Echoguided Angioplasty of Arteriovenous Hemodialysis Fistula Venous - - PowerPoint PPT Presentation

Olivier Pichot – Carmine Sessa Grenoble

Echoguided Angioplasty of Arteriovenous Hemodialysis Fistula Venous Stenosis

• Systematic echo

guidance

– Distal veins

• Fluoroscopic

guidance

– Cephalic arch – Central v.

• AVF DU analysis

– Brachial flow, RI – Stenosis characterization :

• PSV,
• Diameter, localization, type
• Mapping

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• Choice of the vascular access site
• Choice of the

appropriate balloon

• Length & diameter
• Type:
• Regular
• Coated
• High pressure
• Cutting

4

Preoperative DU and PTA management: (Doelman 2005)

• Optimize the choice of the cannulation site in 38% of cases
• Reduce the number of access punctures
• Avoid extra session to perform PTA and shorten examination time
• Avoid extra burden for the patient

Preoperative DU and PTA management: (Doelman 2005)

• Optimize the choice of the cannulation site in 38% of cases
• Reduce the number of access punctures
• Avoid extra session to perform PTA and shorten examination time
• Avoid extra burden for the patient

« Surgery like » set-up

Sterilized supplies

Sterilized supplies

• 1. Venous (or arterial) access
• 2. Introducer tip positioning
• 3. Guide wire catheterization of the vein

(and/or of the artery and anastomosis)

• 4. Balloon positioning
• 5. Balloon inflation
• 6. Angioplasty result analysis:

– Stenosis release – Hemodynamic result (local, access flow) – Complication

• Non systematic EG
• Mandatory (very useful)

– Drainage vein

• Maturation delay
• Retrograde catheterization
• Obesity

– Brachial artery

• Radial or ulnar artery PA

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1.Vascular access

• Mandatory (very useful) EG if:

– Short distance between the vein access site & the stenosis

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2 cm

• 3. Catheterization

• 4. Balloon positioning

• 4. Balloon positioning

• 5. Balloon inflation

• 6. Result evaluation

• Retrospective study

– January 2016 to June 2018 – PTA of any stenosis in any AVF

• Echo guided PTA

– Success criteria

• Velocity normalization :

– No aliasing – PSV < 3m/s

• No anatomical residual stenosis

– Vein diameter normalization /adjacent venous segment – Diameter ≥ 5 mm

• Fluoroscopic guidance

– Success criteria

• No anatomical residual stenosis (>50%)
• No residual collateral vein visualization

• Complications

– Cephalic v. rupture 2.4 % (n=) 2

• Complications

– Perivenous hematoma 2.4 % (n=) 2

• Complications

– Extended dissection 21.7 % (n=) 18

• Successful prolonged compression

19.3 % 16

• Residual stenosis

2.4 % 2

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Patients Access PTA Technical succes Complications (n)

Baccini 2000

9

Graft 12 Stent (2)

100%

Napoli 2007

7

AVF artery 7 Stent (2)

100%

Ascher 2009

25

AVF vein 32

100%

1 rupture 1 dissection Fox 2011

125

AVF Graft 223 Stent (5)

98%

2 hematoma / 6 false aneurysm 8 endoluminal thrombosis / 3 ruptures Gorin 2012

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AVF vein 55

93%

2 catheterization failure 4 hematoma including 3 thrombosis Gallagher 2012

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AVF vein 185

95.5%

1 rupture

total N = 241 N = 514 93-100% n = 31 (6%)

• Avoids the risk linked to radiation exposure

– Patients – Medical team

• Avoids the risk linked to contrast agent using

– Allergy – Néphrotoxicity

• Reduction of the duration of the procedure
• Reduction of the cost

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Fox D et al. Duplex guided dialysis access interventions can be performed safely in the

• ffice setting: techniques and early results. Eur J Vasc Endovasc Surg. 2011
• “In office” practice

• Security and accuracy of the vascular access
• Real time monitoring of all the procedure steps
• Vein and/or catheter mobilization maneuver
• Real time assessment of the procedure outcome

– Anatomical – Hemodynamic +++ – Immediate and postponed (recoil)

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• A valuable alternative to fluoroscopy for upper

limbs veins PTA (cephalic & basilic veins)

• Allows a precise and continuous monitoring of all

the steps of the angioplasty

• Provide anatomical and hemodynamic data
• Avoid X rays and contrast
• Save time (and money!)
• But requires ultrasound skill… and accepting to

change your fluoroscopic usual references!

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