AV Fistula Survailence

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AV Fistula Survailence

  1. 1. RENOVASCULAR CONFERENCE SURVEILLANCE AND ACCESS SURVIVAL Ahad Lodhi
  2. 2. CLINICAL SIGNS OF ACCESS DYSFUNCTION • Failure of the fistula to collapse when the arm is elevated. • Lack of pulse augmentation when the outflow vein is occluded transiently. This may be more useful in relatively new fistulas than in older fistulas that are relatively more rigid • Dialysis events difficult cannulation of fistula, aspiration of clots, inadequate flows, prolonged bleeding after decannulation. • Unexplained decrease in KT/V more than 0.2.
  3. 3. EFFECTIVENESS OF ACCESS SURVEILLANCE AND PROPHYLATIC ANGIOPLASTY ON FISTULA THROMBOSIS AND ACCESS SURVIVAL
  4. 4. Is it beneficial? What is the evidence? Does it prevent further thrombosis? What does it do to the fistula longevity? More Adverse Effects than Benefits?
  5. 5. DECREASED THROMBOSIS RATE WITH INCREASED SURVEILLANCE AND ANGIOPLASTY Observational, Historical controls Besarab, A. et al. Kidney Int. 47:1364-1373, 1995
  6. 6. A RANDOMIZED CONTROLLED TRIAL OF BLOOD FLOW AND STENOSIS SURVEILLANCE OF HEMODIALYSIS GRAFTS Ram, S.J. et al. KI 64:272-280; 2003
  7. 7. INCREASED SURVEILLANCE AND PREEMPTIVE ANGIOPLASTY DID NOT PROLONG TIME TO HEMODIALYSIS GRAFT THROMBOSIS p=0.12 Ram, S.J. et al. KI 64:272-280; 2003
  8. 8. INCREASED SURVEILLANCE AND PREEMPTIVE ANGIOPLASTY DID NOT PROLONG CUMULATIVE HEMODIALYSIS GRAFT SURVIVAL p=NS Ram, S.J. et al. KI 64:272-280; 2003
  9. 9. ULTRASOUND MONITORING TO DETECT ACCESS STENOSIS IN HEMODIALYSIS PATIENTS: A SYSTEMATIC REVIEW Effect on Thrombosis Tonelli et al. AJKD 51:630-640, 2008
  10. 10. ULTRASOUND MONITORING TO DETECT ACCESS STENOSIS IN HEMODIALYSIS PATIENTS: A SYSTEMATIC REVIEW Effect on Access Loss Tonelli et al. AJKD 51:630-640, 2008
  11. 11. A Multi Centre Randomized Controlled Trial of the Clinical and Cost Effectiveness of Duplex Ultrasound Surveillance With Proactive Intervention Versus no Surveillance and Reactive Intervention for the Management of Stenosis in Arterio-venous Fistulae for Dialysis Vascular Access Hull UK, completing in 2014
  12. 12. Increased Cell Proliferation Activity in the Restenotic Hemodialysis Vascular Access After Percutaneous Transluminal Angioplasty Chang et al. AJKD 43:74-84, 2004. Conclusion: “We show markedly high cellular proliferation activity in early restenotic lesions of arteriovenous fistulae. These findings indicate that adjunctive antiproliferative therapy is mandatory in preventing restenosis after PTA, especially in patients with diabetes.”
  13. 13. CONCLUSIONS Monitoring & prophylactic angioplasty may decrease fistula thrombosis but not yet shown to prolong access survival Data from UIHC did not support monthly flow monitoring and prophylactic angioplasty for fistulas
  14. 14. RECOMMENDATIONS FOR ACCESS MONITORING All accesses Monitor regularly using clinical parameters: Exam, achievable blood flow rate, dynamic pressures, adequacy of dialysis For AV grafts: Risk of thrombosis is higher May consider additional monitoring technique: IAP, flow monitoring or Duplex US

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