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Noninfectious Complications From Vascular Access


Noninfectious complications of hemodialysis vascular access are associated with higher morbidity and can be life-threatening. The resulting interruption in the dialysis schedule with inadequate hemodialysis therapy decreased sense of well-being, and overall poor quality of life can lead to frustration amongst patients and their caregivers. Two commonly used long-term hemodialysis vascular accesses are arteriovenous fistula (AVF) and arteriovenous graft (AVG). AVF is preferred over AVG for its lower risks of stenosis and infection, longer patency, and overall lower maintenance cost. However, it may not always be the right choice. In keeping with a patient-centric approach, selecting the right access for the right patient remains practical and is recommended by the 2019 Clinical Vascular Access Guideline from National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (NKF-KDOQI). In this chapter, we provide a broad overview of the noninfectious complications of a long-term dialysis vascular access by categorizing them into perioperative, local, and systemic complications ( Table 18.1 ). The noninfectious complications arising from a central venous access are discussed in Chapter 17 .

Table 18.1
Overview of Noninfectious Complications of Hemodialysis Vascular Access
Perioperative complications

  • Seroma/lymphocele/hematoma

  • Acute thrombosis

  • Acute arteriovenous graft (AVG) cutaneous hypersensitivity

  • Ischemic monomelic neuropathy

Local complications

  • Prolonged bleeding

  • Carpel tunnel syndrome

  • Hemodialysis access–induced distal ischemia (Steal syndrome)

  • Aneurysm/pseudoaneurysm

  • Fatal access hemorrhage

Systemic complications

  • High output cardiac failure

  • Pulmonary hypertension

  • Venous hypertension—central vein stenosis

    • Cardiac implantable electronic devices (CIEDs)

    • Multiple central venous catheters

  • Posttransplant hyperdynamic circulation

Perioperative Complications

Complications generally arising immediately after and up to 30 days in the postoperative period are often related to the surgery and require immediate surgical attention to minimize long-term sequelae.

Neuralgia

Neuralgia from access construction occurs due to direct injury to adjacent nerves or ligation/clipping of a small cutaneous nerve. The patient with neuralgia may experience severe pain during needle cannulation or develop chronic pain and dysesthesias in the scar tissue overlying an access conduit. Frequently, vascular ischemia may manifest with neuropathic pain, which, if left untreated, can result in protracted ischemic neuropathy.

Seroma/Lymphocele Formation

Peri-graft seroma is a troublesome complication generally limited to AVGs. The exact etiology remains unknown but results from exudation of sterile serum, most frequently confined around the arterial anastomosis of the conduit. Lymphocele can occur from disruption of lymphatics during dissection to expose the artery and vein for anastomosis. Poor skin preparation and possible contact between graft and povidone-iodine or alcohol are believed to be causative factors. Patients with protein-energy wasting and hypoalbuminemia may be prone to seroma formation. Treatment options include simple aspiration to surgical exploration with ligation of leaky lymphatics.

Acute Hematoma/Aneurysm

Acute hematoma formation around anastomosis in the immediate postoperative period is a surgical emergency secondary to dehiscence of sutures and requires immediate surgical attention. Acute dilatation of the vessel, mainly around the arterial anastomosis, could result from arterial wall dissection. Although this complication is infrequent, if neglected, it can result in limb loss or even death ( Fig. 18.1 ).

Fig. 18.1, (A) Pseudoaneurysm in a forearm arteriovenous graft. (B) Aneurysm at frequent needle puncture sites with shiny depigmented skin. (C) Multiple enlarging aneurysm in a brachiocephalic arteriovenous fistula. (D) Postop hematoma. (E) Postop large hematoma.

Acute Arteriovenous Graft Hypersensitivity

Erythema and edema around a newly placed AVG are not uncommon. The redness over the tunnel may be associated with pain and edema, often mimicking infection. An experienced examiner will be able to differentiate between infection and an allergic reaction. The presence of edema and erythema may delay the usability of an early cannulation AVG.

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