PERMCATH EXCHANGE AND FIBRIN SHEATH STRIPPING.pptx

Permcath exchange and fibrinsheath stripping techniques for the management of dysfunctional dialysis catheter

1. PERMCATH EXCHANGE AND FIBRIN SHEATH STRIPPING Dr Roshan Valentine MBBS, MD, DNB, MNAMS, FVIR, EBIR Associate Consultant Manipal Hospitals

2. CASE 1 56 Year old CKD patient with right sided tunneled dialysis catheter(TDC) placed almost a year back. Referred because of reduced flow and high venous pressures during dialysis. Assessed for backflow and flushing of both the lumens

3. INTRODUCTION Catheter Dysfunction Definition(2019 KDOQI) Inability to maintain the prescribed extracorporeal blood flow required to ensure adequacy of hemodialysis without increasing the duration of the hemodialysis session Failure to attain or maintain an extracorporeal blood flow >300 ml/min at a prepump arterial pressure more negative than −250 mm Hg 3 sessions for 4 hours each per week Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP; National Kidney Foundation. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020 Apr;75(4 Suppl 2):S1-S164

4. PROTOCOL FOR CATHETER DYSFUNCTION

5. Thrombolysis Protocol Commonly used agents: Streptokinase, urokinase, Alteplase UK- 1 lac units in each lumen SK- 1 lac units in each lumen Dwell time – 2 hours PASSPORT Trial - Urokinase showed a cumulative success rate of thrombolysis 90%, 95%, and 99% with first, second, and subsequent interventions

6. PROTOCOL FOR CATHETER DYSFUNCTION

7. FIBRIN SHEATH Catheter dysfunction 16-57% Blood – Catheter layer contact Thin layer of fibrinogen, albumin, gamma-globulin, lipoproteins, and coagulation factors Starts forming in first 24 hours and matures over weeks Flap valve effect Wang, L., Jia, L., & Jiang, A. (2022). Pathology of catheter-related complications: what we need to know and what should be discovered. Journal of International Medical Research, 50(10), 030006052211278. Wang L, Jia L, Jiang A. Pathology of catheter-related complications: what we need to know and what should be discovered. Journal of International Medical Research. 2022;50(10). doi:10.1177/03000605221127890

8. Thrombolysis Stripping Venoplasty + Exchange Wang L, Jia L, Jiang A. Pathology of catheter-related complications: what we need to know and what should be discovered. Journal of International Medical Research. 2022;50(10). doi:10.1177/03000605221127890 FIBRIN SHEATH - MANAGEMENT

9. FIBRIN SHEATH STRIPPING Success Rates 80-90% Catheter Exchange not necessary Quicker compared to Venoplasty + exchange . Complications Pulmonary Embolism Bacteremia Access site complications Not feasible in patients with occluded iliac veins Crain MR, Mewissen MW, Ostrowski GJ, Paz- Fumagalli R, Beres RA, Wertz RA. Fibrin sleeve stripping for salvage of failing hemodialysis catheters: technique and initial results. Radiology. 1996 Jan;198(1):41-4. doi : 10.1148/radiology.198.3.41a. PMID: 8539402. FIBRIN SHEATH - MANAGEMENT

10. FIBRIN SHEATH - MANAGEMENT

11. FIBRIN SHEATH - MANAGEMENT BASIC MATERIALS

12. FIBRIN SHEATH - MANAGEMENT

13. FIBRIN SHEATH – MANAGEMENT FIBRIN SHEATH VENOPLASTY + CATHETER EXCHANGE KDOQI –Fibrin sheath Venoplasty + catheter exchange preferred Both same efficacy Lesser morbidity No additional cannulations No increase in infectious complications

14. CASE 2 70 Year old CKD patient with right sided tunneled dialysis and multiple access failures Referred because of flow issues

15. FIBRIN SHEATH – MANAGEMENT VENOPLASTY+EXCHANGE

16. All three therapies were equivalent in terms of immediate technical success, complication rates, and durability of catheter function during later follow-up. FIBRIN SHEATH – MANAGEMENT

17. CONCLUSION Lifeline for hemodialysis-dependent patients Try to maintain the existing access as far as possible Fibrin sheath stripping is often underutilized Armamentarium for the catheter exchange should be ready

18. TEAM MANIPAL M – M aintain the existing A ccess as far as possible N – N o Methods are foolproof I - I ncrease the usage of fibrin sheath stripping P – Permcath are never a P ermanent solution A – A ttention towards permanent access L – L ifelines for most patients CONCLUSION