ASDIN 7th Annual Scientific Meeting

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Cody Robertson
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Reported incidence 1-20% Loay Salman, MD Assistant Professor of Medicine University of Miami Miller School of

1975 Rinnaert et al. Am J Surg. 1980 More common in upper arm accesses as compared to forearm accesses I.

Vascular calcification Fistula Low resistance Proximal Antegrade flow 70% of the distal fistulae >80% of the

Radiology, 1995 Asif et al. Am J Kidney Dis. 2006 Derici et al. Semin Dial. 2006 Goldsmith et al. Nephron.

1 Reported incidence 1-20% Loay Salman, MD Assistant Professor of Medicine University of Miami Miller School of Medicine Tordoir et al. J Vasc Endovasc Sur Morsy et al. J Surg Res Haimov et al. Arch Surg Rinnaert et al. Am J Surg More common in upper arm accesses as compared to forearm accesses I. Retrograde flow II.Arterial stenosis III.Vascular calcification Fistula Low resistance Proximal Antegrade flow 70% of the distal fistulae >80% of the proximal fistulae Fistula Proximal Steal Tordoir et al. J Vasc End.Sur Guerra et al. NDT, 2002 Valji et al. Radiology, 1995 Asif et al. Am J Kidney Dis Derici et al. Semin Dial Goldsmith et al. Nephron Distal Retrograde flow Distal Kwun et al: Vasc Surg 13: , 1979 De Massi et al: J Vasc Tech 18: , 1994 Duncan et al:. J Vasc Surg 4: , 1986 Then steal is not the major mechanism of hand ischemia Only a small number of patient might have excessive steal (true steal) to induce ischemia Asif et al: Am J Kidney Dis 48:88-97, 2006 Valgi et al: Radiology 196: , 1995 Asif A, Leon C, Merrill D, et al: Am J Kidney Disease 48:88-97,

Arterial stenoses can severely limit distal blood flow.

LESIONS Asif et al: Kidney Int 67:1986-1992, 2005 Duijm et al: Am J Kidney Dis 48:98-105, 2006 Using

62-100% Valgi et al: Radiology 196:697-701, 1995 Guerra et al: Nephrol Dial Transplant 17:843-851, 2002 De

hyperparathyroidism, increased oxidized lowdensity lipoprotein cholesterol, increased oxidative stress and

2 Arterial stenoses can severely limit distal blood flow. A significant number (8-10%) of patients presenting with dialysis access dysfunction have a PURE ARTERIAL LESIONS Asif et al: Kidney Int 67: , 2005 Duijm et al: Am J Kidney Dis 48:98-105, 2006 Using comprehensive arteriography, these studies have reported the incidence of arterial stenosis to range from % Valgi et al: Radiology 196: , 1995 Guerra et al: Nephrol Dial Transplant 17: , 2002 De Caprio et al: Cardiovasc Surg 5: , 1997 a c b d Vascular calcification Intima and media are affected Multi-factorial (i.e. disturbance in mineral metabolism in the uremic milieu, calciumcontaining phosphate binders, secondary hyperparathyroidism, increased oxidized lowdensity lipoprotein cholesterol, increased oxidative stress and hyperhomocysteinemia may contribute to the pathogenesis) PTA and surgery are not helpful Asif et al: Am J Kidney Dis 48:88-97, 2006 True Steal Arterial Stenosis Generalized Arteriopathy A more appropriate terms might be Distal Hypoperfusion p Ischemic Syndrome (DHIS) Leon and Asif: CJASN January

Hand pain (off and/or on dialysis) Cold hand Numbness Tissue necrosis Onset of symptoms: 8 ± 2 months from the time of access creation.

Asif et al: Am J Kidney Dis, 2006 Leon and Asif: CJASN January 2006 History & Physical exam.

without occlusion of the access) Determination of capillary refill Comparison was made with the contralateral side Asif et al: Am J

3 Hand pain (off and/or on dialysis) Cold hand Numbness Tissue necrosis Onset of symptoms: 8 ± 2 months from the time of access creation. The duration of symptoms was 2 ± 0.5 months at the time of dx. Asif et al: Am J Kidney Dis, 2006 Leon and Asif: CJASN January 2006 History & Physical exam. Non-invasive testing Digital blood pressure (DBP) Digital/ index (DBI) Digital plethysmography Duplex ultrasonography Transcutaneous oxygen saturation Invasive testing. Inspection for atrophic changes Determination of extremity temperature by palpation Pulse volume by using simple palpation p (with and without occlusion of the access) Determination of capillary refill Comparison was made with the contralateral side Asif et al: Am J Kidney Dis 48:88-97, 2006 Digital blood pressure (DBP) Digital/ index (DBI) (<0.6) specificity of only 59% and a positive predictive value of 18%. Valentine et al. J Vasc Surg Papasavas et al. Vasc Endovascular Surg Digital plethysmography Duplex ultrasonography Transcutaneous oxygen saturation Halevy et al. J Vasc Surg Leon and Asif: CJASN

Treatment of arterial lesions during same

groin cannulation) 7/10 revealed arterial

Asif et al: Am J Kidney Dis, 2006 Asif A,

Procedures that target lowering AV access

4 Angiogram/Arteriogram. Full ipsilateral arteriogram. Essential prior to any treatment plan. Diagnose arterial lesions. Treatment of arterial lesions during same procedure. ( Access cannulation vs. groin cannulation) 7/10 revealed arterial stenoses. PTA on 5/7 patients and 4/5 responded. Valgi et al: Radiology, /12 had arterial stenoses and 8/10 were treated with PTA. All 8 pts became symptoms free immediately after the treatment. Asif et al: Am J Kidney Dis, 2006 Asif A, Yevzlin AS. Semin Dial Full arteriogram (no arterial stenosis) Surgical approach: A. Procedures that target lowering AV access flow Banding Tapered graft MILLER procedure B. Procedures that augment distal arterial blood flow w/o affecting the AV access flow Distal Revascularization-interval ligation (DRIL) Revision using distal as inflow (RUDI) Proximalization of the arterial inflow (PAI) Asif A, Yevzlin AS. Semin Dial

MILLER Procedure Combines PC+Surgical Images from A.

11/18 Patients had banding. 6-month patency was only 9%.

2/5 Had PTA Sx resolved. DeCaprio et al. Cardiovasc Surg.

value of its use in decreasing DHIS. Primary patency rates were sig.

patency rates at 6 months for 4-7 mm=64% (p=0.

for 4-7 mm= 37% (p=0.004)} DeCaprio et al. Cardiovasc Surg.

, edited by Henry ML, Ferguson RM, W.L Gore and Associates, Inc.

5 MILLER Procedure Combines PC+Surgical Images from A. Samaha True results/benefits are unknown. Full arteriogram was not done. 11/18 Patients had banding. 6-month patency was only 9%. 5/18 (28%) had arteriogram and they had an arterial lesions. 2/5 Had PTA Sx resolved. DeCaprio et al. Cardiovasc Surg Goel et al: Kidney Int 70: , 2006 Studies do not support the value of its use in decreasing DHIS. Primary patency rates were sig. Lower in the tapered graft {Patency rates at 6 months for 6 mm= 85%, patency rates at 6 months for 4-7 mm=64% (p=0.01); patency rates at 12 months for 6 mm= 75%, patency rates at 12 months for 4-7 mm= 37% (p=0.004)} DeCaprio et al. Cardiovasc Surg Schaffer D: In. Vascular Access for Hemodialysis, V ed., edited by Henry ML, Ferguson RM, W.L Gore and Associates, Inc., and Precept Press; p IL DR Introduced by Schanzer in Schanzer et al. J Vasc Surg /23 Sx improved (Bypass patency was 96% at 2 years. Access patency was 73% and 46% at 1 and 2 years). Haimov et al. Blood Purif % of 53 pts Sx improved. Primary patency of the access was 93% at 1 year. Knox et al. J Vasc Surg Practice limitation (extensive, Bypass) 5

RUDI was first described by Minion et al. in 2005.

All four were patent dialyzing with the same access with a follow-up of 4-14 months. Minion et al. Ann Vasc Surg.

Primary and secondary patency rates of the AV access were 87% and 90% at one year and 67% and 78% at 3 years. Zanow et al.

6 RUDI was first described by Minion et al. in Four patients with DHIS reported resolution of symptoms following the RUDI procedure. All four were patent dialyzing with the same access with a follow-up of 4-14 months. Minion et al. Ann Vasc Surg Zanow et al PAI has been first described by Zanow et al in % of 30 patients Sx improved. Primary and secondary patency rates of the AV access were 87% and 90% at one year and 67% and 78% at 3 years. Zanow et al There are multiple causes. Risk factor modification. Full ipsilateral arteriogram as first step. Aim is the preservation of the digits/hand and controlling the Sx without sacrificing the life line (AV access). Team approach. Access ligation should be last resort. 6

Distal Hypoperfusion Ischemic Syndrome (DHIS)

Pathophysiology Traditional View ( Steal Syndrome ) Distal Hypoperfusion Ischemic Syndrome (DHIS) Steven Wu, MD Director of Interventional Nephrology Massachusetts General Hospital Harvard Medical School