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ARTERIOVENOUS FISTULAS TYPES, TRENDS, PHYSICAL EXAMINATION & TREATMENT B. Karenko, DO January 25, 2014.

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Presentation on theme: "ARTERIOVENOUS FISTULAS TYPES, TRENDS, PHYSICAL EXAMINATION & TREATMENT B. Karenko, DO January 25, 2014."— Presentation transcript:

1 ARTERIOVENOUS FISTULAS TYPES, TRENDS, PHYSICAL EXAMINATION & TREATMENT B. Karenko, DO January 25, 2014

2 I have no disclosures

3 Objectives Identify types of vascular access Evaluate trends of vascular access Physical examination of AV Fistulas – Normal – When to refer Treatment

4 Type of Hemodialysis Access Synthetic AV GraftCentral Venous CatheterAV Fistula

5 Radiocephalic Fistula Radial Artery to Cephalic Vein Forearm Preferential

6 Brachiocephalic Fistula Brachial Artery to Cephalic Vein Antecubital Fossa

7 Brachiobasilic Fistula Brachial Artery to Basilic Vein Upper Arm +/- transposition

8 AV Fistula Advantages Smaller Surgery Decreased Infection Decreased Thrombosis Longer Lifespan – 68% AVF – 49% AVG Disadvantages Long Maturation Time More Difficult Cannulation High Primary Failure with Difficult Vasculature Allon & Robbin, Kidney Int. 62: , Nassar & Ayus. Kidney Int. 60:1-13, 2001 Pisoni RL, et al., Kidney Int. 61: , 2002

9 Best to Worst AVF AVG CVC

10 Vascular Access Use & Outcomes; An International Perspective from the Dialysis Outcomes & Practice Patterns Study Prospective Observational Study >300 Hemodialysis Sites 12 Countries >35,000 patients Nephrol Dial Transplant Oct; 23(10);

11 AV Fistula Use Nephrol Dial Transplant Oct; 23(10);

12 Referral Timeframe Nephrol Dial Transplant Oct; 23(10);

13 Creation to Cannulation Nephrol Dial Transplant Oct; 23(10);

14 Successful Fistula Adequate VesselsGood Pump >0.4 cm Robbins Radiology 225; 59-64, 2002

15 Monitoring/Surveillance New AVF Identify 1° Failures Plan for Early Interventions Plan for Surgical Revision Established AVF Early Detection – Thrombosis – Inadequate Flow

16 Physical Examination Look Listen Feel

17 Look Radiocephalic Brachiocephalic Brachiobasilic (transposed)

18 Look

19 Aneurysm & Hematoma

20 Steal Syndrome

21 Central Vein Stenosis Extremity Swelling Collateral Veins

22 Arm Elevation Test

23 Auscultation Normal Bruit High Pitched (stenosis)

24 Feel (Palpation) Inflow Assessment Outflow Assessment – Augmentation Test – Absence of Thrill – Pulsitile

25 Outflow Obstruction

26 Treatment of Stenosis Venous Anastomosis/Outlet Significant Lesions – <600 ml/min flow – >50% stenosis on angiogram

27 Endovascular Angioplasty First Line Treatment – 7-8mm peripheral – 12-14mm central Poor long term patency 50% require repeat treatment within 6-12 months Am. J Kidney Disease 2001; 37 (5); 1029

28 Stents Three Indications – Angioplasty Failure – Rapid Recurrence of Lesion – Vessel Rupture J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

29 Patency 92% 80% 30 69% 24% 90 35% 3% 180 Clin J Am Soc Nephrol. 2008, 3(3);699

30 Surgical Revision of Stenosis Advantage – Elimination of the lesion Disadvantage – Frequent new lesion development – Loss of venous access sites – Post surgical pain/recovery time

31 Thrombosis Percutaneous/Surgical Thrombectomy Thrombolytic Agents

32 Percutaneous Thrombectomy J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

33 Surgical Thrombectomy J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

34 Thrombectomy Percutaneous/Surgical Thrombectomy Primary Patency – 3 months: 30-60% – 6 months: 10-40% Elective Angioplasty vs Thrombectomy J. Vasc. Interv. Radio. 1999; 10 (2pt1):129

35 Thrombolysis (local) Agents Contraindications Pulse Spray Mechanical Clot Disruption 50% patent at 1 yr

36 Major Concern Development of Clinically Significant PE 650 Thrombectomy Cases – 1 Clinically Significant PE Kidney Int. 1994; 45(5) 1401

37 QUESTIONS?


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