GUIDELINES [ back to index ]
18. Management of graft infection after 1st month of placement (2)
*1 Check for metastatic infection
• Infected grafts can cause metastatic infections, including subdural (epidural) abscesses 1 2, septic arthritis, osteomyelitis 3 and right and left endocarditits and subsequent septic venous embolization into the lung 4.
*2 Ensure correct puncture technique
• Puncturing the graft must be performed under aseptic conditions (f or details see appendix chapter “Aseptic techniques“).
*3 Check for other access options, A/V fistula / graft
• Forearm graft infection leading to graft resection leaves the option of creating a native A/V fistula in the ipsilateral upper arm. Usually, cephalic and/or basilic veins proximal to the elbow are dilated due to the presence of the forearm graft. These veins can be evaluated by inspection and palpation and/or duplex imaging. If they are adequate, a brachiocephalic or brachiobasilic A/V fistula in the ipsilateral extremity can be created. In case of inadequate upper arm veins or in case of upper arm graft resection due to infection, the contralateral extremity may be used.
• Preoperative venous mapping is of particular importance in patients with a failed vascular access in order to decide where to place the next A/V fistula, as physical examination has its limitations especially in obese and elderly patients 5. Thus, duplex ultrasound (see Algorithms “Placement of forearm A/V Fistula”) or, in the case of a history of central vein catheterisation, at the site of planned access, venography is indicated.
*4 Consider use of autologous or cryopreserved vein
• Cryopreserved human femoral veins can be used for creating new accesses, as they are more resistant to infection. There is limited data on the use of cryopreserved femoral vein grafts for difficult haemodialysis access but they have even been placed in the setting of systemic and local infection with good results 6.Matsura et al. placed 38 cryografts in patients with infection 7. None of their patients developed graft infections. One year primary and secondary patency were 49 % and 75 %, respectively. Further studies are necessary to define the appropriate role of this graft material.
*5 Place new access after complete resolution of infection
• After complete resolution of local and systemic signs of infection, a new access can be constructed. In order to reduce the risk of re-infection, prosthetic material should be avoided. Re-infection occurred in 3 out of 9 accesses when a new PTFE graft was created within a mean of three months (range 1 - 10 months) 8.
• A new native A/V fistula using translocated long saphenous vein can be constructed before complete resolution of local and systemic signs of infection. The site of local infection should be avoided.