Vascular Access creation in the US A surgical perspective. Surendra Shenoy M.D., Ph.D. Section of Transplantation Department of Surgery

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1 Vascular Access creation in the US A surgical perspective Surendra Shenoy M.D., Ph.D. Section of Transplantation Department of Surgery

2 Disclosures No specific disclosures pertaining to the topic of presentation

3 Vascular Access in US Surgical perspective.. Background 50 th Anniverseryof Internal (access) shunts Cimino Appel Brescia Brescia XXX Cimino XXX Appel XXX Cimino Appel Brescia Brescia MJ, Cimino JE, Appel K, Hrwich BJ NEJY;1966:1089

4 Vascular Access in US Surgical perspective Background Health care changes in US: Impact on VA Social Security Amendments 1972 All persons with ESRD eligible for medicare Assured reimbursement Improved access to healthcare Increased experience better care and longevity Physician s Behavioral change Patient profile: elderly, diabetics, co morbidities Beneficiaries 10,000 (1970) to >150,000 (1990) USRDS ADR Ch XII 1994

5 Vascular Access in US Surgical perspective. Fistulae better than shunts Need for anatomic suitability Maturation period Uncertainty of success Biologic Xenografts Cross linked Bovine carotid artery (Artegraft, Artegraft Inc) AVF Background Problems with vascular access Cross link Non cross linked non antigenic AVG Allograft Human Umbilical vein (Biograft, Meadox Meds) - Saphenous vein Synthetic 1976 Non cross linked - eptfe Cryopreserved (1985) antigenic Multitudes of sites with very little technical changes Snuff box, high & low wrist fistula, brachiocephalic, Gracz AVF, basilica transposition UA, basilic transposition FA No attention paid to cause of failure no need due to short longevity

6 Vascular Access in US Surgical perspective. Background US ESRD population (200,000) Japan ESRD (175,00) European ESRD (30,000) NKF-KDOQI (1995) Fistula First (2003) ~ 80% AVG ~ 85% AVF ~ 80% AVF Access population differences Access modality differences Outcome differences Goodkin DA et.al. JASN 2003; 14: 3270 Schena FP Kidney Int 2000; 57: S39-45

7 Strategies to improve ESRD mortality Decreased BP Decreased LVH (2000-present) RAS inhibitors, statins, BP control, Phos control, fluid control etc. Increased dialysis dose Improved QOL Phos control Quality of dialysis depends on functioning of vascular access AVG, Catheters and AVF Better nutrition Williams AW. AJKD 2004;43:90 Kliger AS. CJASN 2009;4:S121

8 Vascular access practice patterns Access performed by well-trained surgeons Surgeons trained in graft era Minimal experience in AVF Access = joining a vein/graft to artery High rates of primary failure TDC prevalence Origin and proliferation of image guided procedures and devices and catheter industry Adaptation of medical community to changing practice pattern Dember LM et.al. JAMA 2008;299: Lacson E, et.al. AJKD 2007; 50:379-95

9 Individual data AVF 79% AVG 21% Functional AVF maturation 81.7% Committed to catheter 3.5% AVF maturation (ITT) 72% 1 yr. Primary patency 42.5% 1 yr. Secondary patency 81.8 % Median (range mon) followup 36.1 mon AVF procedures per functional year 0.68 Patient outcome >85% AVF

VA creation: Changing outcome Richardson AI et.al. JVA 2009; 10: 199-02 Dember LM et.al. JAMA 2008;299:2164-71 Jennings WC.

10 VA creation: Changing outcome Richardson AI et.al. JVA 2009; 10: Dember LM et.al. JAMA 2008;299: Jennings WC. Arc Surg 2006; 141:27-32 Lucas J. J Vasc Surg 2016;

11 VA surgical practice patterns Large Academic Medical center ~ 300 cases in 1 year by 8 surgeons 2 Surgeons performed >60% of procedures These surgeons performed >80% AVF One recent trainee also performed >80% AVF Other surgeons performed AVF ~ 50% patients Patterns reflect a changing practice patterns showing improvement in training and importance of access champions Vachharajani N,et.al. J Vasc Surg 2015: s1-s4

12 VA patterns in incident patients CMS 2728 & crown web data 2013 Catheter 20% 80% 17% AVF 65% USRDS 2015

13 Vascular access surgical training Vascular Board certification data 300% increase in AVF (5 in 2003 to 18) VA is considered a resident case 19 residents graduated between Required vascular cases 44 Average AVF/AVG(range 11-73) 33 Revisions (range 1-27) 11 Trainees interested in VA 62 Eidt JF. JVS 2011; 53: Current surgical training provides ample opportunity Vachharajani N,et.al. J Vasc Surg 2015: s1-s4

14 What are some issues? Difficulty to make AVA attractive High rates of failure Lack of scientific understanding Lack of innovative research Multidisciplinary nature of the practice Fragmentation of care Lack of advocacy

15 Physiology: AVA maturation & failure Central outflow Capacity of the pump diameter, stiffness & length of the tubes determines the flow Inflow Peripheral Outflow NAS (Needle access Segment) AVG is NAS of the circuit Stenosis is the cause for majority of access circuit failure

16 Where we are now? Total ESRD population ~661,648 Hemodialysis (91%) ~421,000 Peritoneal Dialysis (9%) ~ 45,000 Post transplant ~ 193,000 ~ 117,000 patients started dialysis in 2012 Growing patient population will propel changes in the field USRDS 2015

17 Summary Surgical problems associated with vascular access were part of the evolution of the speciality. The current eduction system is robust enough to adjust the need of the changing practice patterns. There is a need for better understanding and research in the field to improve the current outcome Increasing prevalence of ESRD will continue to fuel the progress and innovation

18 Vascular Access creation in the US A surgical perspective

KDOQI Guidelines. Overview. Predicting Successful Fistula Maturation Warren Gasper MD UCSF Vascular Surgery Fellow 2011 UCSF Vascular Symposium

KDOQI Guidelines. Overview. Predicting Successful Fistula Maturation Warren Gasper MD UCSF Vascular Surgery Fellow 2011 UCSF Vascular Symposium DISCLOSURES: NONE Predicting Successful Fistula Maturation Warren Gasper MD UCSF Vascular Surgery Fellow 2011 UCSF Vascular Symposium KDOQI Guidelines AV fistulas have better outcomes than grafts or catheters