Disclosures The problem: Gore Vascular- Consultant As fistulas - - PowerPoint PPT Presentation

4/20/2013 1 AV Fistula Salvage: Devising a Plan for Aneurysmal Degeneration Jason Burgess, MD RVT Surgical Specialists of Charlotte CMC-Mercy Charlotte, NC

Disclosures

Gore Vascular- Consultant Covidien- VNUS physician educator and consultant

The problem:

As fistulas become more prevalent in the United States with initiatives like Fistula First, we are managing more chronic fistulas that are several years old Over time aneurysmal degeneration may threaten the longevity of an AV fistula

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What am I going to discuss?

5 stages of progression of aneurysmal degeneration of AV fistulas Indications for treatment of AV fistulas Types of treatment for aneurysms of AV fistulas with examples Treatment for pseudoaneurysms of AV GRAFTS

Stage 1

Skin is normal

Stage 2

Skin becomes shiny

Suggested Treatment: Observe

Stage 2

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Stage 3

Hypopigmented skin

Suggested Treatment:

• bserve vs elective

sequential repair

Stage 3

Hypopigmented skin

Stage 4

Escar

Suggested treatment: Repair 0-2 Days

Stage 5

Open Ulcer Suggested treatment: Operate today!!

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Indications for Intervention

The quality of the overlying skin is almost always the most important factor in deciding if and when to repair an aneurysm

Indications for Intervention

Impending Rupture – 90+% of

• interventions. Thin skin with escar.

Pain at a joint, limited mobility Interference with wearing shirt Congestive Heart Failure- 3-8 L/Minute of volume flow Hypopigmentation- with two aneurysms and room to access above or below

Considerations:

Quality of skin is paramount Important to avoid the need for permcath Rule out outflow obstruction (?fistulagram at aneurysm repair?)

Key points of procedure:

Local with Sedation Tourniquet without systemic heparin Remove thin skin +/- reduce size of aneurysm Raise skin flaps to cover fistula Close in two layers (skin staples) 6 weeks to allow cannulation of fistula in this area

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Example #1- Aneurysm reduction

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4/20/2013 8 Example #2- Aneurysm Reduction

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4/20/2013 11 Example #3- Sequential aneurysm repair: BVT with two aneurysms with thin skin and hypopigmentation

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3/13/13- Doing well Start cannulating access Schedule aneurysm #2 repair

3/28/13

4/20/2013 14 Example 4: AV graft pseudoaneurysm repair

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Final thoughts

The lifespan of AV fistulas can be prolonged indefinitely with timely repair

• f aneurysms that are at risk for rupture

with a somewhat simple revision Careful examination of the quality of the skin overlying the aneurysm will help in deciding when/if to operate This staging system may help dialysis units communicate with surgeons about the urgency of referral/repair

Thank You

jburgess@ssclt.com

References available upon request