2006 NKF-DOQI Guidelines Preferred Vascular Access Order 1. Radiocephalic (wrist) fistula 2. Brachiocephalic (elbow) fistula 3. Basilic vein transposi

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1 Stage 5 Chronic Kidney Disease Assessing the Results of AV Access: Realistic Outcomes in 2009 Sean P. Roddy, MD Albany, NY Defined as a GFR <15 ml/min/1.73 m 2 requiring immediate hemodialysis Incidence by ,000 new cases Prevalence by ,000 total cases Prosthetic AV access in 2002 at 80% in US Current goal in >65% autogenous access In 2007, fistula creation outnumbered prosthetic access creation in Medicare data NKF-DOQI National Kidney Foundation began the Dialysis Outcomes Quality Initiative in 1995 Relied on evidence-based clinical guidelines Published that autogenous access has: Superior patency Fewer complications Fewer reinterventions Improve patient survival 1997 NKF-DOQI Guidelines Preferred Vascular Access Order 1. Radiocephalic (wrist) fistula 2. Brachiocephalic (elbow) fistula 3. Basilic vein transposition OR Forearm loop graft 1

2 2006 NKF-DOQI Guidelines Preferred Vascular Access Order 1. Radiocephalic (wrist) fistula 2. Brachiocephalic (elbow) fistula 3. Basilic vein transposition 4. Forearm loop graft 5. Upper arm graft 6. Chest wall graft or leg fistula/graft Radiocephalic AV Fistula (RCAVF) Meta-analysis analysis of 38 studies using RCAVF Roojiens et al, Eur J Vasc Endovasc Surg 2004 Primary failure rate of 15.3% (6-34%) Primary patency rate at one year 62.5% (54-70%) Secondary patency rate at one year 66.0% (58-73%) Age and gender were not predictive of failure Female, DM & elderly? worse outcomes Brachiocephalic AV Fistula (BCAVF) No meta-analysis analysis of outcomes at present Outcomes vary but parallel RCAVF Zeebregts et al, Eur J Vasc Endovasc Surg consecutive patients undergoing BCAVF Primary failure rate of 11% Primary patency at 1 yr of 55% & 2 yr of 40% Secondary patency at 1 yr of 79% & 2 yr of 68% Basilic Vein Transposition No meta-analysis analysis of outcomes at present Large number of recent publications Options include single stage or 2 stage Basilic vein is theoretically protected by its deeper location in the medial arm Outcomes vary but parallel RCAVF and BCAVF 2

3 Basilic Vein Transposition STUDY N 1 Patency (1 yr) 2 Patency (1 yr) Maturation Rivers NR 58% 95% Hossney NR 87% 94% Taghizadeh NR 66% 92% Rao % 47% 62% El Sayed NR 58% NR Yilmaz % 88% 86% Karakayali % 92% 98% Woo % 76% NR Chemla % 93% NR Casey % NR 74% Harper % 66% 66% MEAN 83 62% 73% 83% Autogenous AV Access Similar maturation/failure rates Similar patency rates Generally constructed in an order distal to proximal as well as simple to more complex Prosthetic Arm Grafting Prospective multicenter evaluation in the Netherlands of 53 forearm loop PTFE grafts by Keuter et al, 2008 Primary patency Primary assisted patency Secondary patency 22% at 1 year 71% at 1 year 85% at 1 year 2 thromboses within 30 days 1 untreatable Prosthetic Arm Grafting Two studies report no difference between 2 PTFE manufacturers (n=131 & n=190) Kaufman et al, 1997 & Hurlbert et al, 1998 Stretch PTFE versus standard wall PTFE Annual primary patency 58% vs. 31%, n=37 Tordoir et al, 1995 Annual primary patency 31% vs. 49%, n=108 Lenz et al, mm versus 4-7 mm taper PTFE p=ns, n=109 Dammers et al,

4 Alternative Access Sites Chest looped PTFE axillary artery to ipsilateral axillary vein loop (n=34) Kendall et al, JVS 2008 Technical early failure 9% Infection occurred 15% One year primary patency 17% One year secondary patency 59% One year survival 59% Thrombosed AV Graft Interventions DOQI recommendations Open surgical 50% at 6 months Endovascular 40% at 3 months Green et al 2002 meta-analysis analysis comparison of open surgery to endovascular methods, n=479 Open surgical had superior patency at 1, 2, 3, and 12 months compared to endovascular Sofocleous et al reviewed 579 thrombosed AV grafts treated by endovascular methods Overall technical success rate 81% Primary patency 36% at 6 months Secondary patency 67% at 6 months Patent AV Graft Interventions Prophylactic PTA of a venous outflow stenosis >50% provides no benefit to 6 months patency,n=64 Lumsden et al, 1997 Correlates with DOQI recommending PTA only in the setting of a functional or clinical abnormality Prophylactic PTA versus PTA + stent no benefit to the addition of stenting, n=58 Beathard et al, 1993 A randomized study of 43 patients comparing open repair to PTA annual patency of 65% vs. 25% Brooks et al, 1987 Infection Incidence Autogenous 0.6% to 5% per year Prosthetic 4.0% to 20% per year Bacteriology Staph aureus 32-53% Enterococci & coag (-) Staph 20-32% Polymicrobial with gram neg 10-18% 18% Staph aureus & Pseudomonas higher risk of anastomotic blowout 4

5 Infection Autogenous access Rare and few reports describe therapies all IV abx Anastomotic involvement or bleeding may require AVF ligation or segmental ligation with a prosthetic jump Prosthetic access Systemic illness or large areas of infection generally require subtotal/total excision seen in half In the other half, the infection is localized and a focal segment can be excised with jump grafting Success rates of 74% to 94% are reported Pseudoaneurysm Diffuse progressive enlargement in an autogenous access is rarely an issue Incidence of 2%-10% while prosthetic graft patent Reported at 0.49 to 0.1 per patient-year Small, stable pseudoaneurysms may resolve Anastomotic pseudoaneurysms are generally caused by infection and require intervention Pseudoaneurysm Options for repair Suture repair Segmental replacement Endovascular stent graft insertion Few reports exist that describe feasibility with early thrombosis rates up to 20% but little patency data All mention concern over use of the graft in the area treated for several weeks until scarring has occurred Venous Hypertension Central vein stenoses are increasingly more common: Pacemakers, PICC lines, Central lines, Tunneled catheters AV access placement may unmask a subclinical stenosis Symptoms of edema and high venous pressure A single center 10-year review revealed 71% incidence of subclavian vein stenosis after pacemaker insertions Another review of AICD insertions confirmed over 50% with central stenosis 5

6 Venous Hypertension Innominate vein PTA 12 month patency of 11% to 35% Innominate vein PTA and stent 12 month patency of 11% to 68% SVC PTA and stent 12 month patency of 67% Steal Syndrome Asymptomatic flow diversion is common clinical diagnosis for steal syndrome Incidence Autogenous 0.3% to 1.8% Non-autogenous 4% to 9% Risk factors Brachial artery origin Diabetes Female gender Distal revascularization interval ligation (DRIL) Described by Schanzer et al in 1988 Updated experience in % relief of symptoms in 42 patients Patency of the reconstruction 96% at 1 year Autogenous 100% versus Prosthetic 73% Huber et al in % success rate in 64 procedures 77% primary patency at 1 year 56% <30 days AVF creation 68% matured Autogenous versus Prosthetic Choice of forearm prosthetic versus upper arm autogenous AV access creation Two prospective studies in literature Pooling the 249 patients, Murad et al found a significantly lower infection rate and a trend toward improved patency at 12 months Unclear whether the failed prosthetic grafts could be converted successfully to upper arm autogenous access after forearm graft failure 6

7 Summary NKF-DOQI guidelines promote use of autogenous reconstructions over prosthetic Superior patency Fewer complications Fewer reinterventions Improve patient survival The Institute for Vascular Health and Disease Albany, NY 7