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

4/15/2016 Disclosures Therapeutic Options to Dialyze the Patient With Central Venous • I have no relationships to disclose Occlusion • I am not discussing the off label use April 15, 2016 of anything Robert C. Harland, MD FACS Professor of Surgery Vice Chair, Academic Affairs University of Arizona College of Medicine- Tucson How long does it take to create a central stenosis? Central Venous Occlusion is an increasing problem Not long! – Long-Term Hemodialysis catheters • One month with a – Pacemaker/AICD leads hemodialysis catheter – Central venous ports and catheters for • Even one catheter decreases chances of a TPN, and long-term IV medications successful AV access in – Venous stents the extremity – Intimal injury from longstanding high • Even after the catheter flow AV access? is removed, the risk of central stenosis – Radiation, Cardiac surgery, etc. persists. 1

4/15/2016 Angioplasty/Stenting of Angioplasty/Stenting of Central Venous Pathology Central Venous Pathology • 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. 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 Efficacy of covered stent placement for central venous occlusive 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) 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) HeRO device: a removable stent HeRO Details • Hemodialysis Reliable Outflow • Allows new access creation in patients with central stenosis or occlusion • Salvages access in patients who develop • Fully implantable device symptomatic central • Classified as a graft • Comparable patency rates, infection rates and Kt/V to AV grafts venous stenosis • 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 2

4/15/2016 HeRO: Long-term outcomes Dialysis patients with Central Venous Obstruction/Stenosis fall into two main groups Review of 8 studies totaling 409 patients through 2014 1. Those who need permanent 2. Those with a “functioning” AV One year Primary Secondary Steal Bacteremia outcomes Patency Patency Syndrome Rate vascular access: access: – Usually dialyzing with a – Decreased clearance on Mean 21.9% 59.4% 6.3% catheter, often in the groin. dialysis – Need evaluation of the – Repeated access thrombosis Range 9.6-37.2% 39.4-78% 1-14.7&% 0.13-0.7 venous anatomy. – Swollen extremity events/1000 – Need to make plans for – “Heavy, aching” extremity, days dialysis while access heals especially towards the end of (now able to use immediate a dialysis treatment stick graft) A Review on the Hemodialysis Reliable Outflow – High venous pressures (HeRO) Graft for Haemodialysis Vascular Access – Bleeding after needle removal Al Shakarchi J, Houston JG, Jones RG, Inston N 2015 Jul;50(1):108-13. – Swollen neck, face and/or breast Tips for HeRO insertion Etiology of Breast/Chest wall swelling • Key thing is getting a wire in the right atrium. • Increased blood flow through chest wall collaterals. – Multi-disciplinary approach may be helpful( • Traditional treatment was to ligate the AV access – Supraclavicular placement preferred to infraclavicular • If access to right atrium is possible, Hero is an • 7 mm balloon helps prepare the tract and can be option to keep the access 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 output or arterial inflow 3

4/15/2016 Sometimes you don’t have to do anything about central venous Unusual HeRO options obstruction • 19 patients: construction of AVF with known central Cross-over to other jugular vein to salvage an existing AV fistula 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 4