Kidney Week 2025 Annual Meeting-Management of Patients with Challenging Dialysis Access

Video Transcription

Video Summary

The session “Management of Patients with Challenging Dialysis Access” focused on difficult vascular access scenarios and emphasized patient-centered planning and multidisciplinary collaboration. Dr. Ted Saad discussed recurrent access thrombosis, arguing it should be defined at the patient level (not program averages) and framed by an “ESKD Life Plan” with a succession strategy for future access. He highlighted the burden on patients, the limited predictive value of flow monitoring in older trials (with some newer supportive data), and the roles of hypotension, cannulation injury, anatomy, and hypercoagulability (Virchow’s triad). He noted little evidence for midodrine improving access outcomes and potential harm signals. While routine thrombophilia workups are often unrevealing, a 2025 randomized trial suggested low-dose apixaban after access thrombosis reduced re-thrombosis without major bleeding differences, supporting selective anticoagulation after correctable anatomy is addressed.<br /><br />Dr. Adina Vojkolescu addressed access in chronic hypotension, stressing that fistulas lower systemic vascular resistance and can worsen cardiac strain, including pulmonary hypertension over time. She advocated considering peritoneal dialysis first in hypotensive patients with heart failure or cirrhosis/ascites, citing data showing feasibility and acceptable infection risk. If hemodialysis is needed, she recommended prioritizing low-flow, distal (forearm) fistulas when possible, monitoring access flow, and using flow-reduction (banding) for high-flow upper arm accesses.<br /><br />Dr. Gerald Bethard reviewed central venous stenosis/occlusion (TCVO): prioritize prevention (avoid subclavian catheters, minimize catheter use), treat only symptomatic/pathophysiologic lesions, use angioplasty first, and covered stents for recoil or rapid recurrence. Management should be “bimodal,” integrating anatomy plus access flow; high-flow accesses may require flow reduction. Options for total occlusion include recanalization techniques, collateral-based strategies, and devices such as HeRO or alternative modalities.<br /><br />Dr. Rick Mishler covered obesity-related access challenges, outlining surgical strategies to superficialize deep fistulas (elevation/transposition, lipectomy, liposuction), graft tunneling principles (keep superficial and out of skin folds), catheter positioning issues in mobile chest tissue, and evidence that PD catheter outcomes can be comparable in obese vs non-obese patients with experienced operators. The session concluded with practical Q&A on hemostasis compression causing thrombosis, PICC/midline risks, and timing of access creation.

Asset Subtitle

Moderator(s): Jennifer Flythe, Bharvi Oza-Gajera

Presentation(s):

Clinical Approach to Patients with Recurrent Dialysis Access Thrombosis - Theodore Saad
Selection and Management of Dialysis Access in Patients with Chronic Hypotension - Adina Voiculescu
Selection and Management of Dialysis Access in Patients with Central Venous Stenosis - Gerald Beathard
Strategies to Create Functional Dialysis Access in Patients with Obesity - Rick Mishler

Meta Tag

Date 11/7/2025

Pathway 1 Interventional Nephrology

Pathway 2 Dialysis

Session ID 507726

Keywords

challenging dialysis access

vascular access thrombosis

recurrent access thrombosis

ESKD Life Plan

access succession planning

flow monitoring

Virchow’s triad

midodrine and dialysis access

low-dose apixaban after thrombosis

chronic hypotension in hemodialysis

low-flow distal forearm fistula

high-flow fistula banding

central venous stenosis/occlusion (TCVO)

angioplasty and covered stents

obesity-related dialysis access