Pierre Bourquelot, Paris 1 I have no potential conflict of interest - - PowerPoint PPT Presentation

Pierre Bourquelot, Paris

1

I have no potential conflict of interest Pierre Bourquelot

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Original Reduction Procedures

Proximal Radial Artery Ligation

Retrograde Flow Proximal Artery Ligation Bourquelot P et al. Eur J Vasc Endovasc Surg 2010

Proximal Radial Artery Ligation

Cephalic Vein Distal Radial Artery Proximal Radial Artery Ligation

Proximal Radial Artery Ligation

P.Bourquelot et al. Eur J Vasc Endovasc Surg (2010)

7 Children 7 Children 27 Adults 27 Adults Flow Flow 2.451 mL/min 2.451 mL/min per 1.73 m per 1.73 m² ² 1.883 mL/min 1.883 mL/min per 1.73 m per 1.73 m² ² Reduction rates Reduction rates 50 % 50 %   11 11 53 % 53 %   16 16

Proximal Radial Artery Ligation Patency rates

74% 78%

Brachial-based AVF High-Flow Reduction

1.Banding 2.Distalisation of the Artery Anastomosis 3.Revision Using Distal Inflow (RUDI) 4.Radial Artery Transposition

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Banding is rarely effective, whatever the technique.

• Peroperative flowmetry may

be inaccurate due to spasm

• More than 80% reduction of

caliber is necessary

• 2 major post-operative risks :

 Persistent high flow  Thrombosis

• Many patients with

recurrent H-F referred to us

• and…

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MILLER

H-F Recurrence after Banding

• 50 patients, H-F > 2 L/min
• Brachial artery based AVF
• Reduction rate >50% initial flow
• Recurrent H-F (>2 L/min)

developed in 52% of patients during a 1 year follow-up (upper curve).

• Risk factors were:
• immediate post-banding flow

>2L/min

• young age

Vaes Tordoir et al. JVS 2014

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>2 L/min <2 L/min

2 L

Brachial AVF High-Flow Reduction

1.Banding 2.Distalisation of the arterial anastomosis 3.RUDI 4.Radial Artery Transposition

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Distalization of the arterial anastomosis

• We reported that in 1989,

at the 1st Gore US Angioaccess meeting

12 Bourquelot, P., Corbi, P., Cussenot, O. Surgical improvement of high-flow arteriovenous fistulas. in: B.G. Sommer, M.L. Henry (Eds.) Vascular access for hemodialysis. W.L. Gore & Associates Inc., Pluribus Press Inc, New York; 1989:124–130.

Distalization of the arterial anastomosis

• We reported that in

1989, at the 1st Gore US Angioaccess meeting

• 21 patients, with high-

flow elbow AVF, 6 mm thin-wall PTFE from the wrist to the elbow

13 Bourquelot, P., Corbi, P., Cussenot, O. Surgical improvement of high-flow arteriovenous fistulas. in: B.G. Sommer, M.L. Henry (Eds.) Vascular access for hemodialysis. W.L. Gore & Associates Inc., Pluribus Press Inc, New York; 1989:124–130.

Distalization of the arterial anastomosis

• We reported that in 1989,

at the 1st Gore US Angioaccess meeting

• 21 patients, with high-flow

elbow AVF, 6 mm thin-wall PTFE from the wrist to the elbow

• Reduction rate: 50%  23
• No recurrence after 2years

14 Bourquelot, P., Corbi, P., Cussenot, O. Surgical improvement of high-flow arteriovenous fistulas. in: B.G. Sommer, M.L. Henry (Eds.) Vascular access for hemodialysis. W.L. Gore & Associates Inc., Pluribus Press Inc, New York; 1989:124–130.

Brachial AVF High-Flow Reduction

1.Banding 2.Distalisation of the arterial anastomosis 3.RUDI 4.Radial Artery Transposition

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RUDI (proximal radial artery)

• Minion et al. 2005
• 4 patients
• 2 to 3 cm distal to the

brachial a. bifurcation

• Flow rates: not reported
• Too short distalization ?

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RUDI (Proximal radial artery)

• Vaes et al. 2014
• 19 patients
• >2 L/min asymptomatic
• 6 to 8 cm extension
• 15 G Saphen.V. / 4 Basilic V.

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Vaes et al. JVA 2014

RUDI (Mid forearm radial artery)

• Initial reduction >50%
• During 1 year observation,

the flow remained well below 2 L/min except 3 pts. when the Basilic V. had been used.

B

• t

h g r

• u

p s GSV Basilic V

Vaes et al. 2014

2 L

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Brachial AVF High-Flow Reduction

1.Banding 2.Distalisation of the arterial anastomosis 3.RUDI 4.Radial Artery Transposition

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Transposition of the Radial Artery

We imagined TRA to avoid the risks of RUDI procedures:

1.

Dilatation of the upper radial artery, with recurrence of high- flow

2.

Stenosis of the venous anastomosis of the PTFE/Vein with fistula thrombosis The interposed vein or PTFE is replaced by the radial artery to increase the length and reduce the caliber

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Transposition of the Radial Artery

• Using preventive

hemostasis with an inflatable tourniquet

• Previous arteriovenous

anastomosis at the elbow is divided

• The radial artery is

dissected free outside its two veins…

• =

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Bourquelot JVS 2009 Bourquelot JVS 2009

Transposition of the Radial Artery

…divided at the wrist and turned upwards to reach the vein above the elbow. The new anastomosis is performed using a microscope. N= 47 patients. Technical failures were treated by 2 redos and 2 abandons.

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Transposed radial artery Bourquelot JVS 2009 Bourquelot JVS 2009

Transposition of the Radial Artery Indications

Bourquelot JVS 2009 Bourquelot JVS 2009

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Reduction rate

43 patients (7>16 years, range 3 43 patients (7>16 years, range 3-

• 82 )

82 )

Mean preop.flow Mean preop.flow 2 2   0.3 L/min per 1.73 m 0.3 L/min per 1.73 m² ² Men reduction rate Men reduction rate 66 66% %   14 14

Bourquelot JVS 2009 Bourquelot JVS 2009

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Transposition of the Radial Artery

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• No recurrence of high-

flow was observed at 48 months

• Patency rates:

40% and 70% at 3 years

40% 70% Bourquelot JVS 2009 Bourquelot JVS 2009

Transposition of the Radial Artery 3 years later

Bourquelot JVS 2009 Bourquelot JVS 2009

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pierre@bourquelot.fr

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