Dr. Murty Mantha MD FRACP Cairns Base Hospital Cairns DNT 2011 Hunter Valley
Approximately 45% of AVF are functional without intervention after creation The procedure rate is 1.45-3.3 procedures/avf required for maturation 1.7 procedures/access/year Once matured- revision rate range from 0.17 to 0.57 and is required in 50% of AVF
Long term patency AVF- prevent and correct thrombosis Ability to predict presence of stenosis prospectively Physical examination U/S Transonic flow measurements Physiological disturbances during dialysis PTA is safe, easily performed and effective Seminars in Dialysis 2004;17, 528-534
Access Progression from creation to interventional maintenance Referral to renal unit Identified CKD Nephrologists CKD NP Pre Dialysis Nurse Referral to Access Nurse Ultrasound for optimal access placement Access Creation Start dialysis Investigation of low flows Ultrasound or Fistula gram Follow up post O.T. by Access Nurse Vascular access clinic Ultrasound fistula Mapping Regular Flow monitoring Intervention as indicated angioplasty / stent Ongoing Survalence
Retrospective review January, 2006 and July, 2009 in a single centre 100 haemodialysis patients with dysfunctional arteriovenous access 187 consecutive percutaneous vascular procedures
Decreased or absent thrill Prolonged bleeding time post dialysis Increased dynamic venous pressures x 3 occasions Decreased arterial flow < 500ml/min ( transonic) Reduction of flow below 25% of base line Recirculation
First PTA Second PTA 1yr 18 months 47% Primary patency rates at 6, 12, and 18 months were 72%, 55% and 47% respectively
1 2 Thrombosis 3 90% 18 months Secondary patency rates at 6, 12, and 18 months were 96%, 93% and 90% respectively Mean cumulative patency was 36.8 months ± SE 1.27(95% CIs 36.8-39.3)
Pre and post access flow studies
Clinical success: 93% (172 of 184 interventions) and Anatomic success: 91% (169 of 184 interventions) Complication rate was 5.9% Major complication leading to access loss occurred in one patient (0.5%).
Impact of vascular access programme Thrombosis rates AVF redo rates Vs primary AVF creation ( use of surgical time) Bacteraemia rates in prevalent dialysis population Procedural cost
135 patients in 2008 (historical control) and 125 patients in 2009 (5 grafts) 0.4 0.35 0.3 Graft AVF Total TQa < 500ml/min or reduction by >25% in three months AVF 0.069-- 0.033 episodes per patient year at risk AVG 0.4 --- 0.2 Overall 0.081 -- 0.04 (50%) 0.25 0.2 0.15 0.1 0.05 0 2008 2009 2010 NEPHROLOGY 2010; 15 (SUPPL. 4)
Retrospective analysis of all surgical procedures by a single vascular surgeon Jan 2002 March 2010 Time Period Total Surgery AVF Formations AVF Total Surgery Revisions and related procedures Dialysis Population Jan 2002 to May 2005 (no formal organization) 658 73 92 19 112 May 2005 to December 2005 (OT only) 141 24 35 11 123 January 2006 to September 2006 (OT and EVR) 123 26 28 2 134 September 2006 to December 2008 (OT,EVR and SC) 476 101 120 19 136 January 2009 to March 2010 (OT,EVR, SC and VAN) 411 59 75 26 136 NEPHROLOGY 2010; 15 (SUPPL. 4)
Population Fisher Exact Test p = 0.012 Population Fisher Exact test p= 0.002 NEPHROLOGY 2010; 15 (SUPPL. 4)
Temporary Access Related Bacteraemia and Patient Catheter Days 3930 1770 16 Patient Catheter Days(1/100 scale) 4 2007 Infection Number 2009 2007 2009 Bacteraemic episodes 16 4 p=0.001 Patient Catheter Days 3930 1770 p=0.0001 Infections/1000 Days 3.9 2.25 p=0.40 NEPHROLOGY 2010; 15 (SUPPL. 4)
Temporary Access Related Bacteraemia and Interventional procedures, Interventional Nephrologist Number, and Vascular Access Surveillance Program with Dedicated Nurse 91 65 21 38 21 31 15 16 16 6 Fistuloplasties(1/2 scale) 2003 1 2004 1 2005 1 2006 1 2007 2 2008 3 2009 2 4 Infection Number Nephrologist Number Access Surveillance Program with dedicated Nurse
SCENARIO 1: Peripheral Angioplasty SCENARIO 2: Surgical Repair of AV Fistula SCENARIO 3: Surgical Creation of AV Fistula Prosthetic 2010-11 2010-11 2010-11 2010-11 DRG AR-DRG Low Trim High Trim Extra High Cost (Incl Inlier Short Stay Long Stay Extra Long MDC Type Description Cost ALOS 5 Point Point Trim Point in DRG) Allocation per Day per Day Stay per Weight ($) ($) ($) ($) Day ($) F14C 5 S VASC PR-MJR RECONSTR-PUMP-CSCC 1.3803 2.4 1 8 13 $64 $5,783 $5,783 $982 $358 F21B 5 S OTH CIRC SYS O.R. PR -CCC 1.8453 4.8 1 25 33 $46 $7,732 $7,732 $982 $358 Z01B 23 S OR PR+DX OTH CNT HLTH SRV-CSCC 0.6704 1.2 1 2 4 $62 $2,809 $2,809 $982 $358
Thrombolysis + Angioplasty Repeat plasty + stent [Unit cost] $1,200 $3,300 [Unit cost] 13 x 1,200 = $15,600 2 x $3,300 = $6,600 Total cost $22,200, At the time of termination of study, duration of patency range 1-37 months. 3 Cases of fistula demise occurred @ 12, 18, 19 months. None required catheter bridge. Surgical Thrombectomy/ revision- 13x7732 = $ 100,516 Cost of Catheter bridge $???
Conclusion An optimal outcome is likely when there is: Multidisciplinary team approach Consensus about goals among interested parties Restriction of access to interested and experienced surgeons Routine pre operative mapping and post operative surveillance and intervention Prospective tracking of outcomes with continuous quality assessment Immediate benefits include: Continuation of Dialysis Avoidance of temporary catheters Avoidance of access abandonment (In some cases) Provides increased surgical time for primary AVF creation