Interventions to Interventions to Improve Access Patency Improve - PowerPoint PPT Presentation

4/7/2017 Disclosures Interventions to Interventions to Improve Access Patency Improve Access Patency • Scientific Advisor for Arrow Interventional, Inc. Mark. W. Wilson, M.D. Mark. W. Wilson, M.D. Professor of Radiology and Professor of Radiology and Biomedical Imaging Biomedical Imaging UCSF UCSF Hemodialysis Access AVF and Graft Monitoring Parameters Fistula Complications: • Elevated Venous Pressures 1. Stenosis (Sensitivity 86% , Specificity 93%) 2. Thrombosis • Urea Recirculation (Sensitivity ? , Specificity 82%) 3. Venous or Graft Aneurysms and Pseudoaneuryms • Duplex Doppler Sonography 4. Arterial Steal 1

4/7/2017 Dialysis Arteriovenous Fistulas Dialysis Grafts Distribution of Stenoses Distribution of Stenoses - Venous Anastomosis 47% - Peripheral Basilic Vein 19% Radiocephalic 85% - W/in 1 cm of Venous Anast. 11% AVF - Central Basilic Vein 8% - Subclavian Vein 6% - Arterial Anastomosis 4% - Mid-graft 2% - Axillary Vein 2% Kanterman, Radiology 195 Rajan, Radiology 232(2) Dialysis Arteriovenous Fistulas Dialysis Fistula Stenosis: Distribution of Stenoses Treatment Options • Surgical Revision Brachiocephalic AVF • Balloon Dilatation • Endoluminal Stenting Rajan, Radiology 232(2) 2

4/7/2017 PTA @ AV Anastomosis PTA @ Venous Anastomosis Dual Balloon Subclavian Venoplasty PTA of Long Segment AVF Stenosis 3

4/7/2017 PTA of arterial-to-arterial graft stenosis Dialysis Arteriovenous Fistulas Median Primary Patency Post-Angioplasty Brachiocephalic AVFs: 6 – 7 months Radiocephalic AVFs: 19 – 20 months Rajan, Radiology 232(2) Dialysis Fistula/Graft Stenting: Dialysis Arteriovenous Fistulas Indications Median Secondary Patency Post-Angioplasty • Treatment of Stenoses Resistant to Balloon Dilatation Brachiocephalic and Radiocephalic AVFs: 70 mos. • Treatment of Venous Rupture or Dissection • Exclusion of Pseudoaneuryms Rajan, Radiology 232(2) 4

4/7/2017 Brachiobasilic AVF stenosis Venoplasty, vein rupture, extravasation of contrast • Prospective, multi-center, randomized trial • 190 pts. With failing AV grafts due to venous anastomotic stenoses • Compared AV graft angioplasty with stent graft placement • Results: – 6 month patency at treatment area was greater in stent graft grp (p<0.001) – 6 month patency of overall circuit was greater in stent graft grp (p=0.008) Treatment: Exclusion by stent graft – 6 month restenosis rate was lower in the stent graft grp (p<0.001) 5

4/7/2017 Recurrent outflow stenosis, Treatment: stent graft across stenosis suboptimal venoplasty result AVF-AVG Thrombosis: Hemodialysis Access Treatment Options Fistula Complications: 1. Stenosis 1. Surgical Thrombectomy +/- Revision 2. Thrombosis 2. Surgical Creation of a New HDAF 3. Venous or Graft Aneurysms and 1. Percutaneous Interventional Pseudoaneuryms Declotting Techniques: > Pharmacologic Thrombolysis 4. Arterial Steal > Mechanical Thrombectomy 6

4/7/2017 AFV-AVG Declotting Techniques AFV-AVG Declotting Techniques • Pharmacologic Thrombolysis: • Pharmacologic Thrombolysis: > Agent: Tissue Plasminogen Activator – Transcatheter Pulse-Spray – Lyse-And-Wait > TPA Dose Range: – Lyse-And-Go 1-2 mg Intra-Graft/Fistula – Continuous Infusion > Supplemental Heparin: 3000-5000 U Intra-Graft or Systemic Multi-Sidehole Fibrin Plug Removal Thrombolytic Infusion Catheter 7

4/7/2017 AFV and AVG Thrombolysis Patency Rates Dialysis Fistula Fibrinolysis: Tseke, Artificial Organs 35(1) Complications 40 thrombosed access sites underwent rt-PA thrombolysis • Hemorrhagic > Primary success rate was 55% • Local Bleeding > Primary patency was 90.9% and 69.8% (e.g., puncture sites) at 30 and 90 days respectively • CNS > No difference in outcomes between AV fistulas and grafts • Other Organ Systems > No major complications Puncture Site Hemorrhage Controlled by Manual Compression Pre Post Hemorrhage following thrombolysis and PTA Treatment: stent graft exclusion 8

4/7/2017 AFV/AVG Declotting Techniques Treretola PTD • Mechanical Thrombectomy Devices: – Treretola PTD – Angiojet Thrombectomy Catheter – Trellis Infusion System – Amplatz Clot Buster – Penumbra Indigo System – Cleaner Device Trellis Infusion System Possis Angiojet 9

4/7/2017 Amplatz Clotbuster Thrombolysis and Thrombectomy Hemodialysis Access Results Fistula Complications: 1. Stenosis 2. Thrombosis 3. Venous or Graft Aneurysms and Pseudoaneuryms Bottom Line: 4. Arterial Steal Preserve access sites as long as possible 10

4/7/2017 Venous or Graft Aneurysms and Venous or Graft Aneurysms and Pseudoaneuryms: Etiologies Pseudoaneuryms: Complications 1. Inadequate hemostasis at puncture sites 1. Mass effect and AVF compression 2. Trauma (e.g., venoplasty-induced) 2. Thrombotic nidus, inducing thrombosis of AVF/AVG 3. Flow dynamics 3. Rupture, subcutaneously or externally 4. Infection 4. Septic emboli if mycotic Venous or Graft Aneurysms and Pseudoaneuryms: Treatment- Depends on Etiology 1. Graft removal 2. Surgical revision 3. Antibiotic therapy as indicated 4. Stent graft exclusion 4. US-guided thrombin injection 11

4/7/2017 Venoplasty-induced venous aneurysm – thrombin injection Venoplasty-induced venous aneurysm - stent graft exclusion Arterial Steal Syndrome Hemodialysis Access Defn: Vascular insufficiency resulting from an AVF or AVG Fistula Complications: Clinical Presentation: 1. Stenosis 1. Ipsilateral hand pain 2. Thrombosis 1. Diminished pulses distal to fistula 3. Venous or Graft Aneurysms and Pseudoaneuryms 2. Wrist/brachial BP ratio < 0.6 4. Arterial Steal 4. Necrosis 12

4/7/2017 Arterial Steal Syndrome Arterial Steal Syndrome Role of IR: Diagnosis Procedure: UE arteriography with and without AVF/AVG compression Treatments: 1. Surgical revascularization (e.g., DRIL procedure) 1. Banding or plication (e.g., Miller banding) 2. Surgical ligation and placement at alternate site Without Compression With Compression Thank You 13