What is new, in the new ESVS vascular access- clinical ......Topic KDOQI European (ERA/EDTA) New...
Transcript of What is new, in the new ESVS vascular access- clinical ......Topic KDOQI European (ERA/EDTA) New...
What is new, in the new ESVS vascular access-clinical practice guidelines?
Jan Tordoir, Maastricht
Faculty Disclosure
Jan H.M. Tordoir
I have no financial relationships to disclose.
▪ 9 chapters
▪ 78 recommendations
▪ 652 references
What is new, in the new ESVS vascular access-clinical practice guidelines?
Volume 55, Issue 6, Pages 757–818
Topic KDOQI European (ERA/EDTA) New European (ESVS)
Evaluation for access placement
History and physical examination, and Duplex ultrasound of the upper-extremity arteries and veins
Clinical evaluation and non-invasive ultrasonographyof upper extremity arteries and veins
Patients should be examined prior to surgery with a tourniquet in a warm room and the proposed site of an arteriovenous fistula should be marked pre operatively
In adults when the inner radial arterial diameter is less than 2.0 mm and/or the cephalic venousdiameter is less than 2.0 mm by ultrasound measurement an alternative site for access shouldbe considered
If there is an indwelling central venous catheter or pacemaker the vascular access should be created in the opposite arm because of the risk of centralvenous stenosis and reduced access patency
Preferred access type
AVF preferred, AVG acceptable, CVC avoid if possible
Autogenous arteriovenous fistulae should be preferred over AV grafts and AV grafts should be preferred over CVC
An autogenous arteriovenous fistula is recommended as the primary option for vascularaccess
Access location
As distal as possible The upper extremity arteriovenous fistula should be the preferred access and should be placed as distal as possible
Regional anaesthesia should be considered in preference to local anaesthesia for vascular access surgery because of a possible improvement in access patency rate
Vascular access-clinical practice guidelinesPreop assessment & Strategy
Regional Versus Local Anaesthesia for HaemodialysisArteriovenous Fistula Formation
A Systematic Review and Meta-Analysis
What is new, in the new ESVS vascular access-clinical practice guidelines?
Topic KDOQI European (ERA/EDTA) New European (ESVS)
Follow-up of VA
placement
If a fistula fails to mature by 6 weeks, a fistulogram or other imaging study should be obtained to determine the cause of the problem
Fistula maturation should be monitored to allow pre-emptive intervention if needed
If an arteriovenous fistula fails to mature by 6 weeks,additional investigations (like duplex ultrasound) should be considered in order toachieve prompt diagnosis and treatment
Timing of cannulation
AVF should be mature, ready for cannulation with minimal risk for infiltration, and able to deliver the prescribed blood flow Fistulae are more likely to be useable when they meet the Rule of 6s characteristics: flow greater than 600 mL/min, diameter at least 0.6 cm, no more than 0.6 cm deep, and discernible margins
An autogenous fistula should be cannulated when adequate maturation has occurred
Arteriovenous fistulas should be considered forcannulation 4-6 weeks after creation, and standard arteriovenous grafts after 2-4 weeks
Access care before cannulation
Access care after needle withdrawal
Access monitoring
Organized monitoring/surveillance approach with access flow as the preferred method
Objective monitoring of access function should be performed at a regular base by measuring access flow
Surveillance of arteriovenous fistulas with duplex ultrasound at regular intervals and pre-emptiveballoon angioplasty should be considered to reducethe risk of arteriovenous fistula thrombosis
Surveillance of arteriovenous grafts with duplex ultrasound at regular intervals and pre-emptiveballoon angioplasty is not recommended to preventthrombosis or improve arteriovenous graft functionality
Vascular access-clinical practice guidelinesCannulation & Monitoring
Access thrombosis
Access loss
Pre-emptive vs “wait and see” AVF
Am J Kidney Dis 2016; 67(3):446-460
What is new, in the new ESVS vascular access-clinical practice guidelines?
Pre-emptive vs “wait and see” AVG
Access thrombosis
Access loss
Am J Kidney Dis 2016; 67(3):446-460
What is new, in the new ESVS vascular access-clinical practice guidelines?
Topic KDOQI European (EDTA/ERA) New European (ESVS)
Treatment of thrombosis
Thrombosed autogenous and graft fistulae should be treated either by percutaneous or surgical thrombectomy
Thrombosed autogenous and graft fistulae should be treated either by interventional radiology or surgery. Individual centers should review their results and select the modality that produces the best results for that centre
Treatment of vascular access thrombosis shouldinclude perioperative diagnosis and treatment of any associated stenosis
Stenosistreatment
A fistula with a greater than 50% stenosis in eitherthe venous outflow or arterial inflow, in conjunctionwith clinical or physiological abnormalities, shouldbe treated with PTA or surgical revision
For venous outflow stenosis percutaneoustransluminal angioplasty (PTA) is the first treatment option
Balloon angioplasty is recommended as primarytreatment for inflow arterial stenosis of anyvascular access
Surgical proximal relocation of the vascular accessanastomosis should be considered in juxta-anastomotic stenosis in the forearm
Endovascular treatment with stent grafts should beconsidered for the treatment of cephalic archstenosis
Treatment of central vein
stenosis
The preferred treatment for central vein stenosis is PTA.
Stent placement should be considered in the following situations:
Acute elastic recoil of the vein (>50% stenosis) after angioplastyThe stenosis recurs within a 3-month period.
If symptomatic central venous obstruction issuspected, angiography of the access and complete venous outflow tract should be performed
Treatment should be performed by percutaneous intervention
The use of stent grafts may be considered for thetreatment of central vein stenosis
Stents or repeat balloon angioplasty should beconsidered if there is significant elastic recoil of thecentral vein after balloon angioplasty or if thestenosis recurs within 3 months
Vascular access-clinical practice guidelinesThrombosis & Stenosis
Primary patency
One-year patency
Stent graft vs AngioplastyWhat is new, in the new ESVS vascular access-clinical practice guidelines?
journal of surgical research j u n e 2 0 1 8 ( 2 2 6 ) 8 2e8 8
Topic KDOQI European (ERA/EDTA) New European (ESVS)
Access-induced
ischaemia
Patients with an AVF should be assessed on a regular basis for possible ischemia
Patients with new findings of ischemia should bereferred to a vascular access surgeon emergentlyIntervention on a fistula should be performedfor the presence of Ischemia in the access arm
Access-induced ischaemia should be detected byclinical investigation and the cause should beidentified by both non-invasive imaging methodsand angiography
Enhancement of arterial inflow, access flow reduction and/or distal revascularizationprocedures are the therapeutic options. Whenthe above methods fail, access ligation should beconsidered
In patients with symptomatic vascular access induced extremity ischaemia with arterial inflowstenosis balloon angioplasty should be considered
Access aneurysm
Intervention on a fistula should be performedfor the presence of aneurysm formation in a primary fistula. Postaneurysmal stenosis that drives aneurysm also should be corrected.The aneurysmal segment should not be cannulated
Not emphasized Surgical revision of vascular access aneurysms isrecommended if cannulation sites and access diameter can be preserved
Surgical revision of pseudoaneurysms in arteriovenous grafts is recommended when theaneurysm: limits the availability of cannulationsites or is associated with pain, poor scar formation, spontaneous bleeding and rapid expansion
Treatment of infected AVF
Infections of primary AVFs should be treated as subacute bacterial endocarditis with 6 weeks of antibiotic therapy. Fistula surgical excision should be performed in cases of septic emboli
Infection of autogenous AV fistulae without fever or bacteraemia should be treated by appropriate antibiotics for at least 2 weeks
Excision of the fistula is required in case of infected thrombi and/or septic emboli
All vascular access late infections should be treatedwith antibiotics to cover both gram positive andgram negative organisms for 6 weeks
Vascular access-clinical practice guidelinesIschaemia/Aneurysm/Infection
Vascular access induced limb ischaemiaTreatment options
DRIL PAVADRAL
Banding RUDI PRAL
What is new, in the new ESVS vascular access-clinical practice guidelines?
Topic KDOQI European(ERA/EDTA) New European (ESVS)
Catheter placement
Avoid if possible
Ultrasound should be used in the placement of catheters.
The position of the tip of any central catheter should be verified radiologically
Central venous catheters should be inserted as a last resort in patients without a permanent access and the need for acute haemodialysis
The percutaneous route should be used for both acute and chronic catheter insertion. Insertion should be guided by ultrasound
A plain X-Ray (chest or abdomen) should be performed before use to locate catheter and detect any complication
Individuals should not undergo the insertion of a high risk complex haemodialysis line without serious consideration of either the placement of a peritoneal dialysis catheter or a tertiary vascularaccess
Catheter type
Short-term catheters should be used for acute dialysis and for a limited duration in hospitalized patients. Noncuffed femoral catheters should be used in bed-bound patients only
Long-term catheters or dialysis port catheter systems should be used in conjunction with a plan for permanent access
Non-tunnelled catheters should only be used in emergency situations and should be exchanged as soon as possible for tunnelled catheters
Not emphasized
Catheter location
The preferred insertion site for tunneled cuffed venous dialysis catheters or port catheter systems is the right internal jugular vein
The right internal jugular vein is the preferred location for insertion
Not emphasized
Vascular access-clinical practice guidelinesCentral Venous Catheter
Exotic vascular access
Ipsilateral thorax loop Necklace AVG
Axillo-iliac/fem/pop AVG
Arterial-arterial chest wallloop AVG
What is new, in the new ESVS vascular access-clinical practice guidelines?
Topic KDOQI European (EDTA/ERA) New European (ESVS)
Neuropathy
Not emphasized Not emphasized Acute ischaemic neuropathy should be treated byimmediate vascular access ligation to preventfurther neurological deficit
VA after renalTx
Not emphasized Not emphasized Routine closure of a functioning vascular access after successful kidney transplantation is notrecommended
Vascular access closure should be considered in patients with refractory heart failure aftertransplantation
Exhaustedupper limb
access
Not emphasized Not emphasized When standard upper limb vascular access sites have been exhausted, complex access procedures should be considered according to the availability of suitable vessels
Vascular access-clinical practice guidelinesMiscellanous issues
Summary
What is new, in the new ESVS vascular access-clinical practice guidelines?
▪ Set of 9 chapters with 78 recommendations
▪ Low evidence because of few randomised studies
▪ Strategy for VA comparable to other guidelines: 1: AVF; 2: AVG; 3: CVC
▪ No separate strategy for subgroups (elderly; diabetics; bridging to Tx/PD)
▪ Little attention for CVC placement and complication treatment
▪ Tertiary/exotic access well adressed
Invitation to
See younext year