What a nephrologist should know about vascular access Tushar Vachharajani, MD VAMC KDIGOSalisbury, NC Kidney Disease: Improving Global Outcomes Why should a nephrologist bother about vascular access? KDIGO Kidney Disease: Improving Global Outcomes Because that is the right thing to do for your patients! KDIGO Kidney Disease: Improving Global Outcomes CKD Management HTN DM Dialysis Cardiovascular Bone problems Metabolism Nutrition Hyperlipidemia KDIGOAnemia Transplantation Kidney Disease: Improving Global Outcomes Dialysis Issues Adequacy Socioeconomic Compliance Factors Cost Factor Modality Selection KDIGOVascular Access Kidney Disease: Improving Global Outcomes Ideal Vascular Access • Easy to construct • No foreign material • No thrombosis • No infections • Easy to cannulate • LongKDIGO lasting • Good blood flow Kidney Disease: Improving Global Outcomes Life line and Achilles heel KDIGO Kidney Disease: Improving Global Outcomes Types of vascular access • Arteriovenous fistula • Arteriovenous graft • Central venous catheter KDIGO Kidney Disease: Improving Global Outcomes Central Venous Catheters • Temporary non-cuffed – emergent situations • Bridging - cuffed – Internal jugular vein – Femoral vein – Subclavian vein – Translumbar IVC – TranshepaticKDIGO IVC Kidney Disease: Improving Global Outcomes • Why is AVF the preferred vascular access for dialysis? A. Lower infection rate B. Lower thrombosis rate C.Less expensive D.Less overall morbidity E. All of the aboveKDIGO Kidney Disease: Improving Global Outcomes Catheter events & complications KDIGO USRDS Kidney Disease: Improving Global Outcomes Arteriovenous graft events & complications KDIGO USRDS Kidney Disease: Improving Global Outcomes Arteriovenous fistula events & complications KDIGO USRDS Kidney Disease: Improving Global Outcomes PPPY expenditures, by type of access KDIGO Kidney Disease: Improving Global Outcomes PPPY access costs by type of access KDIGO Kidney Disease: Improving Global Outcomes Common issues with vascular access • Infection – Catheters >AVG > AVF • Primary failure due to poor maturation of AVF – ~ 60% failure rate -NIH sponsored DAC study, JAMA 2008 • Stenosis due to neo-intimal hyperplasia – AVG: Mainly at the venous anastomosis – AVF: ArterialKDIGO (inflow) anastomosis, venous (outflow) track Kidney Disease: Improving Global Outcomes Primary Patency of AVF Compared to AVG 100 80 60 40 Percentage 20 0 0 1 2 3 4 5 KDIGOYears Mehta S, in Vascular Access for Hemodialysis II. Summer BG, Henry ML 1991 Kidney Disease: Improving Global Outcomes AVF is the preferred access – ↓ incidence of infection • AVF < AVG < CVC – ↓ incidence of thrombosis • AVF < AVG – ↑ patency rate • AVF >KDIGO AVG Kidney Disease: Improving Global Outcomes September 2013, Rajkot Vascular access in incident HD patients KDIGO Kidney Disease: Improving Global Outcomes Vascular access trends –1996 - 2007 KDIGO Kidney Disease: Improving Global Outcomes Vascular access trends –1996 - 2007 KDIGO Kidney Disease: Improving Global Outcomes September 2013, Rajkot How are we doing with vascular access care? KDIGO Kidney Disease: Improving Global Outcomes Vascular access care • Historically has remained fragmented between – Nephrologist – Surgeon – Radiologist KDIGO Kidney Disease: Improving Global Outcomes Drawbacks of fragmented care – Missed dialysis treatments – Treatment decisions sporadic rather than planned – Increases • morbidity/mortality • Hospitalization • Cost ofKDIGO care Kidney Disease: Improving Global Outcomes Concept of Vascular Team Vascular Surgeon Primary Patient care physician Radiologist Dedicated coordinator KDIGODialysis Staff Kidney Disease: Improving Global Outcomes Nephrologist as a team leader – Better understands the complexity of the dialysis process and needs of an ESRD patient – Better understands the importance of access patency – Coordinate with the dialysis personnelKDIGO Kidney Disease: Improving Global Outcomes Role of a nephrologist – Arrange for timely intervention to avoid missing dialysis treatment – Can easily coordinate the surveillance program – Can supervise the education and trainingKDIGO of dialysis personnel Kidney Disease: Improving Global Outcomes Global Awareness • Concept team approach • Procedures being performed by nephrologist • Supported by major renal societies – ASN, ISN, ERA-EDTA, NKF, ISHD • Multiple meetings dedicated to access care – VASA, ASDIN,KDIGO VEITH symposium, VAS Kidney Disease: Improving Global Outcomes • How many sites are available for AVF creation on each upper extremity? A. 3 B. 5 C.6 D.7 KDIGO Kidney Disease: Improving Global Outcomes Upper extremity AVF sites • Traditional AVF • Transposed AVF – Snuff-box – Proximal forearm – Radiocephalic AVF – Brachiocephalic – Transposed basilic vein in upper arm – Transposed basilic vein in forearm – Transposed cephalic KDIGOvein in forearm Kidney Disease: Improving Global Outcomes Radiocephalic AVF KDIGO Vachharajani – Atlas of Vascular Access - 2010 Kidney Disease: Improving Global Outcomes Brachiocephalic AVF KDIGO Vachharajani – Atlas of Vascular Access - 2010 Kidney Disease: Improving Global Outcomes Transposed basilic vein AVF KDIGO Vachharajani – Atlas of Vascular Access - 2010 Kidney Disease: Improving Global Outcomes Transposed forearm AVF Axillary vein Brachial vein Brachial artery Radial artery Brachial Ulnar artery artery - basilic vein Cephalic vein transposed forearm Basilic vein loop fistula KDIGO Kidney Disease: Improving Global Outcomes Brachial Artery-Cephalic Vein Forearm Loop Fistula KDIGO Kidney Disease: Improving Global Outcomes Surgical Innovations • Transposed vessel fistula – Forearm – cephalic and basilic – Upper arm – basilic – Proximal forearm deep perforating vein – Thigh fistula – SecondaryKDIGO AVF Kidney Disease: Improving Global Outcomes When is the ideal time to evaluate a new AVF for maturity? A. 2 weeks B. 4 weeks C. 6 weeks D. 8 weeks E.KDIGO 12 weeks Kidney Disease: Improving Global Outcomes Timing of change in flow and size Normal Fistulae Early AVF Failure KDIGO Asif A, Roy-Chaudhury P, Beathard GA: CJASN 1:332-339, 2006 Kidney Disease: Improving Global Outcomes Common lesions with Early AVF Failure ELBOW Ulnar art Radial art. Radial art. Stenosed forearm basilic vein Stenosis with KDIGOcollaterals WRIST Kidney Disease: Improving Global Outcomes ELBOW Radial art. Stenosed forearm basilic vein WRIST • Juxta-anastomoc stenosis • Transposed forearm basilic vein to radial artery KDIGO fistula Kidney Disease: Improving Global Outcomes Accessory veins – coil embolization Ulnar art Post PTA Radial art. Stenosis with coils collaterals KDIGO Kidney Disease: Improving Global Outcomes Clin J Am Soc Nephrol 1: 275–280, 2006 Salvage of “Failing to Mature” AVF 277 Table 2. Types of AVFa N 119 Radiocephalic 75 (63%) Brachial-cephalic nontransposed vein 28 (23.5%) transposed vein 1 (0.8%) Brachial-basilic nontransposed vein 6 (5.1%) transposed basilic vein 9 (7.6%) aAVF,Overview arteriovenous fistulas. of FTM problem Table 3. General overview of AVF derangements Two or more derangements 85 (71.4%) stenosis (Ն1) and significant 35 (29.4%) Figure 1. A sample of two vascular lesions that were encoun- accessory vein tered during salvage procedures on “failing to mature” arterio- stenosis (Ն2) without significant 50 (42%) venous fistulas (AVF). (A) A tight juxta-arterial anastomosis accessory vein stenosis (arrow) is preventing the maturation of an upper arm Single derangement only 34 (28.6%) brachial-cephalic AVF. (B) Successful angioplasty led to reso- significant accessory vein 4 (3.4%) lution of the stenosis. (C) An extremely tight venous outflow deep AVF 6 (5%) tract stricture (short black arrows) has prevented successful stenosis 24 (20.2%) maturation of a radiocephalic AVF. A collateral vein has devel- oped (white arrow). (D) Successful angioplasty led to resolution KDIGO of the stricture, and the collateral vein is now undetectable by angiography. Table 4. FrequencyNassar and et distribution al - Clin J Am Soc of Nephrol vascular 1: 275–280, stenoses 2006. Kidney Disease: Improving Global Outcomes Peripheral artery stenosis 6 (5.1%) Arterial anastomosis stenosis 56 (47.1%) valuable information that was instrumental in AVF salvage. In Juxta-arterial anastomosis stenosis 76 (63.9%) nine (7.6%) patients, the technique failed for the following Peripheral vein stenosis 70 (58.8%) reasons: Complete occlusion of venous outflow tract (n ϭ 4), Peripheral vein occlusion 25 (21%) venous outflow tract was deep and tortuous (n ϭ 3), venous Central vein stenosis 10 (8.4%) outflow tract was severely strictured (n ϭ 1), and juxta-arterial Arterial with juxta-arterial stenosis 45 (37.8%) segment was strictured (n ϭ 1). Juxta-arterial with peripheral vein stenosis 46 (38.7%) AVF Salvage Rates Ninety-nine (83.2%) fistulas became usable during HD. Twenty (16.8%) fistulas failed to become usable during HD. Of peripheral vein, 70 (58.8%); and central vein, 10 (8.4%). Com- these, nine were due to technique failure as described above plete peripheral vein occlusion was present in 25 (21%). and 11 were due to persistence of AVF “immature” state de- spite apparently successful endovascular treatment. A sum- Technique Outcomes mary of the reasons for failure of AVF salvage is listed in Table In 107 (89.9%) patients, the angiographic procedure suc- 5. Successful AVF salvage was not associated with age (P ϭ ceeded in increasing the AVF blood flow. In Figure 1, we show 0.875), gender (P ϭ 0.215), race (P ϭ 0.514), the presence of a sample of two successful interventions. In three