Cutting Edge in Dialysis

Access Technique

Overcoming Challenges in Dialysis

Access

ANNE LALLY, M.D

Overcoming Challenges in Dialysis Access

► AV Fistula Failure to Mature

► Maintaining Patency

► Central Vein Occlusion

► Fragmentation of Care for the Dialysis Access Patients

AV Fistula Failure to Mature

► Pre-operative vein mapping ► Patient Selection: ESRD vs CKD, Cardiac Valve,

Obesity, Age, Comorbid Illness ► Early Referral to Access Surgeon ► Surgical follow up until AV fistula is functional, or

Open lines of communication back to surgeon/Access Team if Access does not Mature

► Defined Time Frame for Maturation/Cannulation ( 4 weeks in Europe, 8-12 weeks in US)

► OP Report: Should state whether additional procedures (eg. Transposition) are planned

AV Fistula Failure to Mature: Causes

► Small or Scarred Veins

► Deep Veins

► Multiple Side Branch Veins

► Poor Inflow: Peripheral Arterial Disease, Stenosis of arterial Anastamosis, Cardiomyopathy

5

AV Fistula Failure to Mature: Interventions

► Balloon Assisted Maturation

► AVF Transposition or Superficialization

► Side Branch Ligation or Coil Embolization

► Revision of Arterial Anastamosis

Overcoming Challenges in Dialysis Access

► AV Fistula Failure to Mature ► Maintaining Patency

► Central Vein Occlusion

► Fragmentation of Care for the Dialysis Access

Patient

Maintaining Patency of Hemodialysis: Graft and Fistula Patency Rates

6 month patency

18 month patency

AVG Unassisted

58%

33%

AVG Assisted

76%

55%

AVF Unassisted

72%

51%

AVF Assisted

86%

77%

Metanalysis, 34 studies, 1849 AVF and 1245 AVG

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Promising Tissue Graft

► Humacyte Tissue Engineered Graft, Duke University

► Patency far Superior to currently available Grafts

► Not yet FDA approved

9

Maintaining Patency of Hemodialysis: Angioplasy vs Covered stents in AV Graft stenosis

10

Stent Graft and Hybrid Graft

► Stent Grafts (Viabahn, Gore) are Superior to Balloon Angioplasty and to Bare Metal Stents for Maintaining Patency

► Hybrid Graft (Gore) useful for Axillary vein stenosis and allow smaller axillary surgical skin incisions

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Maintaining Patency of Hemodialysis DCB (Drug Coated Balloons) vs POBA (Plain old Angioplasy Balloons)

► Single Center Trial: 6 month Patency 70% vs 25%. (Katsanos et al, Journal endovasc Ther, 2012)

► Multicenter, randomized, controlled trials in Progress an initial results reportedly favor DCB

Paclitaxel

Overcoming Challenges in Dialysis Access

► AV Fistula Failure to Mature ► Maintaining Patency

► Central Vein Occlusion

► Fragmentation of Care for the Dialysis Access

Patient

Central Vein Occlusion, SCV Syndrome

A Tragic and Potentially Fatal (Often Iatrogenic) Problem Cause by:

1. Malignancy

2. Central Vein Catheters, especially left sided and Subclavian vein

3. Central vein catheter infection

4. Pacemaker / AICD

5. Flow related

Severely Limits Future Dialysis Access Options !!!

AV Graft Innovations to Minimize Perm Cath Use

► Accuseal Graft (Gore), allows immediate cannulation. 3 Layer wall

► “Bullet Proof Graft” immediate stick graft designed to prevent cannulation damage / Pseudoaneurysms.

Central Vein Occlusion, Possible Treatment Options

► Hero Catheters

► Central Vein Stenting, Viabahn, Fluency

► Gore Hybrid Graft for isolated Axillary vein stenosis

► Surgical Bypass to an unobstructed venous outflow (eg Ipsilateral IJ, contralateral IJ/SCV)

► AVF Flow Reduction (banding)

► AVF ligation, sacrifice

Overcoming Challenges in Dialysis Access

► AV Fistula Failure to Mature ► Maintaining Patency ► Central Vein Occlusion

► Fragmentation of Care for the Dialysis Access

Patient

Adverse results of Fragmented Dialysis Access Care

► Delays in Surgical care resulting in more Perm-caths, hospital days, expense, patient mortality

► Frustrated healthcare team and Patients

Wait times to create a vascular access drop 35-50%

Posted by Daniel Schwartz on Sep 19, 2013 in Hemodialysis, Vascular Access | 0 comments

Improving our incidence and prevalence rates for permanent vascular access on hemodialysis has been an FHA wide goal.

As part of our strategy to improve our rates, we looked at the wait times to get an access created. We figured that if we could get an AV access created faster for patients on hemodialysis, our prevalence rates would improve. And if we could ensure that wait times for patients with advanced chronic kidney disease were better, we’d see less people starting hemodialysis before their AVF was ready to be used, thereby improving our incidence rates.

As a result of a collection of strategies including a) more dedicated vascular access nurses, b) greater collaboration with our surgical colleagues and c) the implementation of a novel process of expedited vascular access creation under regional block or local anesthesia with recovery outside the post-anesthetic care unit, we’ve noticing striking improvements in wait times from referral to vascular access creation. Between January and September 2013, we’ve seen surgical creation wait times decrease from 138 days to 91 days for patients referred to the Surrey program and 111 to 95 days in the Abbotsford program.

Fragmentation of Care for the Dialysis Access Patient: Traditional Model

Tertiary Center

General Surgeon

Vascular Surgeon

Transplant Center

Nephrologist

Interventional

Dialysis Unit

ESRD Patient

Don’t Forget PD!

Traditional Approach

Interventional Procedure

Early Access Failure, Who Triages care?

Refer back to IR, Repeat angio or

Perm cath?

Open Surgical Revision,

New Access

Dialysis Unit Access Problem

24-48 h

weeks

Fragmentation of Care for the Dialysis Access Patient: a Simpler Patient Centered Model

Transplant Center

Nephrologist

Multidisciplinary Dialysis Access

Center

Dialysis Unit

ESRD Patient And, We Do PD TOO!!!

Multidisciplinary Access Center with Dedicated Surgeons

Access Center Interventional

Procedure

Open Surgical intervention, New Access

Dialysis Unit, Access Problem

24 hours

Dedicated Surgeons,

Interventional

Nephrologists, and

specialized staff

Successful Dialysis Care Models

► All Patients referred to Large Academic University Setting

► Hospital Based Surgeons and Interventionalist collaborate

► Dedicated dialysis access coordinator available 24/7 arranges appropriate procedures and guides patient through process

► Outpatient Dialysis Units and small hospital units setting

► Dedicated multidisciplinary group including interventionalist and surgeons with focus on dialysis access

► Access thrombosis and maintenance treated at outpatient multidisciplinary dialysis access center

Typical Operators

Vascular Surgeons with: ►Open surgical skills ►Endovascular skills

Note: If the surgeon does not have endovascular skills, partner with an Interventionalist. Editorial: Modern vascular access surgeons must have endovascular skills, and optimally work within a dedicated multidisciplinary group as the alternative is fragmented care for ESRD patients.

Shameless self promotion cleverly worked into Access talk

► Starling Physicians Access Center

► Multidisciplinary care from one group including Surgeons and interventional Nephrologists

► Outpatient Access center increases efficiency and quality for select patients, Hospital based procedures for more complex care

► Consistent staff with dialysis access expertise

► Knowledge of KDOQI standards

Where would you rather get your ice cream ?

Overcoming Challenges in Dialysis Access - Summary

► Approximately half of native AV fistula’s fail to mature requiring surveillance. Procedures to assist maturation should be considered in a timely fashion.

► Maintaining Patency: Angioplasty, drug coated angioplasty,

Covered Stents improve patency

► Central Vein Occlusion: Life threatening problem usually secondary to perm caths! May be treated with Stent grafts, Hero Grafts, aggressive surgical revision

► Fragmentation of Care for the Dialysis Access Patients: results in treatment delays. A multidisciplinary dedicated dialysis team puts Dialysis patients first.

Starling Physicians Access Center

505 Willard Ave, Building 1

Newington, CT 06111

P: 860-665-7070

Thank You

Questions?