Ten Tips for Dialysis Management

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Presentation transcript:

Ten Tips for Dialysis Management by Anthony C. Venbrux, MD Professor of Radiology and Surgery Director, Cardiovascular and Interventional Radiology The George Washington University Medical Center Washington, DC

Anthony Venbrux, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

Objectives Discuss clinical aspects. Review current access maintenance procedures: Surgical . Interventional.

Objectives Interventional therapeutic options: PTA. "Mechanical" thrombectomy/thrombolysis. Thrombolytic therapy. Combination therapy. Stents. Tunneled hemodialysis catheters.

The Role of The Interventional Physician Define anatomy. Perform baseline and follow-up studies. Percutaneous interventions: PTA. Thrombolytic therapy. "Mechanical” or pharmacomechanical “thrombolysis.” Stents. Hemodialysis catheter placement.

One

Understand the Anatomy

Permanent Hemodialysis Access Arteriovenous (AV) fistula. Prosthetic graft. Approximately 95+% of the problem is on the venous side!

Brescia-Cimino Fistula Autogenous AV Fistula Brescia-Cimino Fistula Radial artery – cephalic vein. Superior patency. USA: Only 25% of vascular accesses are native fistulae.

"Synthetic Bridge Grafts" Prosthetic Graft "Synthetic Bridge Grafts" Forearm Loop: Brachial artery to cephalic or basilic vein. Arm Graft: Brachial artery to axilliary vein.

Prosthetic Graft Lower patency. Greater physician involvement. USA: Majority of vascular accesses are prosthetic grafts.

Mayo Foundation

Han, Kuo-Ming, L E Duijm, G R P Thelissen, et al Han, Kuo-Ming, L E Duijm, G R P Thelissen, et al . Failing Hemodialysis Grafts: Evaluation of Complete Vascular Tree with 3D Contrast-enhanced MR Angiography with High Spatial Resolution . … RSNA, 2003. http://radiology.rsna.org/content/227/2/601.full

HeRO Graft, Hemosphere Inc, Minneapolis MN

Two

Physical Exam

Physical Examination of Graft or Fistula "Thrill" "Pulse" "Neither"

Failing Dialysis Access Physical examination: Palpation of graft. Arm swelling.

Symptomatic Central Venous Stenosis Arm swelling. Delayed healing of incisions.

Three

Understand Dialysis Parameters

Failing Dialysis Access Dialysis parameters: Venous pressures. Urea recirculation time.

Four

Understand the importance of Screening

Failing Dialysis Access Noninvasive imaging. Ultrasound. Invasive procedures. Contrast studies.

Contrast Evaluation Patent: Image entire fistula or graft. Image central venous system. Thrombosed: Do not inject contrast. Risk of distal emoblization.

Five

Know Your Options

The Failing Access Surgical. Percutaneous interventions: PTA. Thrombolytic therapy. "Mechanical” or pharmacomechanical “thrombolysis.” Stents

Thrombosed Access Graft Surgical. Percutaneous. Crossed catheter technique. Thrombectomy Thrombolytic therapy. Catheter Directed Infusion. "Pulse Spray" Pharmacomechanical. Intervention. PTA first; use stents as a last resort.

Mayo Foundation

"Mechanical" Declotting Average dialysis graft clot volume 3.15 cc. Avoid in a patient with: COPD. Right heart failure. Thrombus extending into the central venous system. Trerotola SO. Venous Interventional Radiology with Clinical Perspectives, Theime, NY 1996

Central Venous Pressure Measurements Patent Fistula or Graft

Six

Know the Natural History

Thrombosed Access Graft Surgical series: A cause is found 50% of the time. Radiologic series: A cause is found approximately 90% of the time.

History of Prior Subclavian Vein Dialysis Catheters Moderate or severe subclavian vein stenosis found in 40% of patients. Surrat, R, et al, AJR 1991;156:623-625

Seven

Know the Alternatives

Eight

Be Realistic

"Mechanical" Thrombolysis Initial patency (“Lysis”) achieved in 94% of patients. Clinical success (patency at 7 days) 59%.

Nine

Be Creative

Ten

Avoid Central Venous Stents

Take Home Points