ASDIN 9th Annual Scientific Meeting

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Can Interventional Programs (IN) Help Popularize Home Dialysis Therapies? Gerald Beathard State of the Art Lecture ASDIN Washington, DC February 16, 2013 Stephen R.

Lafayette, Indiana Clinical Associate Professor, Indiana University Medical School Adjunct Associate Professor, Purdue University Past President of ASAIO, ASDIN 2 and Secretary-Treasurer of IFAO

1 Can Interventional Programs (IN) Help Popularize Home Dialysis Therapies? Gerald Beathard State of the Art Lecture ASDIN Washington, DC February 16, 2013 Stephen R. Ash, MD, FACP Indiana University Health Arnett and WellBound, Inc. Ash Access Technology and HemoCleanse, Inc. Lafayette, Indiana Clinical Associate Professor, Indiana University Medical School Adjunct Associate Professor, Purdue University Past President of ASAIO, ASDIN 2 and Secretary-Treasurer of IFAO Promoting Home Dialysis Therapy is Important Because These Patients are Healthier and Happier The therapy is more nearly continuous and less physiologically stressful Blood and peritoneal fluid access is a challenge for patients, but met with increasing experience The support by the dialysis center is much more one-on-one providing more continuity of care Access placement and maintenance is done by a staff familiar to the patient and center Peritoneal dialysis is a successful therapy that provides greater satisfaction to the patients Decreasing UFR Diminishes CV Mortality, Even On 3/week Treatment Schedule 1

Continuity of Care and Procedures Done by IN will Increase Success of Home Dialysis Therapies Placement of PD Catheters by IN Grows the Home Dialysis Population Urgent start dialysis eases transition

2 Continuity of Care and Procedures Done by IN will Increase Success of Home Dialysis Therapies Placement of PD Catheters by IN Grows the Home Dialysis Population Urgent start dialysis eases transition from uremia to chronic dialysis Embedding the External Portion of the PD Catheter Makes Planning for Dialysis Therapy Easier Vascular Mapping by IN Promotes Successful Creation of Fistulas in Appropriate Patients and Grafts in Other Patients Physical Examination and Early Intervention Promotes Greater Fistula Success Surveillance of Fistula and Graft Function Promotes Timely Use of Intervention to Prolong Access Function Declotting Fistulas Often Provides a Workable Access for Many Months Improvements in Vascular Access Technology Come Mostly from Nephrologists and Nephrology Nurses Placement of PD Catheters by IN Grows the Home Dialysis Population Four Methods of Placement of Tunneled PD Catheters 1.Dissection (surgical) 2.Peritoneoscopic (local procedure, with 2.2 mm diameter scope), with ultrasound examination 3.Seldinger technique (further developed to fluoroscopic technique 4.Laparoscopic (general anesthesia with 5 or 10 mm diameter scopes) 2

3 Surgical Implantation Methods of placing PD Catheters: Surgical (dissection) Peritoneoscpic Implantation Steps of Implantation Y-Tec Peritoneoscopic System Peritonescopic Placement with 2.2 mm diameter scope, Single Puncture Technique Slide Courtesy of MediGroup, Inc. Slide Courtesy of MediGroup, Inc. 3

Purpose of viewing peritoneum through the peritoneoscope: * confirm intraperitoneal position

parietal peritoneum * find direction for Quill guide that avoids adhesions and large loops of

placed catheters to determine if there were mechanical problems * photograph unusual findings

of Tenckhoff catheter survival according to the technique of placement, peritoneoscopic versus

4 Purpose of viewing peritoneum through the peritoneoscope: * confirm intraperitoneal position of cannula after first puncture * after air inflation, assure Quill guide is adjacent to the parietal peritoneum * find direction for Quill guide that avoids adhesions and large loops of bowel * direct catheter through Quill along previously inspected course * observe previously placed catheters to determine if there were mechanical problems * photograph unusual findings using high intensity light source Deep cuff in rectus Fluroscopic Placement Kaplan-Meier plot of Tenckhoff catheter survival according to the technique of placement, peritoneoscopic versus surgery. Gadallah et al. Am J Kidney Dis 33:120, Blind (needle, guidewire and splitsheath) 4

In a randomized study, fluoroscopic placement gave equal long term PD catheter survival as laparoscopic placement,

At one RMS center beginning placements just after training with fluoroscopic placement mostly, early success was

Excellent Results Slide Courtesy of Dr. John Crabtree Omentopexy as described by Dr.

5 In a randomized study, fluoroscopic placement gave equal long term PD catheter survival as laparoscopic placement, but with fewer complications (esp peritonitis) Early catheter success rate is 98% or above in published series. At one RMS center beginning placements just after training with fluoroscopic placement mostly, early success was 99% Laparoscopic Placement Laparoscopic Placement with Omentopexy, Downward Tunnel and Adhesiolysis Also Gives Excellent Results Slide Courtesy of Dr. John Crabtree Omentopexy as described by Dr. John Crabtree, when large amounts of omentum are seen. Slide Courtesy of Dr. John Crabtree Longitudinal rectus tunneling as described by Dr. John Crabtree 5

Urgent start dialysis eases transition from uremia to chronic dialysis Crabtree, 2010 a decision was made whether the patient needed immediate

Embedding the External Portion of the PD Catheter Makes Planning for Dialysis Therapy Easier Advantages: Placement performed when the patient

Avoids need for care of the exit site and catheter flushes before dialysis is implemented Makes initiation of dialysis an easier decision,

Implantation Tools Catheter Burying Procedure Also called Moncrief-Popovich Technique for burying catheters The external limb of the catheter

6 Urgent start dialysis eases transition from uremia to chronic dialysis Crabtree, 2010 a decision was made whether the patient needed immediate PD therapy. If so, the patient was placed on in-center intermittent PD 3 times per week based on a protocoldriven Prescription. Embedding the External Portion of the PD Catheter Makes Planning for Dialysis Therapy Easier Advantages: Placement performed when the patient and physician decide that dialysis is inevitable but in the future Allows the cuffs of the PD catheter to seal for weeks to months before use Avoids need for care of the exit site and catheter flushes before dialysis is implemented Makes initiation of dialysis an easier decision, involving only a procedure done under local anesthesia to provide a workable catheter. Implantation Tools Catheter Burying Procedure Also called Moncrief-Popovich Technique for burying catheters The external limb of the catheter is buried under the skin at the time of the implantation procedure. The external limb is exteriorized weeks to months later when dialysis is needed. Drawings courtesy of Dr. J.H. Crabtree. Slide Courtesy of MediGroup, Inc 6

Alternate approach: after peritoneoscopy, I reassemble the Quill, Cannula and Trocar embed

components, and catheter must be shortened, filled with heparin and plugged Why

the PD Population Improved or at Least Equal Outcomes to Other Techniques Improved

Dialysis Unit to Procedure Room Availability to Perform Procedures in Timely Manner Improved

Procedure and Devices Satisfaction in Training and Career An Economically Neutral to

7 Alternate approach: after peritoneoscopy, I reassemble the Quill, Cannula and Trocar embed the catheter through the single exit site NOTE: not an FDA approved use of the Y-Tec components, and catheter must be shortened, filled with heparin and plugged Why Nephrologists Place Peritoneal Catheters Nephrology PD Catheter Placement Leads to Growth of the PD Population Improved or at Least Equal Outcomes to Other Techniques Improved Diagnosis: Doing it Adds Understanding Continuity of Care: Procedure Room to Ward to Dialysis Unit to Procedure Room Availability to Perform Procedures in Timely Manner Improved Treatment Options for Every Patient Motivation for Continued Improvement of Performance and Procedure and Devices Satisfaction in Training and Career An Economically Neutral to Positive Step Peritoneal Dialysis Program will grow Vascular Mapping by IN Promotes Creation of Fistulas and Grafts in Appropriate Patients 7

8 Physical Examination and Early Intervention Promotes Greater Fistula Success, Especially When the Same Physician Does Both Surveillance of Fistula and Graft Function Promotes Timely Use of Intervention to Prolong Access Function 8

9 Declotting Fistulas Often Provides a Workable Access for Many Months Improvements in Vascular Access Technology Come Mostly from Nephrologists and Nephrology Nurses and Vascular Access is the Achilles Heel of Dialysis 9

Statue of Achilles Dying at the Corfu Achilleion Achilles heel

it Innovations in Vascular Access Come Principally From

Buttonhole technique De-clotting fistulas Acute central venous

dialysis, new designs Tunneled and Cuffed PD catheters

creating fistulas New options for dialysis access My own

10 Statue of Achilles Dying at the Corfu Achilleion Achilles heel gave him no problem until people started sticking things into it Innovations in Vascular Access Come Principally From Nephrologists and Vascular Access Nurses AV Fistula AV grafts Buttonhole technique De-clotting fistulas Acute central venous catheters for dialysis Tunneled central venous catheters for dialysis, new designs Tunneled and Cuffed PD catheters Embedding PD catheters Suture-less end-to-side anastomosis for creating fistulas New options for dialysis access My own current projects in vascular access And we still have time for what matters most 10

Troubleshooting the Dysfunctional PD Catheter

Troubleshooting the Dysfunctional PD Catheter ASDIN Annual Scientific Meeting Phoenix, Arizona February, 2014 Corporate Relationships in PD Area-Dr. Ash Developed Y-Tec System for placing PD catheters