Introduction. Introduction 2/3/2015 ASDIN Vascular Access complications: High associated morbi-mortality. Worsened quality of life

Size: px

Start display at page:

Download "Introduction. Introduction 2/3/2015 ASDIN Vascular Access complications: High associated morbi-mortality. Worsened quality of life"

Oscar Hudson
5 years ago
Views:

1 Introduction Vascular Access complications: Ultrasound Evaluation of the Mature AVF and Process Improvement High associated morbi-mortality Worsened quality of life Up to 2 % hospitalized Jose Ibeas M.D., Ph.D. Nephrology Department Parc Tauli Sabadell, Hospital Universitari Barcelona, Spain Costs Problems of Vascular Access: Creation: Introduction Resources: Radiological: Mapping Surgical: Mapping, Creation or Reconstruction Waiting lists Follow up: Need surveillanceprotocols Flow? Image? Treatment (Preventive) Interventionist Surgical Waiting lists Multidisciplinary requirement (Figure of Coordinator) ASDIN 201 1

2 Stenosis diagnosis capability (III): Δ Qa > 2%: S: 80% and VPP:89% Qa 00 ml/min + Δ Qa > 2%: S and VPP SIMILAR to ONLY SURVEILLANCE Graft: No patency modification AVF: Qa decrease thrombosis No patency modification No Doppler Studies Qa < 00mL/min + EF (+): SIMILAR to ONLY SURVEILLANCE Qa mL/min + Δ Qa > 2%: S: 92-9%, VPP79-86%) BETTER!!! All Qa cut-offs, separately, have similar VPP to EF and lower than DU. The increase in the cut-off remains controversial, once care increases without any clear benefit and even with potential harm (PTA of stable subclinical stenoses). Cohort: 0 patients Qa determination using vs BTM and its capability of diagnosing hemodynamically significant stenosis. NOTE: hemodynamically significant stenosis: reduction vessel lumen> 0% + increase in PSR of more than 2x (PSR in stenosis> 400 cm/s) ASDIN 201 2

3 Qa measurement by Doppler is an excellent direct method of controlling flow. Take into consideration that Qa measured by Doppler varies with several factors, including presence, location and number of stenoses. Besides Qa monitoring, the Doppler detects and characterises the stnosis with regard to its location, residual diameter hemodynamic significance. Doppler can also indicate ethiology of the stenosis. This information is crucial when taking decisions once it is known that not all stenoses involve an imminent risk of thrombosis. Post-detection repair by Doppler implied shorter procedures, fewer complicatons and were more cost efficient. 1. Pre-surgical phase 2. VA Creation 3. VA Care Chapters 4. Monitoring and surveillance. Complications treatment 6. Catheter New Spanish Guideline on Vascular Access Quality indicators 4. Monitoring and Surveillance Can Doppler, performed by an experienced examiner, replace fistulography as the gold standard for confirming a diagnosis of significant stenosis in VA? Sensitivity 89.3 % (IC 9%: %) Meta-analysis made by the Iberoamerican Cochrane group which included 7 patients in 4 studies over the last 10 years, of which 319 were diagnosed with significant stenosis by fistulography (prevalence: 42.3%). Sensitivity of Doppler ruled against fistulography for diagnosis confirmation of significant VA stenosis in patients with clinical suspicion of stenosis: 89,3 % (IC 9%: 84,7-92,6 %). (MetaAnalyst Program, ). Positive and negative predictive values of the EDC according to the prevalence of significant stenosis. Specificity 94.7 % (IC 9 %: %) PREVALENCE SIGNIFICANT STENOSIS (%) Positive predictive value (%) Negative predictive value (%) Accuracy (%) Meta-analysis made by the Iberoamerican Cochrane group, which included 7 patients in 4 studies over the last 10 years, of which 319 were diagnosed with significant stenosis by fistulography (prevalence: 42.3%). Specificity of Doppler ruled against fistulography for diagnosis confirmation of significant VA stenosis in patients with clinical suspicion of stenosis: 94.7% (9% CI: 91.8 to 96.6%). (MetaAnalyst Program, ). ASDIN 201 3

4 4. Monitoring and Surveillance 4. Monitoring and Surveillance Can Doppler, performed by an experienced examiner, replace fistulography as the gold standard for confirming a diagnosis of significant stenosis in VA? R. 4.6) It is recommended using both first and second generation methods for monitoring and surveillance AVFn R 4.2) Ultrasound is recommended first for image exploration in the hands of an experienced examiner, thereby eliminating the need for confirming via fistulography, to indicate elective treatment when significant stenosis is suspected. It is recommended that fistulography be reserved for diagnostic image exploration only in cases where results are non-conclusive and there is a persistent suspicion of significant stenosis. GEMAV advises the periodical application of second-generation screening methods (both dilutional techniques to estimate blood flow or Qa and Doppler ) to surveil the AVFn, as existing evidence indicates a benefical effect and there are no arguments against these methods in relation to thrombosis prediction and the increase in AVFn patency. 4. Monitoring and Surveillance GLOSSARY (III) Significant VA stenosis according to current or valid criteria Presence of a repeated alteration of any parametre obtained by the first- or second-generation screening methods, associated with a reduction lower than 0% of AVFn or AVFp vascular lumen proved by an imaging technique (colour Doppler or fistulography).. Complications treatment R.1.1) In the absence of any contraindication, it is recommended that all stenoses with a vascular lumen reduction equal to or higher than 0% and that fulfil stenosis criteria related to high-risk of thrombosis be treated. R.1.2) It is recommended that fistulography be performed when central venous stenosis is suspected. GLOSSARY (IV) SignificantVA stenosis accordingto the criterion proposed by the new GEMAV Reduction in the vascular lumen higher than 0% shown by colour Doppler in AVFn and AVFp with a high risk of thrombosis according to the criteria set out in Chapter 4, i.e. dependent on elective or preventive treatment. HD Unit incorporation in Situ Flow Measurement Diagnosis Angiography New concept in nephrology: Not only flow screening In situ Image control Stenosis Masses and collections Confusing or aternative collaterals Treatment prioritization Flow criteria Seriousness of stenosis: risk of thrombosis Dangerous masses: pseudoaneurisms Treatment orientation Interventionist Surgical Conservative Pre - HD -guided puncture Deep AVF or difficult to puncture Pathological AVF waiting for treatment ASDIN 201 4

Objectives Present results after creation of a Vascular Access Program based on the use of by nephrology in a multidisciplinary approach, in: Pre-surgical Mapping Early stenosis diagnosis Preventive

Estudio de 00 casos Nefrología, 2012 (32), Sup. 3, 71 Methods I. Prospectivecohorts study. Reference UniversityHospital II.

5 Objectives Present results after creation of a Vascular Access Program based on the use of by nephrology in a multidisciplinary approach, in: Pre-surgical Mapping Early stenosis diagnosis Preventive treatment Hemodialysis incidence of patients by AVF J. Ibeas, J. Vallespin, X. Vinuesa, et al Ecografia bajo protocolo en el accesovascular del pacienteen hemodialisis: del mapeo al seguimiento. Estudio de 00 casos Nefrología, 2012 (32), Sup. 3, 71 Methods I. Prospectivecohorts study. Reference UniversityHospital II. HospitalHD Unit for 14 patients, reference for 48,000 inhabitants+ Other centers III. Period: IV. Methods a) Multidisciplinary team: nephrologist, vascular surgeon, interventional radiologist and nurses. Protocol: 1. Mapping & treatment. 2 periods: initial and consolidation 1st) Physical examination and imaging study on demand by surgeon 2nd) during routine joint nephro-surgeon outpatient visit, and angiogram on demand 2. Priority of VA creation/repair: 1. Pre-dialysis by GFR or AVF stenosis degree 2. Dialysis:, VA dysfunction level or kind of catheter in patients with catheters 3. VA surveillance: by in outpatient nephrology follow up & dialysis unit 4. Treatment: By protocol. Surgery/angioplasty depending stenosis location. Surgery prioritized by creatinine clearance, VA dysfunction level or if catheter carrier. Outcomes: Patency, thrombosis, patients starting hemodialysis (HD) by AVF, patients in HD with AV reconstruction without requiring catheter, maturation failure and need for angiogram in mapping 6. Data Record: NephroCloud Our Center Referrals Follow Protocol VA request Surgeon Visit Visit Image - Indication Surgical Indication Surgery Process times Vascular Access Creation Ultrasound at joint nephrology/vascular surgery outpatient visit 10 patients 00,000 inhabitants Reference Center: - Interventional Radiology - Vascular Surgery Screening Alarm Process times Prioritization Prioritization Vascular Access Follow Up Surgeon Visit Image In Situ Ultrasound - Orientation Surgical Indication Surgery Prioritization Radiological Prioritization Confirmation Decision Interventional Treatment Treatment Protocol Surveillance Clinical Protocol Confirmation Dynamic Mapping Surgery Pre - HD HD Follow up Morphological Functional Analysis Portable Mapping Surgery Pre - HD HD Follow up Morphological Functional Diagnosis Decision Prioritization Priorization Ultrasound Angiography Treatment Screening No Pathology Treament Screening Alarms Alarms ASDIN 201

Morphological Study Anatomical trajectory Artery Anastomosis Vein Subclavia Stenosis % reduction of lumen Thrombosis Masses and

Grafts: measurementof the whole access AVF: measurementin vein and artery Artery: Better measurement in artery?

diameter, turbulence An advantage to guide the puncture efficiently?

ColourDoppler ultrasound in dialysis access. Nephrol Dial Transplant, 2004.

post-surgery by Doppler: Early intervencion lin AVF without maturation Once AVF is mature, less thrombosis Direct visualisation of

6 Morphological Study Anatomical trajectory Artery Anastomosis Vein Subclavia Stenosis % reduction of lumen Thrombosis Masses and collections Haematomas Abscesses Venous dilations Pseudoaneurisms Seromas Steal Flow Functional study Better dysfunctionpredictor Grafts: measurementof the whole access AVF: measurementin vein and artery Artery: Better measurement in artery? Artery measurement: how much is QA underestimated Vein measurement: Difficult because of curves, bifurcations, variations in diameter, turbulence An advantage to guide the puncture efficiently? Flow measurement Shape of Doppler wave Anatomical anomalies Patrick Wiese and Barbara Nonnast-Daniel. ColourDoppler ultrasound in dialysis access. Nephrol Dial Transplant, : Thrombosis Precise to directly detect thrombus in AVf and graft Early detection post-surgery Measurements post-surgery by Doppler: Early intervencion lin AVF without maturation Once AVF is mature, less thrombosis Direct visualisation of the thrombus Careful! Indirect signs are similar in thrombosis and severe stenosis Location and extension Differentiate old and recent thrombus Masses and collections Deep vein Anatomical anomalies Artery proximal to vein Collections that make puncture difficult Apparently short section for puncture ASDIN 201 6

Results AVF: n = 06, 3 Studies: 1. indicated for high or low level alarm: n=230 2. Study of Systematic Mapping vs.

7 Results AVF: n = 06, 3 Studies: 1. indicated for high or low level alarm: n= Study of Systematic Mapping vs. Physical Examination: n=247 Mapping + Surveillance: n=166 Only physical examination: n=81 3. Study of VA type on beginning HD by surgery prioritization: n=37 Age: 64.8 ± 1 y, Sex: 8% m, 42 % f Charlson Index: 7.8 Patency, total sample (n=06) Primary Assisted Patency: 1, 2 and 3 years: 74, 70 and 67 %. Maturation failure: 20% Immediate failure: 12% Tasa Thrombosis / patient / year Study by alarm of high and low level Alarm from high to low level 230 Vascular Access application reason 2% 46% 2% 7% Punction difficulty Qb VP Hemostasia Mixed Difficulties in Puncture 91% QB 0.6% VP 49.3% Hemostasis 27.27% 43% 73.8% Change in puncture area ASDIN 201 7

8 2. Study Mapping + Surveillance No Stenosis Stenosis Qb (ml/min) VP (mhg) ekt/v Hcto SBP pre (mmhg) DBP pre (mmhg) Mean SD group: 166 Mapping + surveillance Control group: 81 Mapping Vs phys.exam (n=247) Mapping: Age > 7 years Physical exam. Physical exam. Mapping: > 7 years + radial artery Total Sample (n=06): Sex Physical Exam. Female Male ASDIN 201 8

9 2/3/201 group (n=166). Sex Female Mapping: angiography need < % Male 3. Study of VA type on beginning HD Results (n = 40) J Ibeas, J Vallespin, JR Fortuño, et al. Reduction in waiting time for vascular access surgery following an computerized algorithm of clinical priorities gets 80% of starting hemodialysis by native fistula and 80% of fistula reparations on patients in hemodialysis without requirement of catheter. XLVIII ERA-EDTA Congress. Praga, June 2011 Priorities Distribution VA New VA n = 372 (82%) 1 00% Patients 9 0% 1 26 (19%) 11 (17%) 112 (81%) 3 (83%) Catheter AVF 13 (93%) 8 0% 7 0% 6 0% 0% Bridge VA n=14 (3%) Reconstruction n = 64 (1%) 4 0% 3 0% Surgical Recovery (n= 64) 9 reanastomosis In Hemodialysis = 38 Pre HD = % 1 0% 0% Pre -HD In ic io HD HD Rea n a s t AVPu en te reconstruction (In HD) Patients beginning HD by AVF (n= 138) Time between Surgery and HD Catheter AVF 1 0 0% 100% 3 9 0% 90% 2 8 0% 80% 4 7 0% 1 70% % P4 P3 P2 P1 60% 0% 10 0% 4 0% 40% 3 0% 30% % 20% % 10% 0% 3m es es 6mes es añ o 2a ños 0% < 3 months ASDIN 201 < 6 months < 1 year < 2 years 9

10 2/3/201 Conclusions Ultrasound used in Nephrology Services makes good use of the multidisciplinary team by providing the nephrologist and the nursing staff with decision-making ability in: Mapping Early diasgnosis Treatment Prioritization -guided puncture It can reduce morbility in patients with high comorbility. It should be part of the arsenal in the hands of nephrology services and learning how to use it should be included in training plans in the speciality. ASDIN

Introduction. Introduction 2/18/2015 ASDIN Vascular Access complications: High associated morbi-mortality. Worsened quality of life

Introduction. Introduction 2/18/2015 ASDIN Vascular Access complications: High associated morbi-mortality. Worsened quality of life Introduction Vascular Access complications: Ultrasound Evaluation of the Mature AVF and Process Improvement High associated morbi-mortality Worsened quality of life Up to 25 % hospitalized Jose Ibeas M.D.,