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

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

Feb 10, 2024 304 likes •711 views

1 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 6s When the fistula is

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Dr Thierry POURCHEZ BETHUNE FRANCE PARIS INSTITUT MONTSOURIS 14 september 2018

PERCUTANEOUS AVF HAS NOTHING TO OFFER

OR NOT TOO MUCH

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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
  • maturation time of 6 weeks
  • segment of vein usable on at least 6 cm

Some people have implemented the rule with:

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

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FIRST ARTERIOVENOUS FISTULA BRESCIA, CIMINO and APPELL 1966

J CIMINO K APPELL M BRESCIA

The first version was a side to side, but rapidly, the side to end fashion was widely used

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Side to side

Side to end

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RADIO-CEPHALIC FISTULA BRACHIO-BASILIC FISTULA BRACHIO-CEPHALIC FISTULA ULNO-BASILIC FISTULA Snuffbox fistula

SURGICAL FISTULA WIDESPREAD OPTIONS

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PERCUTANEOUS FISTULA

PERCUTANEOUS FISTULA ONE FITS FOR ALL CASES?

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What is the real problem with scars?

Which one do you prefer?

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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

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

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It is all about the perforating vein

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ELBOW FISTULAE

Brachio-cephalic fistula Basic anatomy

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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?

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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?

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ELBOW FISTULAE

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

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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

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

ELBOW FISTULAE

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Anastomosis preferably on the beginning of the radial artery

ELBOW FISTULAE

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Brachio-basilic fistula on the median basilic vein Brachio-basilic fistula on the upper part of the forearm basilic vein

ELBOW FISTULAE: OTHER CASES

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The river SEINE with his unique channel allows big boats

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The river LOIRE with his multiple channels allows only small boats

Chaumont sur Loire

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The river LOIRE and SEINE can also expect floodings

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PRO AND CONS FOR ELBOW FISTULAS

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

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Are we creating too much elbow fistulae?

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Mapping of bad quality?

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Mapping by the surgeon in warm conditions

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Warm air tunnel for upper arm

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

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Was the selection good? Picture after TVA technic

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SOME REASONS TO USE THIS DEVICE

  • No vein in the forearm, and thrombosis of the median

basilic vein

  • Skin pathology near the intended scar?
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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?
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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

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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

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« You have the choice between percutaneous and

  • pen fistula. You prefer percutaneous,

and you will (could) have open surgery.

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« You have the choice between percutaneous and

  • pen fistula. You prefer percutaneous,

and you will (could) have open surgery.

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

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