Disclosures Therapeutic Options to Dialyze the Patient With Central - - PowerPoint PPT Presentation

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Therapeutic Options to Dialyze the Patient With Central Venous Occlusion

Robert C. Harland, MD FACS Professor of Surgery Vice Chair, Academic Affairs University of Arizona College of Medicine- Tucson

April 15, 2016

Disclosures

• I have no relationships to disclose
• I am not discussing the off label use
• f anything

Central Venous Occlusion is an increasing problem

– Long-Term Hemodialysis catheters – Pacemaker/AICD leads – Central venous ports and catheters for TPN, and long-term IV medications – Venous stents – Intimal injury from longstanding high flow AV access? – Radiation, Cardiac surgery, etc.

How long does it take to create a central stenosis? Not long!

• One month with a

hemodialysis catheter

• Even one catheter

decreases chances of a successful AV access in the extremity

• Even after the catheter

is removed, the risk of central stenosis persists.

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Angioplasty/Stenting of Central Venous Pathology

• Efficacy of covered stent placement for central venous occlusive

disease in hemodialysis patients

Javier E. Anaya-Ayala, MD, Christopher J. Smolock, MD, Benjamin D. Colvard, BA, Joseph J. Naoum, MD, Jean Bismuth, MD, Alan B. Lumsden, MD, Mark G. Davies, MD, PhD, MBA, Eric K. Peden, MD Journal of Vascular Surgery Volume 54, Issue 3, Pages 754-759 (September 2011)

Angioplasty/Stenting of Central Venous Pathology

• Efficacy of covered stent placement for central venous occlusive

disease in hemodialysis patients

Javier E. Anaya-Ayala, MD, Christopher J. Smolock, MD, Benjamin D. Colvard, BA, Joseph J. Naoum, MD, Jean Bismuth, MD, Alan B. Lumsden, MD, Mark G. Davies, MD, PhD, MBA, Eric K. Peden, MD Journal of Vascular Surgery Volume 54, Issue 3, Pages 754-759 (September 2011)

• Multiple studies have shown good short term results with nearly

universal need for repeat procedures.

• Stenting, especially with covered stents, appears to increase the

length of time between interventions.

HeRO device: a removable stent

• Hemodialysis Reliable

Outflow

• Allows new access

creation in patients with central stenosis

• r occlusion
• Salvages access in

patients who develop symptomatic central venous stenosis

HeRO Details

• Fully implantable device
• Classified as a graft
• Comparable patency rates, infection rates and Kt/V to AV grafts
• Can be attached to an existing graft or AV fistula
• A ‘universal’ connector is now available—but only approved to

attach a Flixene SW or an Acuseal graft

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HeRO: Long-term outcomes

One year

• utcomes

Primary Patency Secondary Patency Steal Syndrome Bacteremia Rate Mean 21.9% 59.4% 6.3% Range 9.6-37.2% 39.4-78% 1-14.7&% 0.13-0.7 events/1000 days A Review on the Hemodialysis Reliable Outflow (HeRO) Graft for Haemodialysis Vascular Access Al Shakarchi J, Houston JG, Jones RG, Inston N 2015 Jul;50(1):108-13.

Review of 8 studies totaling 409 patients through 2014

Dialysis patients with Central Venous Obstruction/Stenosis fall into two main groups

• 2. Those with a “functioning” AV

access: – Decreased clearance on dialysis – Repeated access thrombosis – Swollen extremity – “Heavy, aching” extremity, especially towards the end of a dialysis treatment – High venous pressures – Bleeding after needle removal – Swollen neck, face and/or breast

• 1. Those who need permanent

vascular access: – Usually dialyzing with a catheter, often in the groin. – Need evaluation of the venous anatomy. – Need to make plans for dialysis while access heals (now able to use immediate stick graft)

Etiology of Breast/Chest wall swelling

• Increased blood flow through chest wall collaterals.
• Traditional treatment was to ligate the AV access
• If access to right atrium is possible, Hero is an
• ption to keep the access

Tips for HeRO insertion

• Key thing is getting a wire in the right atrium.

– Multi-disciplinary approach may be helpful( – Supraclavicular placement preferred to infraclavicular

• 7 mm balloon helps prepare the tract and can be

loaded into the outflow component as a “leader”

• Avoid excess outflow segment length
• Graft to connector segment is frequent kink location

– Place connector parallel to clavicle

• Avoid “bridging catheter” if possible—frequent

source of infection.

• Not a way to treat patients with inadequate cardiac
• utput or arterial inflow

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Unusual HeRO options

Cross-over to other jugular vein to salvage an existing AV fistula

Sometimes you don’t have to do anything about central venous

• bstruction
• 19 patients: construction of AVF with known central

venous occlusion with collaterals

• Mean post-op AVF flow rate 640 ml/min (415-910)
• 8 (42%) developed some arm edema

– 2 resolved, 2 had inflow banding, 1 outflow branch coiling, 4 recanalized with angioplasty

• Primary/Secondary patency rates:

– 12 months: 49% and 100% – 24 months: 39% and 80%

• /

Creating arteriovenous fistulas in patients with chronic central venous obstruction

William C. Jennings, Charles Miles Maliska, John Blebea, Kevin E. Taubman J Vasc Access. 2016 Feb 5

Thank you