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  • 1. “Save Your Veins” Campaign in Tennessee
    Vein Preservation for CKD Patients
  • 2. Tennessee
  • 3. Over 500 physicians
    Vascular Surgeons
    Dialysis Clinics
    Senior Centers
    Certified Diabetes Educators
    CKD Legislative Task Force
    CKD Project Information
  • 4.
  • 5. Microalbumin Screening
    Diabetic Protocols
    Automatic eGFR
    Outpatient Diabetes Clinics
    Workflow Analysis PCPs
    Care Management Modules
    Diabetes Flow Sheet
    Co-management/Referral Patterns
    KEEP Screenings (National Kidney Foundation)
    Certified Diabetes Educator (CDE) Outreach
    Diabetes Road Maps
  • 6. ACE/ARB
    Beneficiary Outreach
    Kroger Heart Healthy Screenings
    Bus Advertising
    Senior Centers
    Medicare Open Enrollment Events
    “IF” Campaign
    Tennessee Pharmacists Association
    Interventions, cont.
  • 7. CKD Stages in TN: 2007
  • 8. Fistula
    Save Your Veins
    Exercise Your Fistula Toolkits
    Dialysis CKD Educators
    Opt-out Referrals at Hospital Discharge
    Nephrology/Vascular Surgeon Focus Groups
    Fistula First Coalitions
    Early Referrals from Nephrologists
    Interventions, cont.
  • 9. Save Your Veins
  • 10. THA
  • 11. Dialysis Hemo Access:Save Those Veins!
    Thomas A. Golper, MD, FACP, FASN
    Vanderbilt University Medical Center
    Nashville, TN
  • 12. “Access” refers generally to the technical component of getting to the blood stream (vascular or hemo access) for purpose of performing adequate dialysis.
    Being able to perform adequate dialysis depends on this access lifeline
  • 13. Inherent Principles
    Knowledge/understanding is important
    Team approach is mandatory
    Patient, family, referring physician, technician, nurse, nephrologist, surgeon, radiologist, payer
    Access sites are limited
    Timing of placement/creation is crucial to success
    Time/energy spent on one issue takes it away from another
  • 14. Dialysis population is enlarging, especially as the general population ages
    Older patients tend to have more complicated medical conditions (not just kidney failure)
    Vascular access problems account for 25% of all dialysis patient admissions to the hospital
    Per year vascular access problems cost $1 billion- about $8000 per patient per year
    Magnitude of the Problem
  • 15. Late referral from primary care team to nephrology team, delaying appropriate education and timing of placement
    Physician reluctance to really push patients to do what is best
    Patient denial of the need
    Surgical inadequacies
    Payer refusal to be proactive
    Accidental damage to the veins
    Contributions to the Problem
  • 16. Hemodialysis Access
  • 17. Hemodialysis
  • 18. Vascular Access TypesFrom Least to Most Desirable
    “Acute” non-tunneled, non-cuffed central venous catheters
    Tunneled, cuffed central venous catheters
    Percutaneous central venous implants
    AV grafts
    Autologous (native, primary) AV fistula
  • 19. “Acute” non-tunneled, non-cuffed central venous catheters
    High infection rate
    Intended for very short term use (a few days)
    Cause scar tissue to develop which jeopardizes future access sites
  • 20. Tunneled, Cuffed Central Venous Catheters
    Bridge to more permanent access
    DOQI discourages their use as permanent access
    In absence of other vascular access, can be life saving
    Right internal jugular vein preferred
    Major problems are occlusion (poor or no blood flow) and infection
  • 21. Time to First Infection All Causes
    Burkart, PDI 92, Churchill AJKD 92
  • 22. AV Grafts
    Prosthetic material
    Has to have tunnel created under the skin
    Instantly increases blood flow
    Arm swells
    Very prone to thrombosis
    Less infection than tunneled catheters, but can still occur because of the foreign material.
    Less obtrusive than native fistulae
  • 23. II- Vascular Access Options:B- Arterio-venous Grafts (AVG)
    • Material
    • 24. PTFE, e-PTFE, Diastat…
    • 25. Location
    Upper or lower arm
  • 26. II- Vascular Access Options:A- Primary (Native, autologous) Arterio-Venous fistula (AVF)
    • Anatomic Description
    • 27. Types:
    • 28. Radial-cephalic (Cimino-Brescia)
    • 29. Radial-cephalic (snuff-box)
    • 30. Brachial-cephalic (above elbow)
    • 31. Brachial-basilic (transposed)
  • II- Vascular Access Options:Primary AV fistula Complications
    - Bleeding
    - Infection
    - Thrombosis
    - Steal
    - Non-maturation
    - Stenosis
    - Thrombosis
    - Pseudo-aneurysms
    - Aneurysms
    - Venous hypertension
    - High output
  • 32. Native AV Fistulae
    Undoubtedly to best hemodialysis access
    Requires appropriate vessels/anatomy so vein preservation is crucial
    Takes months to “mature” so create it early
    Requires healthy arteries and veins
    Surgeon must be good and experienced
    Least painful operation
    Least likelihood of infection
    Easiest infection to treat
    Arm looks unusual (badge of honor)
  • 33. 31 Years of Continuous Usage
    Courtesy of Stanley Shaldon
  • 34. Highlights from DOQI
    • Diagnostic Evaluation prior to VA placement
    • 35. Examination
    • 36. Doppler Ultrasound
    • 37. Contrast venography
    • 38. Contrast arteriography (rarely)
    • 39. Selection of VA, order of preference
    • 40. Wrist AVF
    • 41. Elbow AVF
    • 42. followed by:
    • 43. Graft or
    • 44. Elbow AVF
    • 45. Discourages tunneled, cuffed catheters
    • Preservation of veins for VA
    • 46. Avoid cannulation of essential veins in the non dominant arm
    • 47. Avoid placement of temporary catheters
    • 48. If temporary needed, use groin
    • 49. Timing of access placement Primary AVF when:
    • 50. - Cr Cl < 25 ml/min
    - Anticipation of HD within 1yr
    • Graft when:
    - Anticip. HD within 3-6 wks
    Highlights from DOQI
  • 51. Risks for Veins
    Any medical encounter
    Office or general lab draws
    Radiology procedures
    Any other IVs (e.g. conscious sedation)
    Emergency department visits
    Thus, the “Save Your Veins” initiative
    for awareness
  • 52. We Welcome Your
    Thank You for Your Support
    This material was prepared by the Prevention Quality Improvement Organization Support Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents does not necessarily reflect CMS policy. QSource-TN-CKD-2009-66