CATHETER REDUCTION. Angelo N. Makris, M.D. Medical Director Chicago Access Care

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1 CATHETER REDUCTION Angelo N. Makris, M.D. Medical Director Chicago Access Care

2 Objectives Discuss tools/techniques proven to improve AVF rates & decrease catheter rates Implement a change process in your facility to target catheter reduction in eligible patients.

3 CATHETER REDUCTION FROM AN INTERVENTIONAL RADIOLOGIST S PERSPECTIVE

4 Catheter Reduction aka. Increase Fistula Rates

5 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

6 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

7 Patient Education Everyone s Job Patients have fears, concerns, and misconceptions Will I get those bumps on my arm I like to wear short sleeves. I have a permanent catheter, why do I need a fistula? I ve been told I have small veins. They ve tried to place a fistula and it failed. Stress the positives

8 Infection Rate Risk of Infection with Various Access Types 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Nontransposed Fistula Transposed Fistula Graft Catheter

Education Relative Risk of Death by Access Type 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.

9 Education Relative Risk of Death by Access Type Diabetics Non-Diabetics Catheter Graft Fistula

10 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

11 Vein Preservation Central Veins Subclavian Vein Brachiocephalic Vein Peripheral Veins Cephalic Vein Basilic Vein Brachial Vein

12 Venous thrombosis associated with the placement of peripherally inserted central catheters. Allen AW, Megargell JL, Brown DB, Lynch FC, Singh H, Singh Y, Waybill PN. J Vasc Interv Radiol Nov-Dec;11(10): CONCLUSIONS: There is a relatively high rate of venous thrombosis associated with PICCs, particularly cephalic thrombus. Because of the high rate of thrombosis associated with these catheters, an alternative mode of access should be considered in current or potential hemodialysis patients. All patients with a history of PICC line placement requiring dialysis access should undergo upper extremity venography prior to the placement of permanent access.

13 Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Cardiovasc Intervent Radiol Mar-Apr;26(2): The purpose of this study was to determine the incidence of central vein stenosis and occlusion following upper extremity placement of peripherally inserted central venous catheters (PICCs) and venous ports. Catheter caliber showed no effect on the subsequent development of central vein abnormalities. Patients who developed new or worsened central vein stenosis or occlusion had significantly (p = 0.03) longer catheter dwell times than patients without central vein abnormalities. In order to preserve vascular access for dialysis fistulae and grafts and adhere to Dialysis Outcomes Quality Initiative guidelines, alternative venous access sites should be considered for patients with chronic renal insufficiency and end-stage renal disease.

16 Vein Preservation This is important for patients who are on dialysis, but as healthcare workers, we must think about this when caring for all patients.

17 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

22 Pre-op Access Planning Prior Failed Access Prior Catheters Prior dialysis catheters Prolonged Hospitalization/s Poor Venous Access IVDA Elderly I have small veins

23 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

24 Surgeon/Interventionalist Choice Not all doctors are created equal Familiarity with dialysis access Number of dialysis access procedures Success rates Bedside manner Willingness to educate/explain to patients

25 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

26 Promoting Access Development KDOQI Guideline A program should be in place to detect early access dysfunction, particularly delays in maturation. The patient should be evaluated no later than 6 weeks after access placement.

27 Fistula Maturation Fistula should be mature/accessable approximately 4-6 weeks from creation Refer them earlier Decreased or no thrill New fistula maturation techniques

29 Technology

30 Technology

33 Nephrol Dial Transplant Dec;16(12): Salvage of immature forearm fistulas for haemodialysis by interventional radiology.

34 Kidney Int Oct;64(4): Aggressive treatment of early fistula failure.

35 J Vasc Surg Nov;34(5): Impact of secondary procedures in autogenous arteriovenous fistula maturation and maintenance.

37 Failure to Mature xxxxx xxxxx

38 One Month F/U xxxxxx xxxxxx

39 Before & After xxxxxx xxxxx

40 Failure to Mature xxxxxxxxx

41 Several Months Later xxxxxxx

42 Before & After xxxxxxx xxxxxx

43 Failure to Mature xxxxxxxx

44 After Day 1 xxxxxxx xxxxxxx

45 One Month Later xxxxxxx xxxxxxx

46 Before & After xxxxxxx xxxxxxx

47 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

48 Vascular Access Surveillance KDOQI Clinical Practice Guideline Prospective surveillance of fistulae and grafts for hemodynamically significant stenosis, when combined with correction of the anatomic stenosis, may improve patency rates and may decrease the incidence of thrombosis.

49 Vascular Access Surveillance Guideline 4.1: Physical Examination of fistulae and grafts performed at least monthly. Routine monitoring and surveillance gives patients and caregivers the opportunity to plan interventions, avoiding emergency procedures, or worse, access abandonment.

50 Vascular Access Surveillance Guideline 4.2: Surveillance for stenosis includes direct flow measurements, or physical findings such as: (1) arm swelling (2) collateral vein development (3) prolonged bleeding (4) changes in pulse/thrill

51 Warning Signs Signs of stenosis include: - changes in thrill (loss of detection in an area) - presence of pulse (eg, throbbing) - low (or decreasing) dialysis flow rates - high dynamic venous pressure - low arterial pressure - prolonged bleeding when needles removed

52 Vascular Access Maintenance: Grafts After percutaneous thrombectomy, patency should be 40% at 3 months (KDOQI 6.8.2) After successful PTA, about 50% grafts have blood flow decreasing to initial baseline within 3 months (Murray, et al. Am J Kidney Dis 2001; 37: )

53 Primary Patency Graft 3 mo 6 mo 12 mo Median Declot 50% 31% 16% 3 m PTA 79% 57% 38% 7.5 m AVF 3 mo 6 mo 12 mo Median Declot 60% 52% 44% 8.5 m PTA 92% 77% 69% 15.2 m

54 Vascular Access Maintenance: Fistulae Pre-emptive PTA is indicated for fistulae with greater than 50% stenosis in either venous outflow or arterial inflow, in conjunction with clinical abnormalities (KDOQI 5.3) Despite PTA, the vessel wall may collapse or recoil after removal of the balloon Average time for recurrence of stenosis post- PTA is 77 days (Tonelli, et al. J Am Soc Nephrol 13: , 2002)

55 Seven Ways to Catheter Reduction Patient Education Vein Preservation Pre-op Access Planning Surgeon/Interventionalist Choice Fistula Maturation Access Maintenance/Surveillance Clotted Access

56 Clotted Access Fistulas can be declotted Avoid centers/hospitals who place catheters and reschedule the declot Choose a center that will spend the time

61 In Conclusion Most of what I told you is common sense To have a higher fistula rate, you have to place less catheters Save the Subclavians Plan Ahead A squeezeball is not the only way to mature a fistula Take care of what you have Patient education is paramount and is everyone s job

Introduction to the Native Arteriovenous Fistula: A primer for medical students and radiology residents

Introduction to the Native Arteriovenous Fistula: A primer for medical students and radiology residents Jesus Contreras, D.O. PGY-4 John Yasmer, D.O. Department of Radiology No Disclosures Objectives Introduce