No disclosures Warren Gasper MD UCSF Vascular Surgery 4/15/2016 2 - - PowerPoint PPT Presentation

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Cannulation Related Complications Delay the Use

• f AVFs In a Significant Number of Patients

Can anything be done about it?

4/15/2016

Warren Gasper MD UCSF Vascular Surgery

No disclosures

2 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Initiating hemodialysis with an arteriovenous fistula has superior

• utcomes, largely due to avoiding catheter-related infections,

complications and death Fistula maturation is a major hurdle: it takes time, yet it’s unpredictable

• Non-maturation rates are 20-60%

Tools have been developed to predict whether a fistula is mature:

• Rule of 6’s: ≥6mm diameter, ≤6mm deep, ≥600ml/min flow
• Bandyk “5-minute AVF protocol”: ≥600ml/min flow, brachial artery

EDV/PSV >0.4, ≥6mm diameter, ≤6mm deep, >10cm length

Arteriovenous Fistula Maturation

3 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 KDOQI Am J Kid Dis 2006 | Semin Vasc Surg 2013 26:120–126

47 patients with AVFs had a major infiltration between 2000-2004 All events required new or prolonged catheter use Incidence was 5.2% per patient-year Odds ratio for a major needle infiltration in new (<6 mo) vs established (>6 mo) AVF was 2.98 (95% CI 1.61 - 5.54) P<.0004)

Cannulation complications

4 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 Am J Kidney Dis 2006 47: 1020-1026

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Is this fistula mature?

72 year old man with HTN, DM, CKD stage 4 with deteriorating renal function (eGFR 28) who had a left brachiocephalic AVF placed in anticipation of hemodialysis Over the next 7 months his renal function declines and hemodialysis is recommended He has a strong thrill over the AVF Fistula cannulation is attempted twice but is unsuccessful due to infiltration Arm is now bruised, painful and swollen…

5 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 6 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Mean velocity: 194 cm/s Brachial artery diameter: 6mm Mean velocity: (PSV-EDV)/3 + EDV Volume flow: >2000ml/min

7 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Fistula depth is 11mm – too deep Fistula diameter is 6mm – adequate

6mm 11mm

8 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Pre-cannulation ultrasound Flow <600ml/min? Fistulagram / Revision Depth >6mm? Superficialize Diameter <6mm? Fistulagram / Revision

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9 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Open Fistula Elevation

Brondor J Am Coll Surg 2008;206:1069–1075 10 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Lipectomy

J Vasc Surg 2009;50: 369-74. 11 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Ultrasound-guided liposuction

Causey J Vasc Surg 2010;52:1397-400 12 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 Jennings J Vasc Surg 2014;60:1024-32

Venous Window Needle Guide (VWING)

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13 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Pseudoaneurysm

14 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

ReTAP patch

Avoiding cannulation-related complications

3 weeks later the patient successfully initiated dialysis Never needed a catheter Fistula has been functioning without intervention for the past year

15 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 16 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016

Re-TAP patch

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Summary

Cannulation-related complications cause significant delays in fistula access and are most likely to occur in new fistulas (<6mo) Cannulation-related complications may be predicted

17 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 18 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 J Vasc Surg 2009;50: 369-74.

Summary

Cannulation-related complications cause significant delays in fistula access and are most likely to occur in new fistulas (<6mo) Cannulation-related complications may be predicted

• Physical exam
• Pre-cannulation ultrasound

A proactive, preventative management strategy of deep and/or small fistulas may reduce cannulation complications and reduce catheter days

19 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016