UC SF. End Stage Renal Disease. National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) BUT-- No Cephalic Vein What s Next

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Dana Underwood
6 years ago
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1 No Cephalic Vein What s Next End Stage Renal Disease Charles Eichler MD Clinical Professor of Surgery Division of Vascular Surgery UCSF April 5, 2014 Population of patients with ESRD growing rapidly - Over 341,000 pts currently undergoing dialysis in US - ESRD program consumes over $28 billion creation/maintenance of vascular access exceeds $1 billion/year Over 150,000 new access created /year National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) Clinical practice guidelines for vascular access developed by consensus of experts in 1997 Primary AVF should be constructed in at least 50% of all new kidney failure patients electing to receive HD as renal replacement therapy Ultimate goal is to achieve autogenous access rate of 40% for prevalent U.S. HD patients BUT-- Are we trying too hard to do an av fistula? Are we leaving patients with long term TDC in the process of creating av fistulas that don t mature? What if there is no good cephalic vein??? 1

Long Term Tunneled Catheters Patency Rates Considered last access option Primary patency-intervention free Accounts for 20-40% of pts in most centers Assisted primary patency-intervention without

2 Long Term Tunneled Catheters Patency Rates Considered last access option Primary patency-intervention free Accounts for 20-40% of pts in most centers Assisted primary patency-intervention without thrombosis Leads to central vein stenosis/occlusion Secondary patency-salvage after thrombosis Changing the access from TDC reduces mortality risk 50% Inadequate maturation-avf unable to flow 400cc/min Goal to get av access & D/C TDC fistulas are more durable & less prone to infection than av grafts Increase in overall risk of mortality Fistula vs TDC 53% Fistula vs graft 18% 2

3 Fistulas come with a price Downside to Fistula First Up to 60% of primary fistulas fail to mature East Virginia U-JVS 2008 Angiographic procedures are frequently required to obtain maturation Longer dependency on TDC 80 new esrd pts in 6 mo period 26 RCAVF/54 BCAVF f/u<1 yr 48% used Only 11% matured without intervention 37% abandoned Selecting the appropriate patient for the appropriate access is the priority to maximize access functionality and minimize patient morbidity Planning AV Access Hx and PE look at arteries & veins Most/all patients will require imaging of venous anatomy Patient not on HD yet but with renal insufficiency - ultrasound vein mapping Patient already on HD - upper extremity venography - more definitive study; allows assessment of central venous system 3

4 What to do when there is no cephalic vein? Basilic vein transposition-bvt Forearm graft Upper arm graft Thigh graft Hybrid type graft for rx of central vein occlusion/stenosis BVT is first choice best results Almost never do forearm graft 4

5 BVT vs forearm loop graft 105pts randomized to bvt vs graft Primary patency 46% vs 22% Assisted patency 87% vs 71% JVS 2008 Upper arm graft Typically straight graft Immediate stick Can also use in tear drop or necklace configuration 5

6 Gore hybrid graft Combination of viabahn covered stent and ptfe graft Place through central vein stenosis 6

7 HERO graft Central Vein Occlusion Two stages Thigh graft Catheter into right atrium Hybrid approach Combine with acuseal graft for immediate use All arterial access 7

Reduce rate of FTM Consider criteria Sometimes a graft could be best

8 Conclusion Best access for the patient Identify best vein dominant arm not critical BVT next access choice Upper arm graft gore acuseal Reduce rate of FTM Consider criteria Sometimes a graft could be best option Hybrid approach HERO or Gore hybrid graft Thigh or chest graft 8

Sid Bhende MD Sentara Vascular Specialists April 28 th Dialysis Access Review: Understanding the Access Options our Patients Face

Sid Bhende MD Sentara Vascular Specialists April 28 th 2018 Dialysis Access Review: Understanding the Access Options our Patients Face Disclosures Dialysis Background Why is it important? Outline National