Transdermal Nitroglycerin Role In AVF Maturation

1. EFFECTS OF TRANSDERMAL NITROGLYCERIN
ON A NEWLY CREATED ARTERIOVENOUS
FISTULA FOR HEMODIALYSIS
ZACHARIAH PAUL POLACHIRAKAL, GEORGE KURIAN, RAJESH R NAIR, ANIL MATHEW, SANDEEP S
Department of Nephrology, Amrita School of Medicine
Amrita Institute of Medical Sciences & Research Centre
Kochi, Kerala, India

2. AVF MATURATION & ROLE OF
NITROGLYCERIN
Low flow with
poor shear
stress
neointimal
hyperplasia
failure of
venous
dilatation
 Mimics the actions of endogenous nitric
oxide by releasing nitric oxide
 Acts directly on the vascular smooth muscle
 causes
 vasodilatation
 inhibit platelet aggregation
 inhibit leukocyte endothelial interactions.
AVF Maturation Cascade
Medial hypertrophy
further increased flow  increase in
pressure within the venous segment
Arterial and venous dilatation
Increase in NO, ROS and matrix
metalloproteinase
Increase in arterial and venous shear stress
Increased arterial and venous flow

3. Patient selection &
Doppler assessment (D0)
After 24 hours
Doppler assessment (D1)
n = 60
AVF Surgery
After 24 hours
Doppler assessment (D2)
n = 25
Arm 1
Placebo
patch
After 24 hours
Doppler assessment (D2)
n = 25
Arm 2
Nitroderm
TTS 5
 Inclusion
 Age > 20 yrs < 60 yrs.
 CKD Stage 3 – 5.
 Radiocephalic AVFs
 Exclusion
 Evidence of PVOD, CAD, stroke
or vasculitis; thrombotic segment
or thrombophlebitis
 Hypersensitivity to NTG or use of
phosphodiesterase inhibitors or
oral nitrates.
 Failed AVF ~ within 24 hr
Double blind randomized
controlled prospective trial
STUDY DESIGN & METHODOLOGY

4. Doppler parameters
Baseline
Mean ± SD
After 24 hours
Mean ± SD
p value
Artery diameter (cm) .2604 ± .0254 .2612 ± .0261 .161
Arterial PSV (cm/sec)
162.86 ± 23.24 175.26 ± 24.84 .001
Vein diameter (cm) .3352 ± .0466 .3380 ± .0458 .003
Venous PSV (cm/sec)
201.34 ± 38.21 220.62 ± 42.30 <.0001
Flow volume (ml/min) 1071.42 ± 317.67 1207.51 ± 393.90 <.0001
Artery diameter (cm) .2548 ± .0309 .2724 ± .0328 <.0001
Arterial PSV (cm/sec) 151.28 ± 28.00 198.16 ± 37.86 <.0001
Vein diameter (cm) .3340 ± .0552 .3560 ± .0687 <.0001
Venous PSV (cm/sec) 199.20 ± 41.04 250.12 ± 38.01
<.0001
Flow volume (ml/min) 1037.61 ± 293.03 1501.40 ± 526.92 <.0001
PLACEBOArmNITRODERMArm
R
E
S
U
L
T
S

5. Doppler
parameters
Placebo arm
%
Nitroderm arm
%
p value
Artery diameter 0.2 7 < .0001
Arterial PSV 9 33 < .0001
Vein diameter 1 6 .010
Venous PSV 10 28 0.006
Flow volume 12 44 .001
PERCENTAGE DIFFERENCE BETWEEN DOPPLER
INDICES BETWEEN THE TWO ARMSR
E
S
U
L
T
S

6. CONCLUSION
 Percentage increase in the doppler indices were 3 to 5 times
higher in study group
 Superficial location of AVF - ideally suited to local drug delivery
systems.
 Transdermal NTG  vasodilatation  increase blood flow
through the fistula  increased shear stress.
No conflict of interests or financial aids to declare.
This study was not sponsored.
Part of this study was presented at the
11th annual conference of ASDIN, Orlando, Feb 2015
9th annual conference of VAS, Barcelona, April 2015.
Ongoing trial to study the effects of tNTG in
the long term AVF maturation
Primary patency rates
Will AVF mature faster
Dosing of the intervention
ACKNOWLEDGEMENT