Complications and management of av access

1. Complications and
Management of
AV access
Toufic Safa, MD, FACS
Medical Director - AAAVascular Care, Great Neck, NY
Vascular Surgeon, St. Francis Hospital, Roslyn, NY

2. AV Fistula
AV Graft
Types of Hemodialysis
AV Access

3. 47 years after initial description of the AV
fistula, it still remains the best access for
hemodialysis.
38 years after introduction of PTFE graft
material for dialysis access, no alternative graft
material has been proven to be better.
What is the best access
for hemodialysis?

4. Michael J. Brescia, M.D., James E.
Cimino, M.D., Kenneth Appel,
M.D. and Baruch J. Hurwich, M.D.
NEJM 275:1089-1092, 1966.
Chronic hemodialysis using
venipuncture and a surgically
created arteriovenous fistula

5. ProcolR
SliderTM
LifeSiteR
VectraR
CryoVeinR
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HeRo

6. 1- Hematomas
2- Significant Steal
3- Multiple vein branches off of body of fistula
4- Non Maturing AVF’s: Arterial and/orVenous Stenoses
5- Venous Outflow (outside the access zone) Stenosis or
Occlusion
6- Aneurysmal degeneration of access vein or graft +/-
infection
7- Central Venous Stenoses or Occlusions
Complications of
AV ACCESS

8. Hematomas:
POST-OP

9. Hematomas:
Massive infiltration
post needle access
More common when
accessing fistulas for
first time

10. No time for unnecessary
questions or time
consuming tests
Immediate
intervention
is necessary before it is
too late
SIGNIFICANT
Access Related Steal

11. SIGNIFICANT STEAL

12. Can be access and/or LimbThreatening
“Timely Intervention is Necessary”
Techniques:
•Open Banding or Ligation of access
•Proximalization of arterial anastomosis
•DRIL Procedure
SIGNIFICANT
Access Related Steal

13. DRIL PROCEDURE
Distal Revascularization & Interval Ligation
More involved surgical procedure
but can be rewarding in the
carefully selected patient

14. TOO MANY
BRANCHES OFF
OF THE FISTULA
VEIN

15. Side Vein Branches can be large and
numerous. May affect dialysis flow
rates if untreated
Techniques:
•Percutaneous Coil Embolization
•Minimally invasive open ligation
Management of Venous
Side Branches

16. COOK Tornado coils are most
commonly used for that
purpose
Easy to handle and deliver
Caution should be exercised
not to deliver coil in main
fistula vein as that may
embolize to the lungs
Still a relatively expensive
method of taking care of the
problem
Coil Embolization
of Fistula Branches

17. Coil Embolization
of Fistula Vein Branch
Pre-Coiling of AVF Branch SuccessfulCoiling of AVF Branch

18. Minimally Invasive Open Ligation:
PreferredTechnique – Simple Office Procedure, time and cost effective, Less risky

19. Natural History of Primary AV Fistulas is dismal
Only 30% mature into accessible fistulas in one year
without intervention
This figure can be pushed up to 60% with secondary
interventions (surgical and percutaneous).
Up to 40% of fistulas are deemed non utilizable for
access after one year and are abandoned.
Non Maturing AV
Fistulas
BiuckiansA, …, Glickman MH “The natural History of autologous fistulas…” JVS, 2008 Feb; 47: 415-21

20. Reasons for non maturation of AV Fistula vein:
• Vein is small and scarred
• Vein is deep
• Vein has multiple branches that siphon blood away
• Arterial inflow stenosis/disease (calcified radial artery)
• Combination of the above
Current Maturation techniques try to address
these problems in order to salvage the “non-
salvageable” fistulas
WHY AVF’s
DO NOT MATURE ?

21. Percutaneous Access of Fistula
Balloon Assisted Maturation:
Upper arm AVF

22. Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula.
Staged angioplasty of vein and/or artery performed as necessary

23. Balloon Assisted Maturation

24. Pre and Post BAM:
initial stage

25. •1- Arterial Inflow Lesions
•2- Venous Access vein Stenoses
•3- Mixed Arterial andVenous
lesions
Arterial,Venous, or Mixed
Lesions that threaten AV Access

26. Multiple arterial
inflow stenoses seen
in this case
Successfully managed with
angioplasty
Choice of balloons a bit
different than venous
angioplasty (smaller
diameter, flexible, and low
pressure balloons)
Arterial Inflow Stenosis
in a radiocephalic AVF

27. Arterial anastomotic
lesion is often
underdiagnosed and
undertreated
Responds very well to
balloon angioplasty
Sheath access thru body
of AV Graft
Arterial Inflow Stenosis
in a Loop Forearm AV Graft

28. AVF Vein Stenoses
Access with Sheath thru vein at
elbow and balloon till waste is
obliterated

29. Mixed arterial and
venous lesions
A case of arterial
anastomotic stenosis
and a venous outflow
stenosis.
Both lesions were
successfully managed
with balloon angioplasty

30. 1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts:
Most common lesion that threatens AV Grafts
CurrentTechniques of Management:
•Balloon Angioplasty and/or surgical revision
•Stent Graft placement for graft venous anastomotic
stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)

31. Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-
intervention was improved
from
25% to 75% in one year
No LongTerm follow-up
available

32. Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362:494-503 February 11, 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access Grafts
Ziv J. Haskal, M.D., Scott Trerotola, M.D., Bart Dolmatch, M.D., Earl Schuman, M.D.,
Sanford Altman, M.D., Samuel Mietling, M.D., Scott Berman, M.D., Gordon McLennan,
M.D., Clayton Trimmer, D.O., John Ross, M.D., and Thomas Vesely, M.D.
ABSTRACT
Background The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis. Balloon angioplasty, the
first-line therapy, has a tendency to lead to subsequent recoil and restenosis; however, no other therapies have yet proved to be more effective. This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts.
Methods We conducted a prospective, multicenter trial, randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft. Primary end points included
patency of the treatment area and patency of the entire vascular access circuit.
Results At 6 months, the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51% vs. 23%, P<0.001), as was the incidence of patency of the access circuit (38% vs. 20%, P=0.008). In addition, the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32% vs. 16%, P=0.03 by the
log-rank test and P=0.04 by the Wilcoxon rank-sum test). The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78% vs. 28%, P<0.001). The incidences of adverse events at 6 months were equivalent in the two treatment groups, with the
exception of restenosis, which occurred more frequently in the balloon-angioplasty group (P<0.001).
Conclusions In this study, percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft, which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty.
(ClinicalTrials.gov number, NCT00678249 [ClinicalTrials.gov] .)

33. Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
Personal Experience:
Improved one and two year patency of AV Grafts
to 94% and 82% in a series of 20 patients
Abstract presented at theVASA meeting in LasVegas, May of 2010
OpeningAngio Post
Angioplasty
PostViabahn
Stent Placement

34. Aneurysmal
Formation
In AV Access

35. True or false aneurysms
Treat venous outflow stenosis first (very common associated
finding, especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic: pain, ulcer, high
venous pressure on dialysis
Techniques:
• Endovascular Stent Graft Placement for focal and false aneurysms
• Open resection and replacement with PTFE interposition graft for the large,
partially thrombosed, tortuous, dilated, and ulcerated aneurysms
ANEURYSMAL FISTULA

38. Endovascular Stent Graft Placement
Small, Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts
Percutaneous therapy - Instantaneous Exclusion of Aneurysm.
Graft may be accessed immediately post treatment and thru stent graft if
necessary
Upper arm AV Graft with a small PSA treated with aViabahn Stent Graft

39. STENT GRAFTS: Poor Choice for
infected AV Access PSA

40. Open Resection of Aneurysms
Replacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration
and local infection
One Month Post treatment

41. Open Resection of Aneurysms
Another Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment

42. Present in 8-10% of patients with arm access
Precipitating Factors: Prolonged use of
tunneled catheters in central veins and
presence of pacemakers
PreferredTechnique of Management:
•Percutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions

45. Central Venous
Stenoses or Occlusions
ProceduralTips:
Use the biggest balloon and stent size on the shelf (like 14mm)

46. Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with
wire. Sometimes access from 2 sites is necessary (Groin and Arm).
OneYearAccess patency was improved from 22% to 63% in one large series.
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients: a single institutional experience in 69 consecutive
patients.
Nael K, Kee ST, Solomon H, Katz SG. J Vasc Interv Radiol. 2009 Jan;20(1):46-51. Epub 2008 Nov 20.

47. Take Home Message
Create an access for Hemodialysis:
1- With minimal complications to the
patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient

48. THANK YOU