CHALLENGES IN DIALYSIS ACCESS Abbott Vascular Speaker, Abbott - - PowerPoint PPT Presentation

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CHALLENGES IN DIALYSIS ACCESS Abbott Vascular Speaker, Abbott - - PowerPoint PPT Presentation

Mar 05, 2024 16 likes •116 views

DISCLOSURES Healthcare Professional Consultant & Trainer - CHALLENGES IN DIALYSIS ACCESS Abbott Vascular Speaker, Abbott Vascular Niren Angle, MD, RVT, FACS Vascular Surgery & Endovascular Therapy, EBCVT Lieutenant Colonel, USAF,

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CHALLENGES IN DIALYSIS ACCESS

Niren Angle, MD, RVT, FACS

Vascular Surgery & Endovascular Therapy, EBCVT Lieutenant Colonel, USAF, MC Travis AFB, CA

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DISCLOSURES

¥ Healthcare Professional Consultant & Trainer -

Abbott Vascular

¥ Speaker, Abbott Vascular

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COMPLICATIONS

Central venous obstruction Ischemic steal syndrome Graft thrombosis Graft infection

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STEAL SYNDROME Grade of Ischemic Steal

¥ Grade 1: Discoloration without pain ¥ Grade II : Pain during exercise or during dialysis ¥ Grade III : Ischemic pain at rest ¥ Grade IV :Tissue loss/necrosis/gangrene

Pelle MT, Miller III OF. Arch Dermatol. 2002 4

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STEAL SYNDROME

CAUSES Blood ßow restriction to the hand from arterial occlusive disease either proximal

  • r distal to the AV access anastomosis

Excess blood ßow through the AV Þstula conduit (true steal) Lack of vascular (arterial) adaptation or collateral ßow reserve (ie atherosclerosis) to the increased ßow demand from the AV conduit

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ISCHEMIC STEAL

¥ 68 year old

woman - ESRD

¥ Liver transplant ¥ Inadequate

superÞcial veins

¥ Right upper

arm AV graft

¥ Hand pain and

numbness 3-4 weeks post-op

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ISCHEMIC STEAL

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¥ DRIL procedure ¥ Improvement but marginal ¥ Duplex with digit pressures ¥ Patent graft ¥ Normal velocities ¥ Digital pressures improved but

not normal (DBI 0.4) Occlusion of the graft

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SLIDE 3

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THE DISEASED ARTERY

¥ 62 year old woman with previous left arm Þstula ¥ Hand pain for a year ¥ Repeated angioplasty of radial and ulcer arteries ¥ No resolution of pain ¥ Fistula deep

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ASSESSING CAUSE OF ISCHEMIA

¥ Inßow issue? ¥ Outßow issue? ¥ Retrograde ßow?

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Ulnar artery

RIGHT ARM BRACHIOCEPHALIC FISTULA

¥ Duplex vein mapping ¥ Arterial duplex ¥ Digital-brachial pressures

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SLIDE 4

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Given the runoff, I recommend simultaneous access and DRIL procedure to eliminate pressure drops across stenoses.

UPPER ARM ARTERIOVENOUS GRAFT

¥ 67 year old woman, non-

diabetic

¥ Upper arm arteriovenous

graft with venous outßow stenosis

¥ Right hand numbness ¥ Claw hand

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SLIDE 5

STEAL SYNDROME

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STEAL SYNDROME

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DRIL PROCEDURE

ISCHEMIC STEAL

¥ Previous radio-

cephalic Þstula (ligated)

¥ Small or diseased

ulnar artery

¥ Proximal Þstula ¥ Hand steal - pain

and numbness

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RELIANCE ON OTHERS

¥ Persistent pain/

numbness particularly on dialysis

¥ Palpable radial pulse ¥ Arteriogram ¥ Diminutive ulnar

artery

¥ Radial artery

widely patent

¥ Duplex

ÒremarkableÓ

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SLIDE 6

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CENTRAL VENOUS OBSTRUCTION

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PREVIOUS CATHETER PACEMAKER WIRES SVC SYNDROME

MANIFESTATION OF VENOUS HYPERTENSION

¥ Arm swelling ¥ Low access ßows ¥ High venous pressures ¥ Prolonged bleeding on

decannulation

¥ Facial swelling

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Duplex not useful for central venous obstruction CT venogram also of little use Angiogram of central venous system

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SLIDE 7

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CENTRAL VENOUS OCCLUSION

35 YEAR OLD MAN

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CENTRAL VENOUS OCCLUSION

35 YEAR OLD MAN

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RIGHT ANTERIOR MINI-THORACOTOMY

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Right axillary to SVC bypass with right upper arm AV graft

MASSIVE RIGHT ARM & FACIAL SWELLING!

42 YEAR OLD WOMAN

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MASSIVE RIGHT ARM & FACIAL SWELLING!

42 YEAR OLD WOMAN

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MASSIVE RIGHT ARM & FACIAL SWELLING!

42 YEAR OLD WOMAN

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SURGICAL OPTIONS FOR THE UNCROSSABLE CENTRAL VENOUS OCCLUSION

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BRACHIOCEPHALIC VEIN OCCLUSION & BREAST SWELLING

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BRACHIOCEPHALIC VEIN OCCLUSION

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BRACHIOCEPHALIC VEIN OCCLUSION & BREAST SWELLING

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CENTRAL VENOUS CATHETER

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TIPS

¥ Arm swelling after access - central venous stenosis or

  • bstruction till proven otherwise

¥ Signs of venous hypertension - ulcers, hyper pigmentation,

numbness

¥ Catheter in place - must remove ¥ Venogram best option for diagnosis and treatment ¥ PTA alone versus stunting

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COMPLICATIONS? WHAT COMPLICATION?