Endovascular or Surgical AV Access Creation: Which Option ...

Endovascular or Surgical AV Access Creation: Which Option for Which Patient?

Alexandros Mallios, MDDirector of Vasc Access GH Paris St Joseph& Chief of Vascular SurgCH ChartresFrance

DisclosuresAlexandros Mallios, MD

I have the following potential conflicts of interest to report: Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

2 LINC 2021 | AV Symposium | 500568 | 01/2021


2019 KDOQI Guidelines

“The best possible fistula with the least possible interventions”

Patient

Needs, wishes, expected lifetime with

ESKD

ESKD Life-Plan

Anticipated KRT options matched to

patient goals

Dialysis Access

“The right access, in the right patient, at the right time

for the right reasons”

1. Lok CE et al. Am J Kidney Dis. 2020;75:S1-S164.

Why are the Results of Distal AVF so Poor?

MAPPING REPORT:

Forearm cephalic vein of 3 mm

Patent Radial artery 2 mm

Patent Ulnar artery 3 mm



Quality of the Artery

Image courtesy Alexandros Mallios, MD


Patient Selection and Mapping By Surgeons Are KeyWhen in Doubt About Distal – Think Proximal Radial Artery



Proximal Radial Artery Inflow – 2 Options

Journal of Vascular Surgery J Vasc Surg 2018; 67:224-53

Proximal radial artery arteriovenous fistula for hemodialysis vascular accessWilliam C. Jennings, MD,a Alexandros Mallios, MD, b Nasir Mushtaq, PhD, MBBS, MPHc Tulsa, Okla; and Paris, France

Journal of Vascular Surgery

Clinical Research Study Vascular Access | Volume 72, Issue 6, P2097-2106; December 01, 2020

Midterm results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System, technical recommendations and an algorithm for maintenanceAlexandros Mallios, MD, Pierre Bourquelot, MD, Gilbert Franco, MD, Hadia Hebibi, MD, Hortence Fonkoua, MD, Mahmoud Allouache, MD, Alessandro Costanzo, MD, Romain de Blic, MD, Ghazi Harika, MD, Benoit Boura, MD, William C. Jennings, MD


When Anatomy is Appropriate - pAVF



pAVF Creation with Ellipsys™ Vascular Access System


Midterm Results with Ellipsys System

May 2017 – today >300 patients

99% technical success

Mean Follow-up 1 year (1-36 months)

62% Primary patency

88% Primary assisted patency

96% Secondary patency






No procedure-related adverse events in this study

Mean access flow: 925ml/min

(brachial artery / range: 425-1440)

No steal syndrome

12% superficializations (14 patients)

Average maturation time: 4,1 weeks

10% - early cannulation (<2 weeks)





Surgical vs. Percutaneous AVF

Mallios, A. ESVS 2020.

Primary Patency Secondary Patency


Wrist AVF vs pAVF




Elbow AVF vs pAVF




Early vs. Late pAVF



Patient Eligibility for Ellipsys

Prospective study

100 consecutive patients

63% Eligible for Ellipsys system pAVF

45% Eligible for distal

Only 17% over 70 years old

Original research articleJVA 2020. vol. 21(5) 701-704

Feasibility for arteriovenous fistula creation with Ellipsys®Gilbert Franco1, Alexandros Mallios2, Pierre Bourquelot3, Hadia Hebibi2, William Jennings4, and Benoit Boura2

JVA The Journal of

Vascular Access


Candidate for a distal AVF that will mature without need

for many interventions

Think proximal radial artery to deep communicating vein fistula, Is

puncture possible?

Create surgical distal AVFYES

NO

YES NO

Consider:

1. PRA with forearm cephalic?

2. Brachicephalic

3. Brachiobasilic (more common)

4. No superficial veins – Brachial vein AVF or Axillary loop graft

Radial Dominant Patient

NO

Create pAVF with Ellipsys system

Surgical PRA / DCV AVF

Proximal Ulnar / DCV AVF

No deep communicating

vein

1. Jennings WC, Mallios A, Mushtaq N. Proximal radial artery arteriovenous fistula for hemodialysis vascular access. J Vasc Surg. 2018 Jan;67(1):244-253. doi: 10.1016/j.jvs.2017.06.114. Epub 2017 Sep 11. PMID: 28912005.

2. Franco G, Mallios A, Bourquelot P, Hebibi H, Jennings W, Boura B. Feasibility for arteriovenous fistula creation with Ellipsys®. J Vasc Access. 2020 Sep;21(5):701-704. doi: 10.1177/1129729819900114. Epub 2020 Jan 13. PMID: 31928135; PMCID: PMC7476360.

3. Jennings WC, Mallios A. Proximal ulnar artery arteriovenous fistula inflow is an uncommon but useful vascular access option. J Vasc Access. 2017 Nov 17;18(6):488-491. doi: 10.5301/jva.5000783. Epub 2017 Jul 27. PMID: 28777413.

4. Mallios A, Bourquelot P, Franco G, Hebibi H, Fonkoua H, Allouache M, Costanzo A, de Blic R, Harika G, Boura B, Jennings WC. Midterm results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System, technical recommendations, and an algorithm for maintenance. J Vasc Surg. 2020 Dec;72(6):2097-2106. doi: 10.1016/j.jvs.2020.02.048. Epub 2020 Apr 8. PMID: 32276012.

5. Mallios A, Bourquelot P, Harika G, Boura B, Jennings WC. Percutaneous creation of proximal radio-radial arteriovenous hemodialysis fistula before secondary brachial vein elevation. J Vasc Access. 2020 Jun 27:1129729820936921. doi: 10.1177/1129729820936921. Epub ahead of print. PMID: 32597359.

Endovascular or Surgical AV Access Creation: Which Option ...

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