Vascular Access for Chronic Haemodialysis in Elderly Patients: The Lombardy Experience

Abstract

The growing proportion of elderly patients largely accounts for the striking increase in number of patients admitted to renal replacement treatment (RRT) in recent years. Most of them are treated with haemodialysis, which involves various problems connected with vascular access. A survey was therefore conducted amongst the Dialysis Units of Lombardy. The aim was to evaluate how vascular access surgery for elderly patients is organized, and which techniques are used to monitor surgical access as well as the central catheters (CVCs). A questionnaire was sent to the 43 Lombardy Units, 79.1% of which replied. The results of a previous study analyzing the same topics in all patients on RRT in Lombardy were considered as “controls”. In this way it was possible to compare the strategy used for elderly patients with that of the general dialysis population. Forty-one percent (41%) of elderly patients in Lombardy were started on RRT using acute CVCs. This percentage is quite similar to that documented (39%) in the general dialysis population. The distribution is quite different when we consider the patients alive on RRT at 31 December 1999, when a permanent vascular access (distal AVF, proximal AVF or AV graft) was used in about 70% of cases. For elderly patients, as for the general RRT population, first choice access is mainly (79%) distal arterio-venous fistula (AVF) with end-to-end, side-to-side with distal ligature of the vein or side-to-end anastomosis. As a second choice, proximal AVF is more widely used than AV grafts, which are implanted only when all native vessels and related surgical procedures are exhausted. CVCs are valid solutions not only as temporary access, but also as an alternative permanent solution to the problems related to elderly dialysis patients. In the elderly, the jugular vein is the most frequent site of insertion for chronic tunnelled devices (91%) and the femoral vein for acute CVCs (40%). Despite the documented incidence of related episodes of stenosis/obstruction, the subclavian vein is used as a temporary access in quite a high percentage of cases (22% in the elderly and 32% in the general RRT population). Only in selected cases diagnostic procedures (mainly Venography and Doppler studies) are performed prior to permanent access choice. Similarly, vascular access is monitored mainly using a recirculation test, albeit not routinely. As in the general dialysis population, in the cases of vascular access thrombosis and stenosis, surgical revision is the most common approach.