Haemodialysis Fistula Intervention - Dr Ralph Jackson.ppt
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This document discusses arterio-venous (AV) fistulas which are surgically created shunts used for hemodialysis. Native fistulas in the lower arm are better than grafts or those in the upper arm. The most common problems with fistulas are stenosis which can cause poor development, difficult needling, or inadequate dialysis. Treatment options for stenosis include angioplasty using standard, high-pressure, or cutting balloons as well as surgery. Angioplasty is highly successful if performed correctly using high pressure and long inflation times to address recoil, and maintaining dialysis access is an important role of interventional radiologists.
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Haemodialysis Fistula Intervention - Dr Ralph Jackson.ppt
- 1. Haemodialysis Fistula Intervention Dr Ralph Jackson Freeman Hospital Newcastle-upon-Tyne
- 2. What are Arterio-Venous fistulae? • Surgically created “end to side” shunts which allow dialysis. • Lower arm (radio-cephalic) better than upper arm (brachio-cephalic, brachio- basilic, brachio-brachial). • Native better than grafts (PTFE, bovine ureter)
- 3. Anatomy
- 5. Typical AV Fistula “Arterial” needle “Venous” needle Thrill
- 6. Typical AV Fistula Arterial pressure Venous pressure
- 7. Problems with fistulae • Poor development • Difficulty needling • Inadequate dialysis – Low flow rates – Recirculation • High pressures and prolonged bleeding • Thrombosis • Almost all due to stenoses which are recurrent
- 8. Flat AV Fistula: peri-anastomotic stenosis “Arterial” needle “Venous” needle Weak thrill
- 9. Pulsatile AV Fistula: stenosis away from anastomosis Flat Remote Thrill Pulsatile and high pressure
- 11. Treatment options • Angioplasty – Standard balloon angioplasty – High pressure balloon – Cutting or scoring balloon • Surgery • Refashion anastomosis • Patch stenosis • Higher fistula • Whichever way, get on with it.
- 12. Balloon angioplasty • Big enough – Tendency to use too small balloons • High or ultra high pressure – Standard RBP of 15Atm @8mm • Inflation handle (obviously). • Long inflation times as recoil common. • Rupture uncommon but be prepared
- 16. Transarterial
- 18. High Pressure
- 19. Cephalic arch stenosis Much commoner in dysfunctional brachio- than radio-cephalic fistulae (~50%). More prone to rupture and restenosis Primary patency rates at one year after angioplasty only around 30%
- 21. Rupture management • Not that frequent to have major rupture (1- 2%). • Tamponade with long low pressure inflation • Covered stent as bail out • Associated with subsequent loss of fistula
- 28. Conclusion • AV fistulas are simple to understand. – History and examination are diagnostic. • Most problems are due to stenosis. • Angioplasty is highly successful if done right. • Stenoses recur so you will get to know the patients well. • Maintaining dialysis access is one of the most important IR jobs.