1 PERCUTANEOUS AVF HAS NOTHING TO OFFER OR NOT TOO MUCH Dr - PowerPoint PPT Presentation

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PERCUTANEOUS AVF HAS NOTHING TO OFFER OR NOT TOO MUCH Dr Thierry POURCHEZ BETHUNE FRANCE PARIS INSTITUT MONTSOURIS 14 september 2018

WHAT NEED THE NEPHROLOGY TEAM? A GOOD FISTULA THAT MEETS THE RULE OF 6’s When the fistula is mature, - the vein diameter ought to be at least 6 mm - the depth ought to be less than 6 mm - the flow is more than 100 x 6 ml/min Some people have implemented the rule with: - maturation time of 6 weeks - segment of vein usable on at least 6 cm 3

The fistula can deliver at least 500 ml/min in the circuit 4

FIRST ARTERIOVENOUS FISTULA BRESCIA, CIMINO and APPELL 1966 K APPELL M BRESCIA J CIMINO The first version was a side to side, but rapidly, 5 the side to end fashion was widely used

Side to side Side to end 6

BRACHIO-BASILIC FISTULA BRACHIO-CEPHALIC FISTULA SURGICAL FISTULA RADIO-CEPHALIC WIDESPREAD OPTIONS FISTULA ULNO-BASILIC FISTULA Snuffbox fistula 7

PERCUTANEOUS FISTULA PERCUTANEOUS FISTULA ONE FITS FOR ALL CASES? 8

What is the real problem with scars? Which one do you prefer?

THE NORMAL RADIO-CEPHALIC FISTULA Punctures in a high flow vein, with low pressure because the pressure drop is mainly on the anstomosis The « ideal » flow is 750 ml/min 10

Case of a radio-cephalic fistula with punctures in the cephalic accessory vein 11

It is all about the perforating vein

ELBOW FISTULAE Basic anatomy Brachio-cephalic fistula

ELBOW FISTULAE Gracz fistula, modified by Konner Anastomosis of the perforating vein with the distal brachial artery, or the origin of the radial artery There is no flow to the brachial veins Always close the basilic vein to avoid the main flow to the easiest way Where is the knot?

ELBOW FISTULAE Gracz fistula If there is no closing of veins, what is the percentage of flow for the two main ways? Is the vein easy to stick, with a low flow that means small diameter?

ELBOW FISTULAE Closure of the basilic vein If there is a serious doubt on the quality of the cephalic vein, place a tight banding

ELBOW FISTULAE The surgeon choose the vein that will remain open Case of large side to side anastomosis at the elbow, with high flow and ischemia Treated by basilic transposition

ELBOW FISTULAE The surgeon choose also the size of the anastomosis Case of large side to side anastomosis at the elbow, with high flow

ELBOW FISTULAE Anastomosis preferably on the beginning of the radial artery

ELBOW FISTULAE: OTHER CASES Brachio-basilic fistula on the median basilic vein Brachio-basilic fistula on the upper part of the forearm basilic vein

The river SEINE with his unique channel allows big boats 21

The river LOIRE with his multiple channels allows only small boats Chaumont sur Loire 22

The river LOIRE and SEINE can also expect floodings 23

PRO AND CONS FOR ELBOW FISTULAS 24

And what would be the state of the vessels in the future? The low flow is however a good thing 25

Are we creating too much elbow fistulae? 26

27 Mapping of bad quality?

Mapping by the surgeon in warm conditions 28

Warm air tunnel for upper arm 29

Last mapping in the oeprating room, with the help of the brachial plexus block ++++ Can change the indications! 30

Was the selection good? Picture after TVA technic

SOME REASONS TO USE THIS DEVICE • No vein in the forearm, and thrombosis of the median basilic vein • Skin pathology near the intended scar? 32

SOME OTHER REASONS TO USE THIS DEVICE • The lack of dedicated surgeons for vascular accesses • The bad results with some surgeons • The surgeon making too large anastomosis, giving megafistula and/or hand ischemia • The choice of the « informed » patient • The fear of pain or scars? 33

In BETHUNE on 4th october 2016 260 patients on HD • Radio-cephalic, from the wrist to the elbow: 181 • Ulno-basilic: 8 • Cephalic vein transposition on the brachial artery: 3 Forearm fistulas: 192 -> 73,8 % of patients and 83,1 % of AVF • Brachio-cephalic: 27 • Brachio-basilic transposition: 12 • Brachio-basilic PTFE prosthesis: 1 • Central KTR: 28 (11%) and among them, 15 waiting for the maturation of 13 radio-cephalic fistulas and 2 brachio-cephalic fistulas 34

Munich agreement (30 sept 1938) « You were given the choice between war and dishonour. You choose dishonour, and you will have war » To Neville Chamberlain Winston Churchill

« You have the choice between percutaneous and open fistula. You prefer percutaneous, and you will (could) have open surgery.

« You have the choice between percutaneous and open fistula. You prefer percutaneous, and you will (could) have open surgery.

I prefer the one dilated fistula to the V fistula at the elbow

I prefer the one dilated fistula to the V fistula at the elbow