Complications and management of av access

Complications and management of av access

1. Complications and Management of AV access Toufic Safa , MD, FACS Medical Director - AAA Vascular 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. Procol R Slider TM LifeSite R Vectra R CryoVein R INTERING HeRo

6. 1- Hematomas 2- Significant Steal 3- Multiple vein branches off of body of fistula 4- Non Maturing AVF’s: Arterial and/or Venous 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

7. Hematomas: POST-OP

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

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

10. SIGNIFICANT STEAL

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

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

13. TOO MANY BRANCHES OFF OF THE FISTULA VEIN

14. 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

15. 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

16. Coil Embolization of Fistula Vein Branch Pre-Coiling of AVF Branch Successful Coiling of AVF Branch

17. Minimally Invasive Open Ligation: Preferred Technique – Simple Office Procedure, time and cost effective, Less risky

18. 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 Biuckians A, …, Glickman MH “The natural History of autologous fistulas…” JVS, 2008 Feb; 47: 415-21

19. 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 ?

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

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

22. Balloon Assisted Maturation

23. Pre and Post BAM: initial stage

24. 1- Arterial Inflow Lesions 2- Venous Access vein Stenoses 3- Mixed Arterial and Venous lesions Arterial, Venous, or Mixed Lesions that threaten AV Access

25. 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

26. 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

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

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

29. 1- Cephalic arch lesions for AV Fistulas 2- Venous anastomosis for AV Grafts: Most common lesion that threatens AV Grafts Current Techniques 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)

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

31. 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] .) 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] .)   Pr evious Next     Volume 362:494-503      February 11, 2010      Number 6                                                                                                                          Full Text     PDF     PDA Full Text     PowerPoint Slide Set     Supplementary Material     Purchase this article     Editorial         Add to Personal Archive     Add to Citation Manager     Notify a Friend     E-mail When Cited     E-mail When Letters Appear     PubMed Citation   by Kerlan, R. K.

32. Venous O utflow S tenosis 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 the VASA meeting in Las Vegas, May of 2010 Opening Angio Post Angioplasty Post Viabahn Stent Placement

33. Aneurysmal Formation In AV Access

34. 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

35. 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 a Viabahn Stent Graft

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

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

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

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

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

41. 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). One Year Access 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.

42. 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

43. THANK YOU