Vascular Access Options for Apheresis Medicine

Size: px

Start display at page:

Download "Vascular Access Options for Apheresis Medicine"

Tracy Norman
5 years ago
Views:

Vascular Access Options for Apheresis Medicine Josh King, MD Divisions of Nephrology and Medical Toxicology University of Virginia September 21, 2018

1 Vascular Access Options for Apheresis Medicine Josh King, MD Divisions of Nephrology and Medical Toxicology University of Virginia September 21, 2018 Disclosure I have no personal or professional financial relationships or interests with any proprietary entity producing healthcare goods/or services 1

2 Objectives Review available types of vascular access for apheresis Discuss complications of various types of vascular access for apheresis Compare indications for different vascular access options for apheresis Let s start with math! 2

increase resistance to flow 16-fold (clotting, etc.

3 Blood Flow Poiseuille s Law Blood Flow For blood flow, diameter is paramount Decrease in radius by 50%: increase resistance to flow 16-fold (clotting, etc.) Length of catheter matters less Twice as long, half the flow 3

4 Apheresis vs Hemodialysis Conventional HD BFR ml/min Apheresis BFR 150 ml/min CRRT BFR ml/min Access Types Peripheral veins Temporary CVCs Tunneled CVCs Arteriovenous fistulas 4

5 Golestaneh L, Mokrzycki, MH. J Clin Apher 2013; 28:

6 Peripheral Access Most useful for short-term Harvesting Intermittent (not daily or QOD) Total duration of treatments <3 weeks Flow: lowest Centrifugal machines only Complications: least Ultrasound access? Obtaining peripheral access Ideally 16G (or 15G) access and 16-18G return Nurse skill is key Patient selection Frequent hospitalizations with IVs? Habitus? Adult or pediatric? Prewarming access site Pre-hydration by patient 6

7 Temporary CVCs Triple lumen catheters PICC or midline Temporary CVCs Hemodialysis catheters Multiple brands Can support very fast flow Short-term: up to 2 weeks Emergent procedures Many providers can place 7

8 Temporary CVCs Site IJ; subclavian; femoral Stiff vs flexible Ease of insertion Vascular injury risk Multiple indications? E.g., TTP, GPA: need for dialysis as well as apheresis Tunneled HD/apheresis CVCs Medium (>2 weeks) to long-term Interventional Radiology, Surgery, Interventional Nephrology Lower infection rates Higher patency rates Need for outpatient line care Long-term: Venous stenosis 8

9 Tunneled ports Single or dual-lumen Single-lumen: need bilateral Dual-lumen: one catheter, but cosmetic issues and higher clotting rate Smaller lumen than dialysis catheters 9

10 10

11 Hemodialysis Catheters Protrude through skin Greater infection risk Weekly line care needed Short or long-term Can be used for dialysis Fast flow Apheresis ports Subcutaneous: QOL better Fewer infections Little line care needed Long-term only Only used for apheresis Slower flow Ports vs Dialysis Catheters Catheter complications 11

12 Insertion complications Apheresis catheters: ~1-2% rate Vascular Hematoma Arterial puncture Vascular injury Line migration Golestaneh L, Mokrzycki, MH. J Clin Apher 2013; 28: Gandhi and Tournade. Cath Lab Digest, 24;11 - November

13 Gandhi and Tournade. Cath Lab Digest, 24;11 - November 2016 Insertion complications Pulmonary Pneumothorax Pneumomediastinum Cardiac Dysrhythmias Wikimedia Commons: 13

14 Temporary CVC risk Parenti et al. N Engl J Med 2015; 373: ICU only Late complications Indian J Crit Care Med Jan-Mar; 16(1):

15 Late complications Late complications 15

CLABSI: CDC recommendations Educate and train healthcare personnel who insert and maintain catheters Maximal sterile barrier precautions for CVC insertion Avoid routine replacement of CVCs as a

16 CLABSI: CDC recommendations Educate and train healthcare personnel who insert and maintain catheters Maximal sterile barrier precautions for CVC insertion Avoid routine replacement of CVCs as a strategy to prevent infection Catheter troubleshooting My catheter isn t flushing! Positioning Saline flush Reversal of ports tpa 16

17 After tpa Before tpa Catheter troubleshooting Fibrin sheath stripping or disruption Catheter exchange 17

18 Large fibrin sheath with SVC occlusion After fibrin sheath disrupted Catheter troubleshooting Kidney Int Dec;78(12):

19 Catheter troubleshooting Kidney Int Dec;78(12): Line Care Catheter locking Citrate: fewer bleeds in most studies Heparin: risk of HITT Tego caps: saline Patient responsibilities for follow-up Vein preservation strategies Removal: pressure dressing, watch for infection 19

20 Passero et al. Journal of Clinical Apheresis 30:22 27 (2015) Line removal Inpatient: Trendelenburg, minutes pressure Outpatient: Pressure dressing for 24 hours 20

21 AV fistula AV fistula For long-term access (years) Vascular surgery Upcoming: noninvasive fistula creation Grafts vs fistulas 6+ weeks to patency (AVG: 2 weeks) Need for revision not uncommon (extrapolation from ESRD; caveat emptor) Location: radiocephalic > other 21

AV fistula maturation KDOQI: Rule of 6 Flow >600 ml/min Diameter 6 mm No more than 6 mm deep from skin Discernable margins Average time is 6-8 weeks; some

22 AV fistula maturation KDOQI: Rule of 6 Flow >600 ml/min Diameter 6 mm No more than 6 mm deep from skin Discernable margins Average time is 6-8 weeks; some fistulas may be ready in 1 month AV fistula access Nursing expertise is paramount Start with smaller gauge needles (17G) Work up to 14-15G Sharp vs blunt needles 22

23 Fistula Complications Bleeding Clotting Ischemia / steal syndrome Fluid collections and infection AV fistula complications 23

24 AV fistula complications Fistula Bleeding Bleeding happens for a reason Mechanical reasons? Anticoagulation? Uremia? 24

25 25

26 Fistula Bleeding Who to call? Vascular Surgery, Renal What to do? 1. Hold pressure 2. Consider anticoagulation reversal 3. Gelfoam / Surgicel 4. Topical thrombin Fistula Complications What to do? 5. szk#t=140 26

27 AV Fistula Monitoring Access flow monitoring Regular follow-up to ensure patency Apheresis provider, nephrologist, or vascular surgeon Ideally, physical exam of fistula monthly if procedures are less frequent (this can be by apheresis nursing staff) AV Fistulas Infection risk much lower Fewer complications Cosmetic issues Surgical procedure Lead time before start Reversal more difficult Access experience a must Laceration risk (rare) Use for dialysis if needed CVCs (ports or HD catheters) Higher infection risk Higher complication rates Vessel patency over time Much easier to place Immediate use Reversal comparatively easy Line care Less training to access Fistulas vs CVCs 27

Fistulas vs CVCs For indefinite need for apheresis (years expected) If personnel available who can access If patient is a good surgical candidate AVF is probably superior in most ways Extrapolation

28 Fistulas vs CVCs For indefinite need for apheresis (years expected) If personnel available who can access If patient is a good surgical candidate AVF is probably superior in most ways Extrapolation from hemodialysis Fistula troubleshooting Clotted fistula: needs urgent evaluation Risk of loss of access Fistula with higher access pressures or prolonged bleeding Refer for fistulogram (typically IR) 28

29 Fistula troubleshooting Patient complaining of hand numbness, coldness, pain Dusky discoloration (or outright gangrene) on fingertips Urgent surgery evaluation Bypass procedure (or ligation) Patients with Difficult Access Tunneled femoral lines Groin AVF or AVG HeRO grafts Translumbar, transhepatic, and more exotic lines 29

30 HeRO grafts Translumbar lines 30

group to help with vascular access If apheresis need is >2 years (or >1 year with

31 Take-Home Points Use peripheral access when appropriate Use the smallest line possible Use the line with the least complications Find an interested partner / group to help with vascular access If apheresis need is >2 years (or >1 year with poor access) consider a fistula sooner rather than later Question time 31

Victoria Chapman BS, RN, HP (ASCP)

Victoria Chapman BS, RN, HP (ASCP) Considerations: Age Sex Body Composition Hydration Status Chemotherapy Use Access History Considerations: Immunosuppression Use Chemotherapy Frequency of plasma exchanges