Given associated increased risks for catheter-associated infection, higher mortality, and lower patency when compared to AVF and AVG, tunneled dialysis catheters should be avoided if possible or considered a temporizing measure until other hemodialysis access is available [108]. Continued Hemodialysis Access Use with Surveillance There is no evidence to support the continued hemodialysis access use with surveillance in the setting of abnormal skin changes associated with the hemodialysis access cannulation site. Surgical evaluation is prompted before continued use of the hemodialysis access, as significant risk of life-threatening infection, rupture, and bleeding exists [129,130]. The prevalence of this entity ranges from 1% to 20% and it occurs secondary to the shunting of arterial blood flow through the AV access and away from the peripheral system [133]. This results in a constellation of signs and Dialysis Fistula Malfunction symptoms, ranging from mild digital (pedal or hand) numbness to severe motor impairment. It may progress to skin ulceration or gangrene necessitating a digit or limb amputation. The physiologic compensatory response to such a phenomenon is augmentation in cardiac output, arterial vasodilation, as well as formation of arterial collaterals. The presence of an arterial inflow stenosis (eg, subclavian artery stenosis) as well as an outflow stenosis (eg, forearm occlusive disease) will worsen these hemodynamics [135]. The syndrome presents more frequently in patients with proximal accesses supported by brachial artery inflow as opposed to distal accesses, such as those with radial artery inflow. It usually manifests as hand pain during as well as while off dialysis and less commonly as loss of function or tissue death. The central objective in treating a patient with hemodialysis presenting with hand ischemia is to preserve the digits and hand without sacrificing the vascular access.
Dialysis Fistula Malfunction. Given associated increased risks for catheter-associated infection, higher mortality, and lower patency when compared to AVF and AVG, tunneled dialysis catheters should be avoided if possible or considered a temporizing measure until other hemodialysis access is available [108]. Continued Hemodialysis Access Use with Surveillance There is no evidence to support the continued hemodialysis access use with surveillance in the setting of abnormal skin changes associated with the hemodialysis access cannulation site. Surgical evaluation is prompted before continued use of the hemodialysis access, as significant risk of life-threatening infection, rupture, and bleeding exists [129,130]. The prevalence of this entity ranges from 1% to 20% and it occurs secondary to the shunting of arterial blood flow through the AV access and away from the peripheral system [133]. This results in a constellation of signs and Dialysis Fistula Malfunction symptoms, ranging from mild digital (pedal or hand) numbness to severe motor impairment. It may progress to skin ulceration or gangrene necessitating a digit or limb amputation. The physiologic compensatory response to such a phenomenon is augmentation in cardiac output, arterial vasodilation, as well as formation of arterial collaterals. The presence of an arterial inflow stenosis (eg, subclavian artery stenosis) as well as an outflow stenosis (eg, forearm occlusive disease) will worsen these hemodynamics [135]. The syndrome presents more frequently in patients with proximal accesses supported by brachial artery inflow as opposed to distal accesses, such as those with radial artery inflow. It usually manifests as hand pain during as well as while off dialysis and less commonly as loss of function or tissue death. The central objective in treating a patient with hemodialysis presenting with hand ischemia is to preserve the digits and hand without sacrificing the vascular access.