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Nursing care for patients with biological arteriovenous grafts.

In the 1930s, Dr. Wilhelm Kolff developed the basics of hemodialysis therapy. The challenge for healthcare workers then became finding a suitable method for repeated access to the vascular system for hemodialysis. The external Teflon Scribner shunts and Cimino arteriovenous fistulas (AVFs) developed in the 1960s allowed repeated access to the vascular access system; however, not all patients' anatomies were suited for AVF creation. To address the challenge of a consistent and adequate access for hemodialysis for patients, biological grafts that used a bovine carotid artery were introduced in the 1970s (Gage & Lawson, 2010). This article presents information regarding the current types of materials and factors involved in the healing process. It also discusses nursing implications regarding care and the cannulation of biological arteriovenous grafts (AVGs).

Case Study

Having received a report from an inpatient nurse for her patient, Mr. C, who will be returning to the outpatient unit, the registered nurse (RN) Susan realized she was not familiar with the type of vascular access that had been placed for Mr. C. Susan had returned to nephrology nursing after having worked for over 10 years in another specialty; in her previous nephrology nursing experience, the only biological graft she encountered was the bovine carotid artery graft (BCAG).

The report indicated that Mr. C had been admitted to inpatient care with an infected synthetic graft, which was exchanged with a biologic cryopreserved allograft (CyroVein[R] or CyroArtery[R]) placed in the same location. A central venous catheter (CVC) had been placed, and intravenous (IV) antibiotics had been administered.

To ensure she could provide care guided by the most current information, Susan searched the literature and information materials from graft manufacturers. She found that bovine biologic grafts are generally created from a large artery (carotid) or a vein (mesenteric) (Artegraft, Inc., 2016, LeMaitre Vascular, 2016a). She also found there were differences in the graft material characteristics and related clinical applications for those of bovine as opposed to human tissue.

Bovine Artery and Vein Grafts

Bovine Carotid Artery Graft (Artegraft[R])

The biological graft for hemodialysis access is an option for patients who are poor candidates for a native AVF and/or at high risk for infection (Harlander-Locke et al., 2014). The BCAG supplied by Artegraft[R] is a section of a selected bovine carotid artery that the manufacturer has subjected to enzymatic digestion and tanning. This processing provides a "collagen matrix conduit." and according to the manufacture's information, results in a graft devoid of proteins that can cause antigenic reactions in patients (Artegraft, Inc., 2016). In a prospective randomized controlled trial (n = 53), Kennealey et al. (2011) found that BCAGs required fewer interventions to maintain patency and resulted in significantly lower incidences of thrombosis than the expanded polytetrafluorethylene (ePTFE) grafts over a mean follow-up time of 33 months. A recently published retrospective review of 120 grafts placed showed the secondary patency rate was higher for BCAGs compared to the ePTFE grafts (Arhuidese et al., 2017).

According to the manufacturer's instructions for use in hemodialysis, at least 10 days should be allowed after implantation prior to cannulation. Further, if edema appears around or distal to the graft, the edema should be allowed to resolve before cannulation (Artegraft, Inc., 2016). BCAGs are accessed in the same manner as native AVFs. Needles are inserted at a 25[degrees] to 30[degrees] angle. Typically, the first cannulation is done with a 17-gauge needle and enlarged over time to a 15-gauge needle (Kennealey et al., 2011). Early access of BCAGs has been reported as an alternative in patients who require revision of a native AVF due to bleeding and aneurysmal degeneration, reducing the need for a temporary tunneled catheter in this patient population (Mahajan, Abdoli, Han, & Ochoa, 2016).

Vascular Bioprosthesis (LeMaitre[R] Vascular ProCol[R])

The ProCol[R] Vascular Bioprosthesis uses a mesenteric bovine vein for patients with failed AVGs who require a new access. Other implications for use include patients with a high risk of infection and patients needing salvage of an existing access (LeMaitre Vascular, 2016b). One benefit of using the bovine mesenteric vein is its high elastin content and moderate wall thickness. After harvesting the bovine mesenteric vein, the manufacturer treats it with a process that renders it resistant to host rejection and breakdown (Katzman, Glickman, Schild, Fujitani, & Lawson, 2005). The manufacturer identifies key benefits of the mesenteric vein as 1) strength and durability, 2) biocompatibility, and 3) promotion of pulsatile forward flow (LeMaitre Vascular, 2016b). In a multicenter study comparing patency rates of bovine mesenteric vein to synthetic grafts, patency at 12 months was 35.6% compared to 28.4%; at 24 months patency was 53.3% versus 42.9% (Katzman et al., 2005). These researchers also found that complications requiring interventions were lower for the bovine mesenteric vein compared with synthetic grafts, 0.79 versus 1.37 per patient year.

The manufacturer's information identifies the ProCol Bioprosthesis as having cannulation characteristics similar to a native AVF. The ProCol Bioprosthesis requires a minimum of two weeks healing time post-op prior to cannulation, with cannulation readiness guided by the physician. Because this access is similar to a native AVF, there is minimal resistance, and a shallow angle of needle insertion at 25[degrees] or less can be used (LeMaitre Vascular, 2016a). Rotation of needle sites is essential in prevention of pseudoaneuryms. Manufacturer access recommendations include:

* If a CVC exists, begin cannulation with a single, 17-gauge needle and blood flow rate of 200 to 250 mL/minute.

* In 1 week, graduate to a single, 16gauge needle and a blood flow rate of 300 to 350 mL/minute for a duration of three weeks, while maintaining arterial/venous pressures under 200 mmHg.

* At 4 weeks, two 16-gauge needles may be used with a blood flow rate of 350 mL/minute, again, maintaining arterial/venous pressures under 200 mmHg.

* After 6 weeks, two 15-gauge needles may be used without restrictions.

* Laceration may occur if the needle is rotated (flipped) during use. Compression bandages and clamps should be avoided; instead, light finger compression should be used to achieve hemostasis (LeMaitre Vascular, 2016a).


Allografts refer to tissue grafts obtained through a human donation.

Vascular Allografts (CryoLife[R] --CryoArtery[R] and CryoVein[R])

The allografts supplied by CryoLife[R] for AVG access are recovered from human cadavers: femoral arteries, femoral veins, and saphe nous veins. The CryoLife graft is a vascular graft that may be used in patients a) for whom an AVF is not a viable option, b) who have an infected AVF or AVG, c) who are at risk for an AV access infection, or d) who have a limited number of AV access sites (CryoLife, Inc., 2016a). CryoLife vascular allografts are processed with papaverine hydrochloride and antimicrobials, packaged and then supercooled and stored in liquid nitrogen following patented processes and in accordance with the American Association of Tissue Banks (AATB) guidelines (CryoLife, Inc., 2016a). Because these arteries and veins are human tissue, transplantation may induce an antibody response in the recipient. This is one consideration for patients who are candidates for future allograft tissue and/or organ transplantation. As with other graft materials, recipients may require anticoagulant and/or antiplatelet therapy, or immunosuppressive therapy and antimicrobials after placement (CryoLife, Inc., 2016b) at the discretion of the surgeon.

Hemodialysis access creates a major challenge for surgeons, due to graft infection (Lin, Brinkman, Terramani, & Lumsden, 2002). In clinical studies, the cryopreserved allograft has been used in patients to replace infected AV grafts. Two methods for managing infected AVGs are described in a National Kidney Foundation (NKF) (2014) clinical update. The "allograft method" is a single procedure in which the infected AVG is removed and a cryopreserved allograft is implanted in the same site. In the second method, "graft excision" of the infected AVG, placement of a temporary catheter is followed later by a second surgical procedure to place a new AVG in a different location (NKF, 2014). Lin et al. (2002), reviewed the management of infected hemodialysis access grafts using cryopreserved human vein allografts with only one surgical procedure method and concluded there was a low incidence of re-infection. Patency rates of cryopreserved replacement grafts were found to be comparable to those of standard AVGs. In a prospective study of patients with AVG infections (n = 20), bacteremia (n = 14), or compromised venous outflow (n = 10) who received a cryopreserved femoral vein graft showed that primary patency rates at 12 months were 49% and secondary patency rates were 75%, similar to a control group of PTFE grafts (Matsuura et al., 2000).


As Susan begins to consider what she has learned from the review of the literature and information from vascular access manufacturers, she prepares her nursing care plan for Mr. C and his new biological vascular graft. She remembers the nursing practices for assessment--look, listen, and feel with every treatment after placement of an arteriovenous access (see Figure 1). Best practices also include use of aseptic technique and rotation of needle sites for all arteriovenous vascular accesses. In a prospective access database review of 132 patients, Harish and Allon (2011) reported that 9% to 20% of AVGs become infected. Complications from infection can be mitigated by clinicians following aseptic technique (NKF, 2006).

Noting that biological AVGs have several unique considerations, Susan decided to create a list of nursing care tips to help mentor new nephrology nurses in her clinic about biological AVG materials (see Figure 2). Susan has gained confidence and applied what she learned about biological grafts to Mr. C's nursing care plan. A new goal is to pursue additional knowledge regarding the various types of synthetic grafts and their nursing implications.


Arhuidese, I., Reifsnyder, T., Islam, T., Karim, O., Nejim, B., Obeid, T., ... Malas, M. (2017). Bovine carotid artery biologic graft outperforms expanded polytetrefluoroethylene for hemodialysis access. Journal of Vascular Surgery, 65(3), 775-782.

Artegraft, Inc. (2016). Artegraft, bovine carotid artery graft (BACG): The choice to achieve functional hemodialysis access. Retrieved from Products/Artegraft_Instructions-forUse.pdf

CryoLife, Inc. (2016a). CryoLife-Life restoring technologies. Retrieved from and_Infection_Presentation.pdf

CryoLife, Inc. (2016b). Cryopreserved tissue handling instructions. Retrieved from ducts/vascular-reconstructive-surgery/handling-instructions

Gage, S., & Lawson, J. (2010). New developments in hemodialysis grafts: A new era in dialysis access. Endovascular Today, 6, 34-46.

Harish, A., & Allon, M. (2011). Arteriovenous graft infection: A comparison of thigh and upper extremity grafts. Clinical Journal of the American Society of Nephrology, 6(7), 1739-1743.

Harlander-Locke, M., Jimenez, J.C., Lawrence, P.F., Gelabert, H.A., Derubertis, B.G., Rigberg, D.A., & Farley, S.M. (2014). Bovine carotid artery (Artegraft) as a hemodialysis access conduit in patients who are poor candidates for native arteriovenous fistulae. Vascular and Endovascular Surgery, 48(7-8), 497-502.

Katzman, H.E., Glickman, M.H., Schild, A.F., Fujitani, R.M., & Lawson, J.H. (2005). Multicenter evaluation of the bovine messenteric vein bioprotheses for hemodialysis access in patients with an earlier failed prosthetic graft. American College of Surgeons, 201(2), 223-230.

Kennealey, P.T., Elias, N., Hertl, M., Ko, D.S., Saidi, R.F., Markmann, J.F., ... Kawai, T. (2011). A prospective, randomized comparison of bovine carotid artery and expanded polytetrafluoroethylene for permanent hemodialysis vascular access. Journal of Vascular Surgery, 53(6), 1640-1648.

LeMaitre Vascular. (2016a). ProCol vascular bioprothesis: Information for the dialysis team. Burlington, MA: Author.

LeMaitre Vascular. (2016b). ProCol vascular bioprothesis: The solution for AV access. Burlington, MA: Author.

Lin, P.H., Brinkman, W.T., Terranmani, T.T., & Lumsden, A.N. (2002). Management of infected hemodialysis access grafts using cyropreserved human vein allografts. The American Journal of Surgery, 184(1), 31-36.

Mahajan, A., Abdoli, S., Han, S., & Ochoa, C. (2016). Abstract: Early access of bovine carotid artery graft can eliminate the use of tunneled hemodialysis catheters. Journal of Vascular Surgery, 64(2), 550.

Matsuura, J.H., Johnansen, K.H., Rosenthal, D., Clark, M.D., Clarke, K.A., & Kirby, L.B. (2000). Cyropreserved femoral vein grafts for difficult hemodialysis access. Annals of Vascular Surgery, 14(1), 51-55.

National Kidney Foundation (NKF). (2006). Clinical vascular guidelines for vascular access. Retrieved from H D_PD_VA/va_guide 3 .htm

National Kidney Foundation (NKF). (2014). A clinical update on the management of infected arteriovenous graft (AVG) access for the hemodialysis patient. Retrieved from http://www.kidney. org/sites/default/files/02-10-6071_ GBD_Infected_AVG-Cryolife.pdf

Michelle Gilliland MSN, RN, CNN, is a Principal, Clinical Innovation Initiatives, the Medical Office of Fresenius Medical Care, Bennington, NE; a member of ANNA's Administrative SPN Group; and a member of ANNA's Nebraska Platte River Chapter.

Billie Axley, MSN, RN, CNN, is Chief Nursing Officer, Sanderling Renal Service, Nashville, TN, and a Member of ANNA's Music City Chapter.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can be found on page 353.
Figure 1

One-Minute Check--Look, Listen, and Feel


[check] Changes in the extremity
[check] Skin integrity
[check] Bruising/hematorma
[check] Steal syndrome (discoloration, cold
fingers, blue fingers)
[check] Check the surgical incision:
--Is it intact?
--Free of infection?


[check] Low pitched
[check] Continuous swooshing sound
[check] Increasing pitched
[check] Discontinuous swooshing sound


[check] Purring
[check] Vibrating
[check] Pulsation
[check] No sensation

* Contact expert clinician if any anomalies noted.

Source: [C] Michelle Gilliland. Used with permission.

Figure 2

Nursing Care Tips for Biological AV Graft Materials

Follow manufacturer instructions and
physicians' orders for cannulation.

10 to 14 days healing time is required.

Avoid using a tourniquet for cannulation.

Shallow angle of needle insertion: 25[degrees] to 30[degrees] or less.

Apply light pressure with finger tips
post-needle removal.

Biological materials are similar in appearance
and palpitation as an arteriovenous fistula.

Post-surgical edema/swelling must
subside prior to cannulation.

Avoid clamps post-needle removal.

Avoid compression dressings post-needle

Source: [C] Michelle Gilliland. Used with permission
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Author:Gilliland, Michelle; Axley, Billie
Publication:Nephrology Nursing Journal
Date:Jul 1, 2017
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