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

4/20/2013 Jason Burgess, MD RVT AV Fistula Salvage: Devising a Plan for Surgical Specialists of Charlotte Aneurysmal Degeneration CMC-Mercy Charlotte, NC Disclosures The problem: � Gore Vascular- Consultant � As fistulas become more prevalent in the United States with initiatives like Fistula First , we are � Covidien- VNUS physician educator and managing more chronic fistulas that are several consultant years old � Over time aneurysmal degeneration may threaten the longevity of an AV fistula 1

4/20/2013 Stage 1 What am I going to discuss? Skin is normal � 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 2 Stage 2 Skin becomes shiny Suggested Treatment: Observe 2

4/20/2013 Stage 3 Stage 3 Hypopigmented skin Hypopigmented skin Suggested Treatment: observe vs elective sequential repair Stage 4 Stage 5 Escar Open Ulcer Suggested treatment: Repair 0-2 Days Suggested treatment: Operate today!! 3

4/20/2013 Indications for Intervention Indications for Intervention � Impending Rupture – 90+% of � The quality of the overlying skin is interventions. Thin skin with escar. almost always the most important � Pain at a joint, limited mobility factor in deciding if and when to repair an aneurysm � 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 Key points of procedure: Considerations: � Local with Sedation � Quality of skin is paramount � Tourniquet without systemic heparin � Important to avoid the need for � Remove thin skin +/- reduce size of permcath aneurysm � Rule out outflow obstruction � Raise skin flaps to cover fistula (?fistulagram at aneurysm repair?) � Close in two layers (skin staples) � 6 weeks to allow cannulation of fistula in this area 4

4/20/2013 Example #1- Aneurysm reduction 5

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

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

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4/20/2013 3/13/13- Doing well Start cannulating access Schedule aneurysm #2 repair 3/28/13 13

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

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4/20/2013 Final thoughts � The lifespan of AV fistulas can be prolonged indefinitely with timely repair of 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 16