2. The Problem!
• Steady increase in no. of ESRD patients
requiring RRT (usually being Hemodialysis).
• We need an adequate vascular access (VA) to
be able to deliver this extracorporeal blood
purification treatment (HD)
• VA and it’s associated complications,
constitute the most common cause of
morbidity, hospitalization, and cost among
those patients
4. Monitoring and Surveillance of VA!
Monitoring
• This term refers to the examination and evaluation of the vascular
access by means of physical examination to detect physical signs that
would suggest the presence of pathology.
Surveillance
• This term refers to periodic evaluation of the vascular access by
means of tests, which may involve special instrumentation, for which
an abnormal test result suggests the presence of pathology.
Diagnostic Testing
• This term refers to testing that is prompted by some abnormality or
other medical indication and which is undertaken to diagnose the
presence of pathology (i.e.,angiography).
5. Prospective Diagnosis of Venous Stenosis
NKF-K/DOQI Clinical Practice Guideline 4
4.1 Physical examination (monitoring):
• Physical examination should be used to detect dysfunction in fistulae and grafts at
least monthly by a qualified individual
4.2 Surveillance of grafts:
• Techniques, not mutually exclusive, that may be used in surveillance for stenosis in
grafts include:
• 4.2.1 Preferred:
• o 4.2.1.1 Intra-access flow by using 1 of several methods that are available, using
sequential measurements with trend analysis.
• o 4.2.1.2 Directly measured or derived static venous dialysis pressure by 1 of
several methods that are available
• o 4.2.1.3 Duplex ultrasound
• 4.2.2 Acceptable:
• o 4.2.2.1 Physical findings of persistent swelling of the arm, presence of collateral
veins, prolonged bleeding after needle withdrawal, or altered characteristics of
pulse or thrill in a graft
• 4.2.3 Unacceptable:
• o 4.2.3.1 Unstandardized dynamic venous pressures should not be used.
6. 4.3 Surveillance in fistulae:
• Techniques, not mutually exclusive, that may be used in surveillance for
stenosis in AVFs include:
• 4.3.1 Preferred:
• o 4.3.1.1 Direct flow measurements
• o 4.3.1.2 Physical findings of persistent swelling of the arm, presence of
collateral veins, prolonged bleeding after needle withdrawal, or altered
characteristics of pulse or thrill in the outflow vein
• o 4.3.1.3 Duplex ultrasound
• 4.3.2 Acceptable:
• o 4.3.2.1 Recirculation using a non–urea-based dilutional method
• o 4.3.2.2 Static pressures, direct or derived
7. The Main Goal In Managing A Failing
VA!
“Prospective Diagnosis of Venous Stenosis”
• It is important that all hemodialysis facilities
have in place a system designed to detect
venous stenosis so that it can be diagnosed
and treated prospectively
9. Physical Examination
• Look
– Well-developed main venous outflow
– Collateral venous effluent vessels
– Collapses or softens when arm is raised
• Listen
– Low-pitched continuous systolic-diastolic bruit
• Feel
– Gentle thrill at the arterial anastomosis
– Should NOT be hyperpulsatile
11. ‘Standardized’ Dynamic Venous
Pressure
Determinants of Dynamic Venous Pressure
• Pressure within the access (this is an asset)
• Pressure related to the resistance created by the
system (this is a liability)
- Venous return blood tubing
- Any constriction in the system
- Venous return needle (gauge)
- Hematocrit (viscosity of blood)
“Dynamic venous pressure: >120 (with needle
gauge 15) and >150 (with needle gauge 16)”
13. Possible sites of stenosis in relation to clinical
findings & physical exam
Clinical findings Physical examination Possible sites of stenosis
High dynamic or static
venous pressure
Pulsatile AVF Outflow stenosis
Prolonged bleeding after
removal of dialysis needle
Pulsatile AVF Outflow stenosis
Upper limb swelling Swollen arm Central vein stenosis
Decreased thrill Flat AVF Inflow stenosis and body
Difficult cannulation Flat or difficult to palpate
Good thrill
Inflow stenosis and body
No stenosis, AVF too deep
for cannulation
Failure to mature Flat AVF
Multiple dilated veins
Inflow stenosis
Presence of accessory
veins or collaterals
18. AV access salvage
• Balloon angioplasty for short segment of stenosis
(inflow, intra-access, outflow)
• Balloon angioplasty/stenting for central vein stenosis
• Mechanical thrombectomy or pharmacologic
thrombolysis
• Graft interposition for long segments of stenosis
• Ligation of side branches/stealing branches
• Covered stents or resection for aneurysms
27. • Micropuncture Needle (This is a 21-gauge needle that
allows for the passage of a guidewire (0.018 inch in
diameter) followed by a compound (two-step) dilator. The
dilator is of double construction. It consists of a 3 French
dilator which is tapered to 0.018 inch that is inside and
extends beyond the tip of a 5 French one which is tapered
to 0.035 inch.)
33. “Note – Most of the devices used in the
interventional lab are measured using a unit
of measure called a French.
There are 2.8 French in a millimeter. Actually, it
is useful to think in terms of 3 French to the
millimeter. In other words, a 9 French dilator is
approximately 3 mm in diameter (to be
precise it is 3.14 mm).
44. Fundamentals of Venous intervention as compared to
Arterial intervention
Venous intervention Arterial intervention
Heparin Usually not required Usually required
Complications Rupture, thrombosis,
pulmonary embolism
Dissection, thrombosis,
rupture
Balloon length Oversize Cover lesion and little
beyond
Balloon diameter Oversize Do not oversize
Duration of inflation Long (min 3 min) Short
Type of balloon High pressure balloon Choice depends on type of
lesion
48. Indications for stent placement
1. Central vein stenosis where there is acute
elastic recoil of the vein (>50%) after
angioplasty OR recurrence of stenosis within
3 months period.
2. angioplasty induced vascular rupture,
patients with surgically inaccessible lesion, or
contraindication to surgery
53. (A) Retrograde fistulogram revealing > 90% stenosis (arrow) at the
arterial anastomosis.
Case 2:52 years old female with difficult puncture of her left AV fistula.
54. (B) 5 mm. balloon inflated (arrows) within the stenotic lesion.
56. (A) Fistulogram revealing complete occlusion of the right subclavian vein (black
arrows) with multiple superficial collaterals (white headed arrows).
Case 3: 75 years old female with malfunctioning right arm AV graft, on examination
the right arm was swollen, and multiple superficial collaterals were seen on the right
side of the chest wall.
57. (B) 9 mm. balloon inflated (arrows) within the stenotic lesion.
.
.
58. (C) Fistulogram revealing no flow even after angioplasty so decision of
stent placement was taken.
.
59. (D) 10 mm. balloon inflated within 10 x 80 mm. covered stent (arrows).
60. (E) Angiogram was done after deploying the stent, and showed partial
opening of the central vein. Decision was done to put another stent in
the axillary vein overlapping the proximal stent because there were
some clots in that area.
61. (F) Second 10 x 80 mm. stent (stent 2) deployed within the axillary vein
overlying the first stent.
62. (G) Angiogram revealing complete restoration of flow in the central
veins with no collaterals.
63. (A) Fistulogram revealed 80% venous stenosis at the venous anastomosis (arrow)
Mechanical thromboaspiration was done and revealed multiple clots.
Case 4: 74 years old female patient with clotted left arm AV graft. On examination
the graft thrombus was felt with weak thrill felt over..
