Pitfalls in pushing fistulas ----

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1 Pitfalls in pushing fistulas ---- An argument for more grafts Marc Webb, MD, FACS Michigan Vascular Access, PC March 27 th, 2009

3 Vascular Access for Hemodialysis Basic facts - the need for Access Hemodialysis is a life-sustaining treatment that must be provided on a regular basis Vascular access is essential for the provision of dialysis - no blood flow, no hemodialysis Disruptive and life-threatening loss of access occurs frequently in the dialysis population Problems with dialysis access is the leading cause of morbidity and dissatisfaction

4 Vascular Access for Hemodialysis Basic facts - new patients 96,000 new patients are added each year Half of new patients will need a catheter to initiate dialysis and then get their permanent access placement 10% of grafts and 30% of fistulas require secondary procedures prior to usability Vascular access is responsible for 25-30% of ESRD costs - $1.5 billion dollars in 1998 (!!!)

5 The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI 1997) Created a framework of evidence-based guidelines and benchmarks to clarify best-practices in the provision of Vascular Access

6 The DOQI three key points toward better care Avoiding central catheterization, thus avoiding loss of central patency Maintenance of existing access by detecting impending failure and prompt intervention Maximizing creation of fistulas as the best long-term access

7 NVAII The National Vascular Access Improvement Initiative Mission Statement (1) To increase the likelihood that every eligible patient will receive the most optimal form of vascular access (in the majority of cases an AV fistula); and (2) that vascular access complications will be avoided through appropriate access monitoring and intervention

8 The traditional case for superiority of fistulas Relatively minor tissue trauma Best long term patency 1 yr) Tolerates low blood pressure (systolic BP <100 mm Hg) Low infection rate (< 1%/yr) Low incidence of Steal Syndrome (<2%)

9 The problem with fistulas Greater rate of primary failure with fistulas 50-60% maturation of fistulas being reported recently Reports of increased prevalence of catheters and prolonged duration of catheterization More maintenance and maturation procedures are being required More and more tissue trauma required with advanced fistulas (superficialization/transposition) More central venous damage due to prolonged catheterization

10 Central venous stenosis The sad consequence of catheters left in too long

26 Stented subclavian

27 Ten month follow-up - the fourth reintervention

28 Delays and problems in creating fistulas

29 Problems in achieving functional fistulas on the venous side Most people have vessels that are intrinsically small and have to grow This process of growing the veins takes weeks or months and sometimes they just don t grow Venous depletion or injury due to IV catheters and PICC lines can preclude or doom the process Depletion of veins due to previous accesses Central venous stenosis due to prolonged catheterization, pacemaker or AICDs

30 Venous variation at the elbow

32 Clot in basilic vein

35 Problems in achieving functional fistulas on the arterial side Intrinsically small arteries small stature, female gender Congenital variation - high bifurcation Vascular disease diabetes, lupus, systemic atherosclerosis Deficits due to previous accesses

36 Arteries at the elbow Normal and variant high bifurcation

37 Ultrasound examination of brachial artery (high bifurcation)

38 High bifurcation of the brachial artery

39 Brachial artery disease

40 Outcome fistulas in the obese maturation rates type total released usable pend fail/sac lost/exp AVF, wrist % AVF, forearm % AVF, brachiocephalic % simple fistulas - total % brachiocephalic by transposition % brachiocephalic, superficialized % one stage BVT % two stage BVT % complex fistulas - total % overall totals %

41 Outcome - 90 fistulas in the elderly maturation rates type overall released %usable pending fail/sac lost/exp AVF, wrist % AVF, forearm % AVF, brachiocephalic % simple fistulas - total % brachiocephalic by transposition % brachiocephalic, superficialized % one stage BVT % two stage BVT % complex fistulas - total % totals % 3 9 7

42 The elderly with and without complex fistulas catheter simple complex graft catheter simple complex graft 61% fistulas 37% fistulas

43 Complex fistulas Superficialized and transposed fistulas Are they wonderful or not?

44 Transposed Brachial-Basilic Fistula

45 Completed Transposed Basilic Fistula

55 Superficialization of existing fistula

56 Superficialization before and after

57 Superficialization of existing fistula

58 Superficialization of existing fistula

59 Superficialization of existing fistula

60 Repairing ring in fistula

61 Repaired ring of fistula

62 Branch venoplasty of fistula

63 Branch venoplasty of fistula

64 Percutaneous venoplasty of fistula stenosis

65 Percutaneous venoplasty of fistula stenosis

66 Percutaneous venoplasty of fistula stenosis

67 Percutaneous venoplasty of fistula stenosis

69 Time to release of transposed basilic fistulas versus Artegrafts BVT above previous access (37) 37.2 days BVT one-stage naïve (62) 51.4 days BVT two-stage (110) 123 days Artegrafts (60) days

70 The argument for a graft in selected patients Lower failure rate, more predictable results Earlier availability leading to shorter central venous catheterization, and thus: Lower risk of central venous stenosis Eliminate need for maturation procedures Less tissue trauma than transposed fistulas More versatile in configuration

71 Forearm loop graft

72 Arm graft

73 Arm loop graft

74 Venaflo with Carbon eptfe

75 Almost a fistula - the Procol bovine mesenteric vein prosthesis

76 The Artegraft

77 Conclusions Central stenosis Central venous stenosis is the most common, most serious and most ignored limiting factor in dialysis Loss of central patency can be fatal Reducing duration of central venous catheterization and preventing loss of central patency is the most important goal, not what type of material is used for the conduit

78 Conclusions Graft versus fistula A good fistula is better than a good graft A good graft is better than a bad fistula Patients not yet on dialysis can afford a long development phase - patients with a central catheter cannot afford to keep it too long Surgeons should be more aware of the passage of time, and should be more willing to use a graft to get the catheters out in time

79 Conclusions Graft materials Shifting the paradigm back toward grafts is aided by the development and promotion of better techniques, and better graft materials Less thrombogenic, less infection prone, and more biologically compatible grafts may be the answer we need For the last six months I have been using the Artegraft for all of my grafts and questioning my dialysis access algorithms re fistulas.

80 I am Marc Webb, and I approve this message

81 The End

2006 NKF-DOQI Guidelines Preferred Vascular Access Order 1. Radiocephalic (wrist) fistula 2. Brachiocephalic (elbow) fistula 3. Basilic vein transposi

2006 NKF-DOQI Guidelines Preferred Vascular Access Order 1. Radiocephalic (wrist) fistula 2. Brachiocephalic (elbow) fistula 3. Basilic vein transposi Stage 5 Chronic Kidney Disease Assessing the Results of AV Access: Realistic Outcomes in 2009 Sean P. Roddy, MD Albany, NY Defined as a GFR