Dr. Murty Mantha MD FRACP Cairns Base Hospital Cairns. DNT 2011 Hunter Valley

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1 Dr. Murty Mantha MD FRACP Cairns Base Hospital Cairns DNT 2011 Hunter Valley

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5 Approximately 45% of AVF are functional without intervention after creation The procedure rate is procedures/avf required for maturation 1.7 procedures/access/year Once matured- revision rate range from 0.17 to 0.57 and is required in 50% of AVF

6 Long term patency AVF- prevent and correct thrombosis Ability to predict presence of stenosis prospectively Physical examination U/S Transonic flow measurements Physiological disturbances during dialysis PTA is safe, easily performed and effective Seminars in Dialysis 2004;17,

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11 Access Progression from creation to interventional maintenance Referral to renal unit Identified CKD Nephrologists CKD NP Pre Dialysis Nurse Referral to Access Nurse Ultrasound for optimal access placement Access Creation Start dialysis Investigation of low flows Ultrasound or Fistula gram Follow up post O.T. by Access Nurse Vascular access clinic Ultrasound fistula Mapping Regular Flow monitoring Intervention as indicated angioplasty / stent Ongoing Survalence

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13 Retrospective review January, 2006 and July, 2009 in a single centre 100 haemodialysis patients with dysfunctional arteriovenous access 187 consecutive percutaneous vascular procedures

14 Decreased or absent thrill Prolonged bleeding time post dialysis Increased dynamic venous pressures x 3 occasions Decreased arterial flow < 500ml/min ( transonic) Reduction of flow below 25% of base line Recirculation

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18 First PTA Second PTA 1yr 18 months 47% Primary patency rates at 6, 12, and 18 months were 72%, 55% and 47% respectively

19 1 2 Thrombosis 3 90% 18 months Secondary patency rates at 6, 12, and 18 months were 96%, 93% and 90% respectively Mean cumulative patency was 36.8 months ± SE 1.27(95% CIs )

20 Pre and post access flow studies

21 Clinical success: 93% (172 of 184 interventions) and Anatomic success: 91% (169 of 184 interventions) Complication rate was 5.9% Major complication leading to access loss occurred in one patient (0.5%).

22 Impact of vascular access programme Thrombosis rates AVF redo rates Vs primary AVF creation ( use of surgical time) Bacteraemia rates in prevalent dialysis population Procedural cost

23 135 patients in 2008 (historical control) and 125 patients in 2009 (5 grafts) Graft AVF Total TQa < 500ml/min or reduction by >25% in three months AVF episodes per patient year at risk AVG Overall (50%) NEPHROLOGY 2010; 15 (SUPPL. 4)

24 Retrospective analysis of all surgical procedures by a single vascular surgeon Jan 2002 March 2010 Time Period Total Surgery AVF Formations AVF Total Surgery Revisions and related procedures Dialysis Population Jan 2002 to May 2005 (no formal organization) May 2005 to December 2005 (OT only) January 2006 to September 2006 (OT and EVR) September 2006 to December 2008 (OT,EVR and SC) January 2009 to March 2010 (OT,EVR, SC and VAN) NEPHROLOGY 2010; 15 (SUPPL. 4)

25 Population Fisher Exact Test p = Population Fisher Exact test p= NEPHROLOGY 2010; 15 (SUPPL. 4)

26 Temporary Access Related Bacteraemia and Patient Catheter Days Patient Catheter Days(1/100 scale) Infection Number Bacteraemic episodes 16 4 p=0.001 Patient Catheter Days p= Infections/1000 Days p=0.40 NEPHROLOGY 2010; 15 (SUPPL. 4)

27 Temporary Access Related Bacteraemia and Interventional procedures, Interventional Nephrologist Number, and Vascular Access Surveillance Program with Dedicated Nurse Fistuloplasties(1/2 scale) Infection Number Nephrologist Number Access Surveillance Program with dedicated Nurse

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30 SCENARIO 1: Peripheral Angioplasty SCENARIO 2: Surgical Repair of AV Fistula SCENARIO 3: Surgical Creation of AV Fistula Prosthetic DRG AR-DRG Low Trim High Trim Extra High Cost (Incl Inlier Short Stay Long Stay Extra Long MDC Type Description Cost ALOS 5 Point Point Trim Point in DRG) Allocation per Day per Day Stay per Weight ($) ($) ($) ($) Day ($) F14C 5 S VASC PR-MJR RECONSTR-PUMP-CSCC $64 $5,783 $5,783 $982 $358 F21B 5 S OTH CIRC SYS O.R. PR -CCC $46 $7,732 $7,732 $982 $358 Z01B 23 S OR PR+DX OTH CNT HLTH SRV-CSCC $62 $2,809 $2,809 $982 $358

31 Thrombolysis + Angioplasty Repeat plasty + stent [Unit cost] $1,200 $3,300 [Unit cost] 13 x 1,200 = $15,600 2 x $3,300 = $6,600 Total cost $22,200, At the time of termination of study, duration of patency range 1-37 months. 3 Cases of fistula demise 12, 18, 19 months. None required catheter bridge. Surgical Thrombectomy/ revision- 13x7732 = $ 100,516 Cost of Catheter bridge $???

32 Conclusion An optimal outcome is likely when there is: Multidisciplinary team approach Consensus about goals among interested parties Restriction of access to interested and experienced surgeons Routine pre operative mapping and post operative surveillance and intervention Prospective tracking of outcomes with continuous quality assessment Immediate benefits include: Continuation of Dialysis Avoidance of temporary catheters Avoidance of access abandonment (In some cases) Provides increased surgical time for primary AVF creation

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