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

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1 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., 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) Surveillance advised! ASDIN

2 Stenosis diagnosis capability (III): Δ Qa > 25%: S: 80% and VPP:89% Qa 500 ml/min + Δ Qa > 25%: S and VPP SIMILAR to ONLY SURVEILLANCE Graft: No patency modification AVF: Qa decrease thrombosis No patency modification No Doppler Studies Qa < 500mL/min + EF (+): SIMILAR to ONLY SURVEILLANCE Qa mL/min + Δ Qa > 25%: S: 92-95%, 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: 50 patients Qa determination using vs BTM and its capability of diagnosing hemodynamically significant stenosis. NOTE: hemodynamically significant stenosis: reduction vessel lumen> 50% + increase in PSR of more than 2x (PSR in stenosis> 400 cm/s) ASDIN

4. Monitoring and Surveillance Chapters 1. Pre-surgical phase 2. VA Creation 3. VA Care New Spanish Guideline on Vascular Access - 2015 4. Monitoring and surveillance 5. Complications treatment 6.

Quality indicators Centro Cochrane Iberoamericano Iberoamerican Cochrane Centre Can Doppler, performed by an experienced examiner, replace fistulography as the gold standard for confirming a

3 4. Monitoring and Surveillance Chapters 1. Pre-surgical phase 2. VA Creation 3. VA Care New Spanish Guideline on Vascular Access Monitoring and surveillance 5. Complications treatment 6. Catheter 7. Quality indicators Centro Cochrane Iberoamericano Iberoamerican Cochrane Centre 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 95%: %) Specificity 94.7 % (IC 95 %: %) Meta-analysis made by the Iberoamerican Cochrane group which included 755 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 95%: 84,7-92,6 %). (MetaAnalyst Program, ). Meta-analysis made by the Iberoamerican Cochrane group, which included 755 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% (95% CI: 91.8 to 96.6%). (MetaAnalyst Program, ). PREVALENCE SIGNIFICANT STENOSIS (%) Positive predictive value (%) Positive and negative predictive values of the according to the prevalence of significant stenosis 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 4.2) 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. Negative predictive value (%) Accuracy (%) 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. As positive predictive value of Doppler, i.e. the percentage of patients actually presenting significant stenosis among those diagnosed by Doppler, progressively increases, so does prevalence of clinicalsuspicionof significantstenosis among patients. Prevalence of significant stenosis: 50 % positive predictive value of the Doppler : 94.4% and this percentageincreases as higher prevalencesare reached. ASDIN

4. Monitoring and Surveillance 4. Monitoring and Surveillance R. 4.6) It is recommended using both first and second generation methods for monitoring and surveillance AVFn.

4 4. Monitoring and Surveillance 4. Monitoring and Surveillance R. 4.6) It is recommended using both first and second generation methods for monitoring and surveillance AVFn. 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, because existing evidence indicates a beneficial effect and there are no arguments against these methods in relation to thrombosis prediction and the increase in AVFn patency. GLOSSARY (III) Significant VA stenosis according to current or valid criteria Presence of a repeated alteration of any parameter obtained by the first- or second-generation screening methods, associated with a reduction lower than 50% of AVFn or AVFp vascular lumen proved by an imaging technique (colour Doppler or fistulography). GLOSSARY (IV) SignificantVA stenosis accordingto the criteria proposed by the new GEMAV Reduction in the vascular lumen higher than 50% 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. º 5. Complications treatment R 5.1.1) In the absence of any contraindication, it is recommended that all stenoses with a vascular lumen reduction equal to or higher than 50% and that fulfil stenosis criteria related to high-risk of thrombosis be treated. R 5.1.2) It is recommended that fistulography be performed when central venous stenosis is suspected. Concept in nephrology: Not only flow screening In situ Image control Stenosis Masses and collections Confusing or alternative collaterals Treatment prioritization Flow criteria Seriousness of stenosis: risk of thrombosis Dangerous masses: pseudoaneurisms Treatment orientation Interventionist Surgical Conservative -guided puncture Deep AVF or difficult to puncture Pathological AVF waiting for treatment 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 500 casos Nefrología, 2012 (32), Sup. 3, 71 ASDIN

Our Center Follow Protocol Vascular Access Creation Referrals VA request Surgeon Visit Visit Image - Indication Surgical Indication Surgery Process times

Screening Alarm Process times Vascular Access Follow Up Surgeon Visit Image In Situ Ultrasound - Orientation Surgical Indication Surgery Radiological

Morphological Functional Analysis Portable Mapping Surgery Pre - HD HD Follow up Morphological Functional Diagnosis Decision Priorization Ultrasound Angiography

reduction of lumen Thrombosis Masses and collections Haematomas Abscesses Venous dilations Pseudoaneurisms Seromas Steal Anatomical anomalies Flow Functional

Artery measurement: how much is QA underestimated Vein measurement: Difficult because of curves, bifurcations, variations in diameter, turbulence An advantage to

5 Our Center Follow Protocol Vascular Access Creation Referrals VA request Surgeon Visit Visit Image - Indication Surgical Indication Surgery Process times Ultrasound at joint nephrology/vascular surgery outpatient visit 150 patients 500,000 inhabitants Reference Center: - Interventional Radiology - Vascular Surgery Screening Alarm Process times Vascular Access Follow Up Surgeon Visit Image In Situ Ultrasound - Orientation Surgical Indication Surgery Radiological 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 Priorization Ultrasound Angiography Treatment Screening No Pathology Treatment Screening Alarms Alarms Morphological Study Anatomical trajectory Artery Anastomosis Vein Subclavia Stenosis % reduction of lumen Thrombosis Masses and collections Haematomas Abscesses Venous dilations Pseudoaneurisms Seromas Steal Anatomical anomalies 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 Patrick Wiese and Barbara Nonnast-Daniel. ColourDoppler ultrasound in dialysis access. Nephrol Dial Transplant, : ASDIN

Results AVF: n = 506, 3 Studies: 1. indicated for high or low level alarm: n=230 2. Study of Systematic Mapping vs.

6 Results AVF: n = 506, 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=357 Age: 64.8 ± 15 years and Sex: 58% m, 42 % f Charlson Index: 7.8 Patency, total sample (n=506) 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 50.6% VP 49.35% Hemostasis 27.27% 43% 2. Study Mapping + Surveillance group: 166 Mapping + surveillance Control group: 81 ASDIN

Mapping Vs phys.exam (n=247) Mapping: Age > 75 years Physical exam. Physical exam. Mapping: > 75 years + radial artery Total Sample (n=506): Sex Physical Exam. Female Male group (n=166). Sex 3.

7 Mapping Vs phys.exam (n=247) Mapping: Age > 75 years Physical exam. Physical exam. Mapping: > 75 years + radial artery Total Sample (n=506): Sex Physical Exam. Female Male group (n=166). Sex 3. Study of VA type on beginning HD Results (n = 450) New VA n = 372 (82%) VA Patients Female Male Reconstruction n = 64 (15%) Surgical Recovery (n= 64) 59 reanastomosis Bridge VA n=14 (3%) In Hemodialysis = 38 Pre HD = 21 5 reconstruction (In HD) ASDIN

8 2/18/2015 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 1 00% 9 0% 1 26 (19%) 11 (17%) 112 (81%) 53 (83%) Catheter AVF 13 (93%) 8 0% 7 0% 6 0% 5 0% 4 0% 3 0% 2 0% 1 0% 0% Pre -HD In ic io HD HD Rea n a s t AVPu en te 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 diagnosis Treatment -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

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

Introduction. Introduction 2/3/2015 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 2 % hospitalized Jose Ibeas M.D.,