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Vascular Access for Hemodialysis
A Programmatic Approach
Lee Kirksey MD MBA
Assistant Professor of Surgery Case Western Le...
Care of ESRD patient
• CKD team NPs, Physicians
• Vascular surgery team
• Dialysis center team
Nursing
Physicians
Technici...
Background
• CKD/ESRD is the 9th
cause of death in the
US.
• One in ten Americans have some level of
CKD
• 341,000 patient...
Vascular Access at initiation of HD
• 43% of incident patients had no prior
nephrology contact
• 80% begin HD with a CVC
•...
Vascular access use at initiation
and on day of eligibility, 2010
Figure 1.18 (Volume 2)
Incident hemodialysis patients, J...
Background
• Adjusted individual first year mortality for
newly initiated HD patient is 24%
compared to 5-7% annually for ...
Fistula First
Breakthrough
Initiative
(FFBI)
Primary Goals
• Increase the placement of native fistulas.
• Detect access dysfunction before access
thrombosis.
Quality Standards
• Initial goal: AVF 50% Incident and 40%
Prevalent groups
• Current goal: 66% AVF overall
• TDC dependen...
0.02
0.08
0.03
0.08
0.25
0.10
0.24
0.22
0.09
0.18
0.17
0.25
0.0
0.1
0.2
0.3
0.4
0.5
Fistula Graft Catheter Fistula Graft C...
Clinical abnormality
> 50% stenosis
Catheters are benign?
Non maturation rates for AVF
reported between 50-60%
Dialysis Access Consortium DAC Dember et al. JAMA
2008:299:2164-71.
A...
Access Maturation Definition
• Rule of 6’s (Anatomic)
– 6 mm diameter
– 600 ml/min flow
– 6 cm accessible
– < 6mm depth
• ...
What’s the goal: clinically
significant vs insignificant variables
• Patency
• Maturation
• Consistent Cannulation that pe...
Fistula First
Functioning prosthetic access/timely
removal of Dialysis Catheter
Catheter last
A Systems Approach
ESRD-chronologic stages of
Management
• Diagnosis of CKD: acute or chronic time course
• Initiation of referral for access...
Timing of access
• GFR of 30 ml/min should prompt referral and
site protection.¹
• Access should be created 6 months in ad...
Discussion Topics
• Barriers to timely access
• Find your vascular access champion. Vascular
access should not be second t...
OR> 3 wks> 6wks> Maturation> Cannulation
Stratify catheter dependent
/Low GFR patients relative
priority when OR access is...
Discussion Topics
• Barriers to timely access
• When/how do we cannulate
• I release the fistula at 2/3 weeks post op with...
Fish or Cut Bait
Discussion Topics
• Barriers to timely
access
• When do we
cannulate
• When do we abandon
a fistula
• How do we monitor
th...
Discussion Topics
• Barriers to timely
access
• When do we
cannulate
• When do we abandon
a fistula
• How do we monitor
th...
Preferred Access Sites
• Radiocephalic AV fistula.
• Brachiocephalic AV fistula.
• Basilic vein transposition.
• Forearm A...
Upper Extremity Fistulas
PTFE*
Graft
* Polytetrafluoroethylene
- requires 3 - 4 weeks
for maturation
- usually placed in the
nondominant forearm
Upper Extremity Fistulas
Upper Extremity Grafts
Humacyte:
Autologous vein in a
bottle
Products listed may not be available in all markets.
GORE®
, and designs are trademarks of W. L. Gore & Associates. © 2011...
Tri-Layer Design
• Outer Graft Layer
 Expanded polytetrafluoroethylene
• Middle Graft Layer
 Elastomeric membrane
• Inne...
May Reduce Risk of Seroma/Aneurysm
Experienced
in Standard ePTFE grafts*
Seroma capsule
Ultrafiltration (fluid leakage) th...
SECONDARY ACCESS
Brachial Access with Femoral Vein
• Primary patency 79% 12 mo
• Secondary patency 100% 12 mo
• Steal 27%
• 23% vein harves...
General Principles
• Obtain complete access history.
• Delineate anatomy of the inflow and outflow
(venography).
• Exhaust...
Axillary-Axillary Grafts
• 24 month 40-80%
patency.
• Preserves contralateral
access.
• The venous limb should
be lateral....
Femoral Vein Transposition
• 2 year primary patency of 75%.
• 2 year secondary patency of 94%.
• High risk of steal. Limit...
Caveat for leg access
• Exhaust all upper extremity-Last ditch
means last ditch
• Objective documentation of arterial
perf...
SFA-SFV Grafts
• Comparable patency.
• 21% infection rate.
• Avoids some of the
pannus and lymphatics.
• Preserves more pr...
Axillary art to right atrium
Brachial artery to right atrium
graft
Thanks for your attention!!Thanks for your attention!!
Femoro-Femoral Grafts
• 60% secondary
patency at 2 years.
• 8 to 41% infection
rate.
• Higher complications
in obese patie...
Axillary/Brachial- Jugular Grafts
• 60% secondary
patency at 2 years.
• No incidence of steal.
• 4-15% incidence of
infect...
Arterial Interposition Grafts
• 87% secondary
patency at 3 years.
• 5% ischemia rate.
• Ischemia better
tolerated in the u...
Unconventional Procedures
• Axillary artery to left renal vein.
• External iliac artery to left renal vein.
• Axillary to ...
• Tri layer
• Elastic membrane between 2 layers ePTFE
• Covalently bonded heparin
What’s Unique About Flixene:What’s Unique About Flixene:
Trilaminate StructureTrilaminate Structure

Incorporation ZoneIn...
Features of FlixeneFeatures of Flixene
• The graft has the sliderThe graft has the slider
capability with acapability with...
Features of Flixene:Features of Flixene:
Improved StrengthImproved Strength
• High Radial Tensile StrengthHigh Radial Tens...
Dangers of Weeping: SeromaDangers of Weeping: Seroma
Dangers of Weeping: SeromaDangers of Weeping: Seroma
Computational Fluid Dynamics (CFD)**
** CFD 600 mL / min, 4.8 mm 30°, t = 0.4s
Conventional End-to-side Anastomosis
Endolu...
ESRD stages of Management
• Cannulation technique: button hole/rope ladder
• Removal of catheter
• Monitoring of access
• ...
Patients Dialyzing with
Catheters at Initiation
Nonmaturation vs Unusable
• 6 mm
• 600ml/mm
• 6 mm surface
• At least 6 mm in length
Discussion Topics
• Barriers to timely
access
• When do we
cannulate
• When do we abandon
a fistula
• How do we monitor
th...
Discussion Topics
• Barriers to timely
access
• When do we
cannulate
• When do we abandon
a fistula
• How do we monitor
th...
HERO Catheter
Hero Anatomy
Post-PTA 10 minutes 15 minutes
Elastic Recoil of Central Veins
Immediately
Post-PTA
20 minutes
Post-PTA
stent
positioning
Return of original stenosis
due to elastic recoil phenomenon.
20 minutes
Post-PTA Post-Stent
Use of a stent to salvage a failed angioplasty
Instent Restenosis
Stenosis
within
stent
Flair Endograft
Arm straight Arm bent 90 degrees
Arm straight Flair implanted Arm bent with Flair implant
Flair 8mm x 40mm
“We have met the enemy and he is
us”
Catheter events
& complications
Figure 5.48
Prevalent hemodialysis patients age 20 and older, ESRD CPM data; only includes...
Short-Term Catheters
Hohn Hemocath
Single lumen = 5 Fr
Double lumen = 7 Fr
Dual lumen 11 Fr
Short-term pheresis
PICC
Singl...
Intraluminal Thrombus
Intraluminal
thrombus
“Saran-wrap” layer of thin fibrin and thrombus
Tunneled hemodialysis catheter
that had been used for...
Management of Thrombosed
Catheters
Endoluminal thrombolytic agent
Exchange catheter
Four hour infusion of lytic agent
Fibr...
Loop configuration PTFE graft
venous anastomosis
arterial anastomosis
Straight configuration PTFE graft
venous anastomosis
arterial anastomosis
The Problem
The rapid, progressive development
of intimal hyperplasia at the anastomosis
of hemodialysis fistulae and graf...
Hemodialysis Graft Stenosis
stenosis
at the
venous
anastomosis
“ A well performed fistulogram is the
foundation for all percutaneous interventions ”
Thorough evaluation of the entire va...
Diagnostic Fistulogram
21 g butterfly needle
non-ionic contrast
multiple venous stenoses
Multiplicity of Lesions
multiple intragraft stenoses
Diffuse severe stenoses
stenoses stenoses
Multiplicity of Lesions
Angioplasty Procedures
Blood Flow vs. Time
• Document baseline blood flow value
• Development of stenoses can be monitored
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
No Monitoring Monitoring
ThrombosisRate
Grafts
Fistulae
Blood Flow Monitoring
McCarley e...
.
In Search of an Optimal Bedside Screening
Program
for Arteriovenous Fistula Stenosis
Nicola Tessitore,* Valeria Bedogna,...
Angioplasty Procedure
Diagnostic fistulogram
access
vascular
sheath
position
angioplasty balloon
across stenosis
fully inf...
Selecting the Appropriate Angioplasty Balloon
• Length
• Diameter
In general, high pressure balloons are used
for angiopla...
5.3 cm
4.5 cm
4.0 cm
DialEase
Arrow
Inner Lock
Vascular sheaths are color-coded
Vascular Sheaths for
Hemodialysis Access
I...
The length of the angioplasty balloon should
extend ~ 5mm beyond each end of the stenosis.
PTFE
graft
3cm
Use 4cm length b...
Endovascular Stents
If angioplasty fails, stents may be useful
in the following situations:
Indications for Stents
• Angioplasty-induced venou...
graft
venous
stenosis
contrast inject through
angioplasty balloon catheter
Philadelphia Facilities
0
10
20
30
40
50
60
70
Prevalence %
Phila.
Region 2 of Network
Fistula Average 40.5%
Axillary vein to right atrium
Brachial artery to right atrium
graft
FlixeneFlixene
Lee Kirksey MD, MBALee Kirksey MD, MBA
Problem with Vascular AccessProblem with Vascular Access
• Not all patients are candidates for fistulas.Not all patients a...
The Problem with GraftsThe Problem with Grafts
• Traditional vascular grafts are often complicatedTraditional vascular gra...
The Problem with GraftsThe Problem with Grafts
• Bovine GraftsBovine Grafts
– Prone to aneurysms.Prone to aneurysms.
– Whe...
The Ideal Vascular Access GraftThe Ideal Vascular Access Graft
• Never clotsNever clots
• Never gets infectedNever gets in...
It is nice to dream!!It is nice to dream!!
The Attempt to Achieve anThe Attempt to Achieve an
Ideal GraftIdeal Graft
• Grafts are now being designed specificallyGraf...
What is Flixene?What is Flixene?
• FLIXENE* is a next generation “compositeFLIXENE* is a next generation “composite
graft”...
Why Was Flixene Developed?Why Was Flixene Developed?
• Grafts are commonly placed in patientsGrafts are commonly placed in...
Why Was Flixene Developed?Why Was Flixene Developed?
• Grafts are usually placed in the forearm,Grafts are usually placed ...
Why Was Flixene Developed?Why Was Flixene Developed?
• There is therefore a need for a graft thatThere is therefore a need...
What’s Unique About Flixene?What’s Unique About Flixene?
• FLIXENE is a state-of-the-art PTFEFLIXENE is a state-of-the-art...
Features of Flixene:Features of Flixene:
Superior ResistanceSuperior Resistance
• Compression ResistanceCompression Resist...
Features of Flixene:Features of Flixene:
Superior ResistanceSuperior Resistance
• Kink ResistanceKink Resistance
– Better ...
Features of Flixene: Non-WeepingFeatures of Flixene: Non-Weeping
• It has superior water entryIt has superior water entry
...
Features of Flixene:Features of Flixene:
Comparative BenefitsComparative Benefits
0
50
100
150
200
250
300
350
Water Entry...
Features of Flixene:Features of Flixene:
Improved StrengthImproved Strength
Impact of Cannulation on Radial Tensile Streng...
Features of FlixeneFeatures of Flixene
• There is also an extra polyethylene sheathThere is also an extra polyethylene she...
Summary:Summary:
The Goals of FlixeneThe Goals of Flixene
• Flixene was designed with the mostFlixene was designed with th...
Summary:Summary:
The Goals of FlixeneThe Goals of Flixene
• Decreased graft complications such asDecreased graft complicat...
Post-PTA
Elastic Recoil of Central Veins
Pre-PTA
Options
• Short term. <3 weeks.
– Non – Cuffed Catheters.
• Mid-Term. Weeks to months.
– Cuffed Catheters.
• Long Term. Mo...
Non-Cuffed Catheters
Cuffed Catheters
Change in adjusted all-cause & cause-
specific hospitalization rates, by
modality
Figure 3.1 (Volume 2)
Period prevalent E...
Vein Preservation
• Do not access cephalic or basilic veins.
• Use dorsal hand veins.
• Avoid all subclavian access. 50% i...
Patient Evaluation for Long Term
Access
• Expected time of hemodialysis.
• Previous venous and arterial access. Previous
p...
Historical findings
• Diabetic duration, upper or lower extremity
neuropathy
• Carpal tunnel syndrome
Social cues
• Know your patient
– Who can/can’t accept failure.
– Patient frustration/prior failed attempts in
secondary p...
Altering remodeling…Biologics?
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Vascular access

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Vascular access

  1. 1. Vascular Access for Hemodialysis A Programmatic Approach Lee Kirksey MD MBA Assistant Professor of Surgery Case Western Lerner School of Medicine Department of Vascular Surgery The Cleveland Clinic Foundation kirksel@ccf.org 216.296.3209 216.445.8079, 4508
  2. 2. Care of ESRD patient • CKD team NPs, Physicians • Vascular surgery team • Dialysis center team Nursing Physicians Technicians • Access maintenance service
  3. 3. Background • CKD/ESRD is the 9th cause of death in the US. • One in ten Americans have some level of CKD • 341,000 patients on hemodialysis. • 107,000 new ESRD patients in 2010
  4. 4. Vascular Access at initiation of HD • 43% of incident patients had no prior nephrology contact • 80% begin HD with a CVC • 16% AVF • 3% AVG
  5. 5. Vascular access use at initiation and on day of eligibility, 2010 Figure 1.18 (Volume 2) Incident hemodialysis patients, July-December, 2010
  6. 6. Background • Adjusted individual first year mortality for newly initiated HD patient is 24% compared to 5-7% annually for ensuing years • 20% annual mortality for prevalent population
  7. 7. Fistula First Breakthrough Initiative (FFBI)
  8. 8. Primary Goals • Increase the placement of native fistulas. • Detect access dysfunction before access thrombosis.
  9. 9. Quality Standards • Initial goal: AVF 50% Incident and 40% Prevalent groups • Current goal: 66% AVF overall • TDC dependent <10% overall • Incidence of thrombosis < 0.5 episodes/pt year • Lifetime infection rates <1% for AVF’s and 10% for AVG’s. Source: http://esrdncc.org
  10. 10. 0.02 0.08 0.03 0.08 0.25 0.10 0.24 0.22 0.09 0.18 0.17 0.25 0.0 0.1 0.2 0.3 0.4 0.5 Fistula Graft Catheter Fistula Graft Catheter Admissionsperpatientyear Infectious Other 0.12 0.32 0.47 0.12 0.26 0.42 With permission : Paul Eggers Admissions by Access Type 1999 2003
  11. 11. Clinical abnormality > 50% stenosis Catheters are benign?
  12. 12. Non maturation rates for AVF reported between 50-60% Dialysis Access Consortium DAC Dember et al. JAMA 2008:299:2164-71. Allon et al. Kidney Int 2002;62:1109-24. Dhingra et al. Kidney Int 2001;60;1443-51.
  13. 13. Access Maturation Definition • Rule of 6’s (Anatomic) – 6 mm diameter – 600 ml/min flow – 6 cm accessible – < 6mm depth • 6 consecutive uses of new dialysis
  14. 14. What’s the goal: clinically significant vs insignificant variables • Patency • Maturation • Consistent Cannulation that permits removal of tunneled catheter
  15. 15. Fistula First Functioning prosthetic access/timely removal of Dialysis Catheter Catheter last
  16. 16. A Systems Approach
  17. 17. ESRD-chronologic stages of Management • Diagnosis of CKD: acute or chronic time course • Initiation of referral for access creation: when to whom • TDC placement-initiation of dialysis • Creation of Access: fistula/graft/PD/Txplt • Maturation and initiation of dialysis per access- when/who determines/--”fish or cut bait”
  18. 18. Timing of access • GFR of 30 ml/min should prompt referral and site protection.¹ • Access should be created 6 months in advance.¹ • Maturation of AV fistulas ideally requires 6 to 8 weeks. • Incorporation of AV grafts takes 3 to 6 weeks. 1 KDOQI guidelines
  19. 19. Discussion Topics • Barriers to timely access • Find your vascular access champion. Vascular access should not be second tier importance • Hold your proceduralist accountable both for quality and service • 216.444.VEIN
  20. 20. OR> 3 wks> 6wks> Maturation> Cannulation Stratify catheter dependent /Low GFR patients relative priority when OR access is limited Does 2 Staged approach add time to access? No…..But
  21. 21. Discussion Topics • Barriers to timely access • When/how do we cannulate • I release the fistula at 2/3 weeks post op with visit/exam and prescription • I reserve button hole for reliable home cannulator/ limited access length in facility • Cannulation team training—I’m happy to visit and discuss anatomy
  22. 22. Fish or Cut Bait
  23. 23. Discussion Topics • Barriers to timely access • When do we cannulate • When do we abandon a fistula • How do we monitor the fistula? exam, flows, angio, nihilism You must have a good access maintenance team—After surgery, the work has just begun. Limited use of stents 216.445.vein
  24. 24. Discussion Topics • Barriers to timely access • When do we cannulate • When do we abandon a fistula • How do we monitor the fistula? exam, flows, angio, nihilism • Alternative sites in the challenging pt
  25. 25. Preferred Access Sites • Radiocephalic AV fistula. • Brachiocephalic AV fistula. • Basilic vein transposition. • Forearm AV loop graft. • Upper arm AV graft. • Unconventional sites – Chest wall, legs, right atrium • Cuffed tunneled catheters should NOT be used as definitive access….except in?
  26. 26. Upper Extremity Fistulas
  27. 27. PTFE* Graft * Polytetrafluoroethylene - requires 3 - 4 weeks for maturation - usually placed in the nondominant forearm
  28. 28. Upper Extremity Fistulas
  29. 29. Upper Extremity Grafts
  30. 30. Humacyte: Autologous vein in a bottle
  31. 31. Products listed may not be available in all markets. GORE® , and designs are trademarks of W. L. Gore & Associates. © 2011, 2013, 2014 W. L. Gore & Associates, Inc. Accuseal Graft
  32. 32. Tri-Layer Design • Outer Graft Layer  Expanded polytetrafluoroethylene • Middle Graft Layer  Elastomeric membrane • Inner Graft Layer  Expanded polytetrafluoroethylene • CBAS® Heparin Surface CARMEDA® and CBAS® are trademarks of Carmeda AB, a wholly owned subsidiary of W. L. Gore & Associates. Products listed may not be available in all markets. GORE® and designs are trademarks of W. L. Gore & Associates. © 2011, 2013, 2014 W. L. Gore & Associates, Inc.
  33. 33. May Reduce Risk of Seroma/Aneurysm Experienced in Standard ePTFE grafts* Seroma capsule Ultrafiltration (fluid leakage) through the graft wall Products listed may not be available in all markets. GORE® , and designs are trademarks of W. L. Gore & Associates. © 2011, 2013, 2014 W. L. Gore & Associates, Inc. * Data on file
  34. 34. SECONDARY ACCESS
  35. 35. Brachial Access with Femoral Vein • Primary patency 79% 12 mo • Secondary patency 100% 12 mo • Steal 27% • 23% vein harvest site complications. • Indicated for vascular access associate arm infection
  36. 36. General Principles • Obtain complete access history. • Delineate anatomy of the inflow and outflow (venography). • Exhaust upper extremity options. • Anticipate/reduce complication • Favor the use of autogenous conduits via transposition and translocation.
  37. 37. Axillary-Axillary Grafts • 24 month 40-80% patency. • Preserves contralateral access. • The venous limb should be lateral. • Not associated with steal.
  38. 38. Femoral Vein Transposition • 2 year primary patency of 75%. • 2 year secondary patency of 94%. • High risk of steal. Limit anastomosis to 4-5mm. • Patients with PVD are not candidates. • High flows (2000 ml/min) may exacerbate CHF.
  39. 39. Caveat for leg access • Exhaust all upper extremity-Last ditch means last ditch • Objective documentation of arterial perfusion, pvrs with toe pressures • Preserve CFV, profunda femoris • Mild Chronic limb swelling is common • Anticoagulate 3-4 months • Amputation is not absolute contraindication to leg access
  40. 40. SFA-SFV Grafts • Comparable patency. • 21% infection rate. • Avoids some of the pannus and lymphatics. • Preserves more proximal access. • Complications are easier to manage.
  41. 41. Axillary art to right atrium
  42. 42. Brachial artery to right atrium graft
  43. 43. Thanks for your attention!!Thanks for your attention!!
  44. 44. Femoro-Femoral Grafts • 60% secondary patency at 2 years. • 8 to 41% infection rate. • Higher complications in obese patients.
  45. 45. Axillary/Brachial- Jugular Grafts • 60% secondary patency at 2 years. • No incidence of steal. • 4-15% incidence of infection lower than that of thigh access. • Difficult control in the setting of complications.
  46. 46. Arterial Interposition Grafts • 87% secondary patency at 3 years. • 5% ischemia rate. • Ischemia better tolerated in the upper extremity. • May have a role in CHF. • Higher risk of bleeding.
  47. 47. Unconventional Procedures • Axillary artery to left renal vein. • External iliac artery to left renal vein. • Axillary to right atrium.
  48. 48. • Tri layer • Elastic membrane between 2 layers ePTFE • Covalently bonded heparin
  49. 49. What’s Unique About Flixene:What’s Unique About Flixene: Trilaminate StructureTrilaminate Structure  Incorporation ZoneIncorporation Zone - 60 microns- 60 microns  Flixene MembraneFlixene Membrane - <5 microns- <5 microns  Flow Interface ZoneFlow Interface Zone (Hybrid(Hybrid Structure)Structure) - 60/20 design- 60/20 design
  50. 50. Features of FlixeneFeatures of Flixene • The graft has the sliderThe graft has the slider capability with acapability with a polyethylene clear, slidepolyethylene clear, slide sheath that allows ease ofsheath that allows ease of tunneling.tunneling. • It has a pre-attachedIt has a pre-attached tunneler tip.tunneler tip.
  51. 51. Features of Flixene:Features of Flixene: Improved StrengthImproved Strength • High Radial Tensile StrengthHigh Radial Tensile Strength – Greater resistance to cannulationGreater resistance to cannulation • BenefitBenefit – Withstand repetitive cannulationsWithstand repetitive cannulations – Fewer revisions and less pseudoaneurysmsFewer revisions and less pseudoaneurysms
  52. 52. Dangers of Weeping: SeromaDangers of Weeping: Seroma
  53. 53. Dangers of Weeping: SeromaDangers of Weeping: Seroma
  54. 54. Computational Fluid Dynamics (CFD)** ** CFD 600 mL / min, 4.8 mm 30°, t = 0.4s Conventional End-to-side Anastomosis Endoluminal Anastomosis with the GORE® Hybrid Vascular Graft * Data on file
  55. 55. ESRD stages of Management • Cannulation technique: button hole/rope ladder • Removal of catheter • Monitoring of access • Thrombosis of access- 2/month • Maintenance intervention of access
  56. 56. Patients Dialyzing with Catheters at Initiation
  57. 57. Nonmaturation vs Unusable • 6 mm • 600ml/mm • 6 mm surface • At least 6 mm in length
  58. 58. Discussion Topics • Barriers to timely access • When do we cannulate • When do we abandon a fistula • How do we monitor the fistula? exam, flows, angio, nihilism • When do we abandon the fistula
  59. 59. Discussion Topics • Barriers to timely access • When do we cannulate • When do we abandon a fistula • How do we monitor the fistula? exam, flows, angio, nihilism • When do we abandon the fistula • Alternatives to prosthetic
  60. 60. HERO Catheter
  61. 61. Hero Anatomy
  62. 62. Post-PTA 10 minutes 15 minutes Elastic Recoil of Central Veins
  63. 63. Immediately Post-PTA 20 minutes Post-PTA stent positioning Return of original stenosis due to elastic recoil phenomenon.
  64. 64. 20 minutes Post-PTA Post-Stent Use of a stent to salvage a failed angioplasty
  65. 65. Instent Restenosis Stenosis within stent
  66. 66. Flair Endograft
  67. 67. Arm straight Arm bent 90 degrees Arm straight Flair implanted Arm bent with Flair implant
  68. 68. Flair 8mm x 40mm
  69. 69. “We have met the enemy and he is us”
  70. 70. Catheter events & complications Figure 5.48 Prevalent hemodialysis patients age 20 and older, ESRD CPM data; only includes patients who are also in the USRDS database. Year represents the prevalent year & the year the CPM data were collected. Access is that listed as “current” on the CPM data collection form.
  71. 71. Short-Term Catheters Hohn Hemocath Single lumen = 5 Fr Double lumen = 7 Fr Dual lumen 11 Fr Short-term pheresis PICC Single or double lumen 4, 5, or 6 Fr ( Non-Tunneled Catheters )
  72. 72. Intraluminal Thrombus
  73. 73. Intraluminal thrombus “Saran-wrap” layer of thin fibrin and thrombus Tunneled hemodialysis catheter that had been used for 6 weeks
  74. 74. Management of Thrombosed Catheters Endoluminal thrombolytic agent Exchange catheter Four hour infusion of lytic agent Fibrin sheath stripping Brush catheter New catheter at new site
  75. 75. Loop configuration PTFE graft venous anastomosis arterial anastomosis
  76. 76. Straight configuration PTFE graft venous anastomosis arterial anastomosis
  77. 77. The Problem The rapid, progressive development of intimal hyperplasia at the anastomosis of hemodialysis fistulae and grafts. anastomotic stenosis PTFE graft anastomotic stenosis AV fistula
  78. 78. Hemodialysis Graft Stenosis stenosis at the venous anastomosis
  79. 79. “ A well performed fistulogram is the foundation for all percutaneous interventions ” Thorough evaluation of the entire vascular access circuit including the graft, native veins, and inflow arteries
  80. 80. Diagnostic Fistulogram 21 g butterfly needle non-ionic contrast
  81. 81. multiple venous stenoses Multiplicity of Lesions multiple intragraft stenoses
  82. 82. Diffuse severe stenoses stenoses stenoses Multiplicity of Lesions
  83. 83. Angioplasty Procedures
  84. 84. Blood Flow vs. Time • Document baseline blood flow value • Development of stenoses can be monitored
  85. 85. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 No Monitoring Monitoring ThrombosisRate Grafts Fistulae Blood Flow Monitoring McCarley et al. Kid Int 2001; 60:1164-1172 0.71 0.160.14 0.07
  86. 86. . In Search of an Optimal Bedside Screening Program for Arteriovenous Fistula Stenosis Nicola Tessitore,* Valeria Bedogna,* Edoardo Melilli,* Deborah Millardi,* Giancarlo Mansueto,† Giovanni Lipari,‡ William Mantovani,§ Elda Baggio,‡ Albino Poli,§ and Antonio Lupo* Clin J Am Soc Nephrol 6: 819–826, 2011. doi: 10.2215/CJN.06220710
  87. 87. Angioplasty Procedure Diagnostic fistulogram access vascular sheath position angioplasty balloon across stenosis fully inflate balloon stenosis Post-PTA
  88. 88. Selecting the Appropriate Angioplasty Balloon • Length • Diameter In general, high pressure balloons are used for angioplasty of neointimal hyperplastic stenoses Primary selection criteria :
  89. 89. 5.3 cm 4.5 cm 4.0 cm DialEase Arrow Inner Lock Vascular sheaths are color-coded Vascular Sheaths for Hemodialysis Access Interventions • short length • high-flow sidearm • ± stopcock
  90. 90. The length of the angioplasty balloon should extend ~ 5mm beyond each end of the stenosis. PTFE graft 3cm Use 4cm length balloon Minimize the length of balloon within normal vein. Angioplasty damage the venous endothelium and can incite neointimal hyperplasia.
  91. 91. Endovascular Stents
  92. 92. If angioplasty fails, stents may be useful in the following situations: Indications for Stents • Angioplasty-induced venous rupture • Surgically inaccessible lesions - central venous stenoses
  93. 93. graft venous stenosis contrast inject through angioplasty balloon catheter
  94. 94. Philadelphia Facilities 0 10 20 30 40 50 60 70 Prevalence % Phila. Region 2 of Network Fistula Average 40.5%
  95. 95. Axillary vein to right atrium
  96. 96. Brachial artery to right atrium graft
  97. 97. FlixeneFlixene Lee Kirksey MD, MBALee Kirksey MD, MBA
  98. 98. Problem with Vascular AccessProblem with Vascular Access • Not all patients are candidates for fistulas.Not all patients are candidates for fistulas. • It has been reported that 30% of AVIt has been reported that 30% of AV fistulas never mature or are able to befistulas never mature or are able to be cannulated.cannulated. • There are still a number of problemsThere are still a number of problems associated with grafts.associated with grafts.
  99. 99. The Problem with GraftsThe Problem with Grafts • Traditional vascular grafts are often complicatedTraditional vascular grafts are often complicated by weeping during implantation.by weeping during implantation. • Pseudoaneurysm formation after repeatedPseudoaneurysm formation after repeated needle sticks, and poor or incomplete healingneedle sticks, and poor or incomplete healing are common occurrences.are common occurrences. • Ordinarily, grafts are cannulated anywhere fromOrdinarily, grafts are cannulated anywhere from 2 weeks to a month after implantation.2 weeks to a month after implantation.
  100. 100. The Problem with GraftsThe Problem with Grafts • Bovine GraftsBovine Grafts – Prone to aneurysms.Prone to aneurysms. – When infected, tend to fall apart.When infected, tend to fall apart.
  101. 101. The Ideal Vascular Access GraftThe Ideal Vascular Access Graft • Never clotsNever clots • Never gets infectedNever gets infected • Easy to implantEasy to implant • Easy to cannulateEasy to cannulate • Does not bleed after cannulationDoes not bleed after cannulation • Never forms pseudoaneurysmsNever forms pseudoaneurysms
  102. 102. It is nice to dream!!It is nice to dream!!
  103. 103. The Attempt to Achieve anThe Attempt to Achieve an Ideal GraftIdeal Graft • Grafts are now being designed specificallyGrafts are now being designed specifically for vascular access and dialysis.for vascular access and dialysis. • Advances in design and technology areAdvances in design and technology are overcoming many of the problems seen inovercoming many of the problems seen in some of the older grafts.some of the older grafts.
  104. 104. What is Flixene?What is Flixene? • FLIXENE* is a next generation “compositeFLIXENE* is a next generation “composite graft”.graft”. • This vascular graft has been engineeredThis vascular graft has been engineered to overcome the major drawbacks ofto overcome the major drawbacks of conventional grafts and is projected toconventional grafts and is projected to become the new graft of choice.become the new graft of choice. *Atrium Medical Corporation
  105. 105. Why Was Flixene Developed?Why Was Flixene Developed? • Grafts are commonly placed in patientsGrafts are commonly placed in patients who have no veins available for anwho have no veins available for an autologous fistula because they have hadautologous fistula because they have had many prior access procedures.many prior access procedures. • Also many have spent inordinate time withAlso many have spent inordinate time with double lumen catheters.double lumen catheters. • Flixene is designed specifically for theseFlixene is designed specifically for these patients.patients.
  106. 106. Why Was Flixene Developed?Why Was Flixene Developed? • Grafts are usually placed in the forearm,Grafts are usually placed in the forearm, upper arm or thigh.upper arm or thigh. • What is unique about these areas?What is unique about these areas? – Higher flowsHigher flows – More difficult turns and bendsMore difficult turns and bends – Which leads to more weepingWhich leads to more weeping
  107. 107. Why Was Flixene Developed?Why Was Flixene Developed? • There is therefore a need for a graft thatThere is therefore a need for a graft that will:will: – Decrease weepingDecrease weeping – Designed for better incorporationDesigned for better incorporation – Can be cannulated within 72 hoursCan be cannulated within 72 hours – Withstand needle sticksWithstand needle sticks
  108. 108. What’s Unique About Flixene?What’s Unique About Flixene? • FLIXENE is a state-of-the-art PTFEFLIXENE is a state-of-the-art PTFE vascular graft composed of three distinctvascular graft composed of three distinct layers.layers. • This layered design maximizes handling,This layered design maximizes handling, strength, and implantation properties ofstrength, and implantation properties of this graft.this graft.
  109. 109. Features of Flixene:Features of Flixene: Superior ResistanceSuperior Resistance • Compression ResistanceCompression Resistance – More resistance than any non-helixed graft.More resistance than any non-helixed graft. – More compression resistant than thin-wallMore compression resistant than thin-wall ringed grafts.ringed grafts.
  110. 110. Features of Flixene:Features of Flixene: Superior ResistanceSuperior Resistance • Kink ResistanceKink Resistance – Better than any non-helixed productBetter than any non-helixed product • Torque ResistanceTorque Resistance – Equal to the best in the industryEqual to the best in the industry
  111. 111. Features of Flixene: Non-WeepingFeatures of Flixene: Non-Weeping • It has superior water entryIt has superior water entry pressure (WEP)pressure (WEP) • This tends to eliminatesThis tends to eliminates blushing and weeping of theblushing and weeping of the graft.graft.
  112. 112. Features of Flixene:Features of Flixene: Comparative BenefitsComparative Benefits 0 50 100 150 200 250 300 350 Water Entry Pressure Flixene Graft A Graft B Graft C
  113. 113. Features of Flixene:Features of Flixene: Improved StrengthImproved Strength Impact of Cannulation on Radial Tensile Strength of Vascular Grafts 168 131 113 84 62 46 27 20 15 0 50 100 150 200 0 10 20 Number of Punctures/CM Lbsofforce Flixene Competetor A Competetor B
  114. 114. Features of FlixeneFeatures of Flixene • There is also an extra polyethylene sheathThere is also an extra polyethylene sheath that covers the entire system and protectsthat covers the entire system and protects the graft from coming into contact with thethe graft from coming into contact with the skin and other items (Blue Transferskin and other items (Blue Transfer Sleeve).Sleeve).
  115. 115. Summary:Summary: The Goals of FlixeneThe Goals of Flixene • Flixene was designed with the mostFlixene was designed with the most complex dialysis patients in mind.complex dialysis patients in mind. • It’s layered design helps to minimizeIt’s layered design helps to minimize weeping.weeping. • The graft also boasts excellent kink andThe graft also boasts excellent kink and compression resistance.compression resistance.
  116. 116. Summary:Summary: The Goals of FlixeneThe Goals of Flixene • Decreased graft complications such asDecreased graft complications such as seromas and pseudoaneurysms.seromas and pseudoaneurysms. • Studies are in progress to evaluate theStudies are in progress to evaluate the early stick potential of Flixene.early stick potential of Flixene. • Early cannulation is perhaps the greatestEarly cannulation is perhaps the greatest advantage for AV grafts.advantage for AV grafts. • This decreases the time and need forThis decreases the time and need for double-lumen catheter use and itsdouble-lumen catheter use and its associated complications.associated complications.
  117. 117. Post-PTA Elastic Recoil of Central Veins Pre-PTA
  118. 118. Options • Short term. <3 weeks. – Non – Cuffed Catheters. • Mid-Term. Weeks to months. – Cuffed Catheters. • Long Term. Months to years. – Arteriovenous Grafts. – Arteriovenous Fistulas.
  119. 119. Non-Cuffed Catheters
  120. 120. Cuffed Catheters
  121. 121. Change in adjusted all-cause & cause- specific hospitalization rates, by modality Figure 3.1 (Volume 2) Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2005.
  122. 122. Vein Preservation • Do not access cephalic or basilic veins. • Use dorsal hand veins. • Avoid all subclavian access. 50% incidence of stenosis after 2 weeks. • 10% incidence of stenosis with internal jugular access.
  123. 123. Patient Evaluation for Long Term Access • Expected time of hemodialysis. • Previous venous and arterial access. Previous pacemaker placement. • Arm dominance. • Physical exam. • Duplex ultrasound and venography. • Minimal diameters: • Artery 2mm. • Vein 2.5mm.
  124. 124. Historical findings • Diabetic duration, upper or lower extremity neuropathy • Carpal tunnel syndrome
  125. 125. Social cues • Know your patient – Who can/can’t accept failure. – Patient frustration/prior failed attempts in secondary procedures – Explain that all access ultimately fails…Duh? – Take ownership of access
  126. 126. Altering remodeling…Biologics?

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