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The Good Old Days of Dialysis Access Surgery Eric D. Ladenheim MD.

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Presentation on theme: "The Good Old Days of Dialysis Access Surgery Eric D. Ladenheim MD."— Presentation transcript:

1 The Good Old Days of Dialysis Access Surgery Eric D. Ladenheim MD

2 Support gratefully acknowledged from David Kennedy W. L. Gore. & Associates, Inc

3 Overview of talk  There are a lot more AV Fistulas than in the good old days and more are coming.  Some AV Fistulas and Grafts have weird anatomy.  The Dialysis Access Surgeon can help make cannulation much easier for you and your patient.

4 The Good Old Days Ladenheim

5 How Did the USA Compare to the Rest of the World Prior to 2003?

6 The Good Old Days Ladenheim

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9 Secondary patency of AVG higher than AVF out to 900 days!

10 Why is the AVF rate low if it is the “gold standard”?  50% of patients start dialysis emergently, thus catheters are inserted for a quick vascular access to initiate hemodialysis  Patients may resist changing to an AVF due to fear of needles  Reimbursement for an AV graft is higher AV Grafts can be used sooner than an AV fistula AV Grafts can be used sooner than an AV fistula

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12 Madness and Folly Ladenheim 1999 – 2001

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14 Where we were in 2003? 33 % Prevalent AVF Northern Cal Region 17

15 Have we made any progress? Source: March 2006 Network Provider Fistula First Reports Region Northern California 46.3%

16 End Stage Renal Disease Network Regional Map Prevalent AVF Percentage Rates in US 38.1% 48% 44.2% 46.3% 58.5%37.6% 40.7% 38.8% 36.3% 34.6% 41.5% 37.5% 47.5% 48.9% 39.5% 35% 40.4% Date Source: FF Dash Board 100% of facilities may not of reported in each Network Rates across USA & Possessions US US Rate =US Rate =

17 Central Valley trails region 17 – but at least we’re better than Sacramento

18 New and Improved Dr. Ladenheim 2004 to 2007

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21 Overview of talk  There are a lot more AV Fistulas than in the good old days and more are coming.  Some AV Fistulas and Grafts have weird anatomy.  The Dialysis Access Surgeon can help make cannulation much easier for you and your patient.

22 Drawing courtsey of James F. Whiting, MD22 Sites for Native Fistulas

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26 ( Very Much )

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28 Collaborative Care of Vascular Access  Surgeons have a role as vascular access advocates through:  diagramming new accesses & labeling arterial limb  communicating specific access orders directly to the nurses  visiting the dialysis units to do patient & staff education and to familiarize staff c surgeon’s point of view  be readily accessible for consultation

29 Surgeon’s Role: Diagramming accesses and marking blood flow direction

30 Available for Consultation  Failure of fistulas to mature  High negative pressures  Difficult cannulation situation  Re-Mapping of Fistulas  Ligation of parasitic veins  Monitoring of aneurysms and pseudoaneurysms  Dealing with hematomas  Evaluation of swollen extremity  Poor Blood flow  Poor dialysis adequacy  Surgical Follow up after graft thombosis

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