Vascular Access in Clinical Practice PDF

Preface

Vascular Access in Clinical Practice was conceived during my training in both general surgery and vascular surgery. As a senior resident and fellow, I was often charged with the establishment of vascular access for hemodialysis and longterm venous access. Although there were a plethora of reference texts on surgical techniques, vascular access often received little if any attention in the broad scope of general or vascular surgery. I was disappointed at the lack of practical information available about access techniques.

The concept of a ‘‘how to'' text evolved simultaneously with the development of my large practice of hemodialysis patients in the Southwest. Establishing, and—often more vexing—maintaining, vascular access became a daily challenge. It became apparent to me that many techniques applied in this patient group were passed along by word of mouth through training programs, and more recently through a biennial conference devoted to hemodialysis access organized by Ohio State University under the guidance of Mitchell Henry, M.D. As a regular attendee at that symposium, I witnessed firsthand the thirst for tips and knowledge regarding vascular access that existed in the community of healthcare providers who care for the end-stage renal disease patient.

What started as a simple ‘‘how to'' reference has evolved into a comprehensive manual. The contributors all have experience caring for large numbers of hemodialysis patients on a regular basis, and the chapters include not only published tehcniques but also some well-known yet not well-publicized tricks of the trade such as use of the pneumatic tourniquet for access construction and revascularizatrion for access-related steal. The text begins with an overview of hemodialysis.

The next chapters in Part I are devoted to preoperative assessment and anesthetic techniques for access surgery. These are followed by chapters that are devoted to hemodialysis access fistulae and grafts and describe surveillance techniques and salvage techniques, both surgical and nonsurgical. The section on hemodialysis concludes with a discussion of the pathophysiology of access failure at cellular and biochemical levels.

Part II, which covers dialysis access complications, begins with a chapter devoted to central venous access catheters specifically used for hemodialysis. The subsequent chapter discusses accessing fistulae, grafts, and catheters and provides information regarding the care of these sites. A chapter follows on the complications of dialysis access fistulae and grafts. The section's final chapter examines biomaterials used for access devices. Part III is devoted entirely to central venous access catheters used for nondialysis indications. This section outlines catheter selection, placement techniques, and complications. In Part IV the text concludes with three chapters devoted to peritoneal dialysis and includes catheter placement techniques and complications.

I have attempted to minimize redundancy throughout the text by careful use of cross-referencing of other chapters rather than repetition of previously covered material.

As this text evolved, so too has the treatment of access surgery by the medical profession. The National Kidney Foundation's publication of the Dialysis Outcome Quality Initiative (NKF-DOQI) provided insight into the state of the art of dialysis access and, moreover, established goals for all access surgeons in managing this difficult clinical problem. I have incorporated and referenced the DOQI guidelines throughout the text where appropriate to provide the reader with a practical method of correlating the text information within the context of national guidelines. Thanks to these national standards, vascular access surgery has been elevated in stature in the scope of practice of general and vascular surgery. The attention that access surgery now receives at U.S. and international surgery meetings is evidence of this change.

My commitment to this field is the product of my experience as as surgical resident and vascular fellow. Two surgeons, Roger T. Gregory and Marc H. Glickman, instilled in me the challenge of excellence in the care of dialysis patients and the concept of applying vascular surgery principles to the clinical problems presented by the hemodialysis patient, at a time when that approach was not embraced readily by the surgical community.

This work could not have been accomplished without the efforts of the contributors. A special thanks to Beth Campbell, formerly of Quality Medical Publishing, for her confidence in this project, and Brian Black at Marcel Dekker, Inc., for his persistence and drive to complete this project. It is my hope that this work will serve to motivate others to view vascular access not as ‘‘a work order'' but as a clinical challenge equal in magnitude and intellectual enthusiasm to other problems addressed by the healthcare community.