriovenous fistula at the wrist level allows the preservation of proximal vessels for the sake of future vascular access.

Poorly functioning fistulas are characterized by changes in the nature of thrill, pulsation, and altered bruit at auscultation. Doppler ultrasonography, alongside clinical examination, is the basic method of assessing arteriovenous fistulas. Early occlusion of the arteriovenous fistula is mainly caused by operator error or pre-existing venous stenosis.

For six weeks after surgery, the fistula matures, meaning it acquires the ability to be used clinically as a dialysis vascular access. In some cases, additional endovascular treatments are required to make it efficient.

Thrombosis is the most frequent late complication. In the majority of patients, it occurs as a result of stenosis. Stenosis should be treated if the fistula diameter is reduced by >50% and accompanied by clinical criteria or if there is a reduction in measured dialysis adequacy. In stenosis, balloon angioplasty is associated with a certain degree of failure and may require the use of various additional techniques or instrumentation for patency restoration. Cutting or drug-eluting balloons, catheter-directed thrombolysis, thromboaspiration, and mechanical thrombectomy are some of the examples.

Many scientific publications indicate that minimally invasive endovascular procedures provide good and durable results for haemodialysis fistula treatment.

Learning objectives

• To become familiar with the anatomy, location, morphology, and preferred order of fistula creation.
• To understand the pathophysiology of arteriovenous access failure and become familiar with the clinical presentation and signs of complicated, failing, or failed haemodialysis.
• To understand the modern approach to diagnostic work-up and management of failing haemodialysis access.
• To become familiar with indications and contraindications for treatment.
• To achieve technical competence of venous, arterial, and anastomotic stenosis and occlusion management related to fistulae.
• To become familiar with possible complications and their treatment.
• To understand the differences between primary, primary-assisted, and secondary patency and become familiar with the published literature relating to these different outcome points.

Further information

This course covers a basic level of IR knowledge and is designed for trainees, students or young consultants aiming to acquire essential knowledge or prepare for the EBIR exam. Thereby, it is tailored to the European Curriculum and Syllabus for Interventional Radiology and corresponds to chapter 2.2.1.3.6 Haemodialysis vascular access.

The format of the course is interactive and easy to use, including texts, graphics, videos and a quiz to support your learning. The course duration is around one hour and is accredited by the European Accreditation Council for Continuing Medical Education (EACCME) to award 3 European CME credits (ECMEC). The CME accreditation for this course will expire on March 14, 2027. A non-CME accredited version of the course will remain available until March 17, 2029.

The acquired CME Certificate will be available in the myCIRSE area under CIRSE Academy.

The enrolment period of this course is linked to the validity of the All-Access Pass.

Release date: March 2025