Proximal radial artery AVFs: The best access for the majority of - - PowerPoint PPT Presentation

Department of Surgery Department of Surgery

Proximal radial artery AVFs: The best access for the majority of patients

William Jennings, MD FACS

PARIS - Friday, September 14th 2018 Institut Mutualiste Montsouris

DISCLOSURE POLICY It is the policy of The University

• f Oklahoma Health Sciences

Center College of Medicine to ensure balance, independence,

• bjectivity and scientific rigor in

all its educational programs. All faculty participating in these programs are expected to disclose to the program audiences any real or apparent conflict of interest related to the content of their presentation.

University of Oklahoma, Tulsa DaVita: Speaker Gore: Speaker Avenu Medical: Consultant

• St. John Medical Center

Vascular access for prevalent hemodialysis patients (2002)

81 93 9

4

24

20 40 60 80 100

Europe Japan United States

% of patients

Fistulas Grafts Catheters

10

3 52

24

Dialysis Outcomes and Practice Patterns Study (DOPPS)

AV Fistulas in use

Fistula First start date 2018

Catheters AV Grafts

U.S. Vascular Access Prevalence

Vassalotti JA, Jennings WC, Beathard GA, et al. Fistula First Breakthrough Initiative: Targeting Catheter Last in Fistula First. Seminars in Dialysis 25(3):303-310, 2012

63.3%

New England Journal of Medicine, Nov 17, 1966; 275(20) 1089-1092

A radiocephalic AVF remains the first choice for vascular access…..

………However, in my referral practice only 10-15% of individuals are identified as good candidates for a RC-AVF. Careful patient selection yields excellent results.

• Jennings WC, et al. Creating Radiocephalic Arteriovenous Fistulas: Technical and Functional Success. J Am Coll Surg. 2009

Mar;208(3):419-25

• Jennings WC, Parker DE. Creating arteriovenous fistulas using surgeon-performed ultrasound. J Vasc Access. 2016 Jul

12;17(4):333-9.

First choice….. when a functional AVF is expected to mature promptly. Ultrasound by the surgeon is a key element of success!

Median Antebrachial V. Cephalic V.

Median Cephalic V. Median Cubital V.

Proximal radial artery inflow AVFs account for 67% of the new access operations in my experience.

Jennings WC. Mallios A, Mushtaq N. Proximal radial artery arterovenous fistula for hemodialysis access. J Vasc Surg, 2018, Jan;6(1):244-253.

Many PRA-AVF venous outflow opportunities

Jennings WC. Mallios A, Mushtaq N. Proximal radial artery arterovenous fistula for hemodialysis access. J Vasc Surg, 2018, Jan;6(1):244-253. Jennings WC, Turman MA, Taubman KE. Arteriovenous Fistulas For Hemodialysis Access in Children and Adolescents Using the Proximal Radial Artery Inflow Site. J Ped Surg. J Pediatr Surg. 2009 Jul;44(7):1377-81 Jennings WC, Landis L, Taubman KE, Parker DE. Creating Functional Autogenous Vascular Access in Older

• Patients. J Vasc Surg. 2011 Mar;53(3):713-9

Cephalic v. Median antebrach. V. Radial art. Basilic v. Deep communicating V. Hand

Consider ligation

Proximal radial artery AVF Proximal radial artery AVF

Why use the PRA for inflow?

• Minimize risk of steal

syndrome

• Lower flow access than

brachial artery inflow (Cardiac status, outflow limitations…..)

• Ease of exposure and

mobilization

• Potential for bidirectional flow
• Ease of converting AV Grafts

to AVFs by avoiding previous

• perative sites

Hand Ischemia Risk

• Brachial artery inflow has as much as a ten fold higher risk
• f steal syndrome when compared with radial artery access

and more intense ischemia in affected patients

• Brachial access conversion to PRA inflow is often the

definitive treatment for steal syndrome while preserving a functional AVF.

• In a recent meta-analysis of PRA-AVFs only 0.5% of the

patients developed steal syndrome.

• Ischemic monomelic neuropathy (IMN) is a rare but severe

complication associated with brachial artery access, most

• ften in diabeties and female gender, however, not

encountered with PRA-AVFs

Wu CC, Jiang H, Cheng J, et al.The outcome of the proximal radial artery arteriovenous fistula. J Vasc Surg. 2015 Mar;61(3):802-8. Jennings WC. Mallios A, Mushtaq N. Proximal radial artery arterovenous fistula for hemodialysis

• access. J Vasc Surg, 2018, Jan;6(1):244-253.

Rodriguez V, Shah D, Grover DO Mandel S, Fox D, Bhatia N. Ischemic Monomilic Nephropathy: A Disguised Diabetic Neuropathy. Practical Neurology March/Ap 2013. 22-23

Lower flow AVFs

• Lower flow AVFs offer less cardiac risk and are the

preferred access for older patients in our practice.

• Lower flow AVFs are more likely to remain

asymptomatic in patients with central venous stenosis or occlusion, (lower outflow may be accommodated by existing collateral venous return). Wu, et al found venous hypertension developed in

• nly four of 284 patients (1.4%) with PRA-AVFs.
• Individuals with a radial artery originating near the

axilla may have a successful PRA-AVF created if the vessel is relatively free of calcific disease and > 2cm

Jennings WC, et al Creating functional autogenous vascular access in older patients. J VascSurg 2011,53(3):713 Malik J, et al Cardiac safety in vascular access surgery and maintenance. Contrib Nephrol 2015;184:75-86. Wu CC, et al.The outcome of the proximal radial artery arteriovenous fistula. J Vasc Surg. 2015 Mar;61(3):802-8. Jennings WC, et al Creating Arteriovenous Fistulas in Patients with Chronic Central Venous Obstruction. J Vas Access 2016 May 7;17(3):239-42.

Other potential benefits of lower flow and lower pressure PRA-AVFs:

• Less risk for aneurysms / bleeding
• Lower turbulence / wall shear stress with

less risk for long-term stenosis

• Less risk for cephalic arch stenosis

Proximal radial artery-AVF Patency

1396

673 333 1048 729

Percent Functional Patency

Jennings WC. Mallios A, Mushtaq N. Proximal radial artery arterovenous fistula for hemodialysis access. J Vasc Surg, 2018, Jan;6(1):244-253.

149 480 303 59 29 181 102 57 25

10 year experience with PRA inflow

Background: Brachial-cephalic arteriovenous fistulas (BC-AVFs) are associated with high-flow volumes, leading to potential risks such as arm swelling, steal syndrome, pseudoaneurysm (due to a pressurized access), and cephalic arch stenosis. The authors hypothesized that a PRA-AVF mitigates these risks because a lower flow state is created and that despite these lower flows, access patency is sustained. Prospectively collected database over 8 years.

345 AVFs and 72 AVGs were primarily placed. 56 patients underwent BC-AVF and 50 patients underwent PRA-AVF.

The primary end point was a composite of arm swelling, steal, and pseudoaneurysm at 2 years. Fistulograms, interventions, and patency were analyzed between BC and PRA AVF configurations.

Arnaoutakis DJ, Deroo EP, McGlyn P, Coll MD, Belkin M, Hentschel DM,Ozaki CK. Improved outcomes with proximal radial-cephalic arteriovenous fistulas compared with brachial-cephalic arteriovenous fistulas. J Vasc Surg. 2017 Nov;66(5):1497

Proximal radial AVFs vs Brachial cephalic AVFs

Results:

BC-AVF had higher flow rates at 6-weeks (1060mL/min vs 735 mL/min P < .001). Complications (arm swelling, steal, pseudoaneurysm) were significantly more common in the BC-AVF group (P < .02). There was a

trend for the BC group to require more cephalic arch stenosis interventions. Primary, primary assisted, and secondary patency (85% at 2 yrs) rates were

similar between the groups. Functional success was no different.

Conclusions: PRA-AVFs have fewer complications yet similar durability

compared with BC-AVFs. When it is anatomically feasible, PRA-AVFs should be constructed over BC-AVFs….

Arnaoutakis DJ, Deroo EP, McGlyn P, Coll MD, Belkin M, Hentschel DM,Ozaki CK. Improved outcomes with proximal radial-cephalic arteriovenous fistulas compared with brachial-cephalic arteriovenous fistulas. J Vasc Surg. 2017 Nov;66(5):1497

Proximal radial AVFs vs Brachial cephalic AVFs

Jennings WC, Mallios A, Blebea J. Upper Extremity Permanent Hemodialysis Access Placement. Darling RC, Ozaki CK, eds. Master Techniques in Surgery: Vascular Surgery: Hybrid, Venous, Dialysis Access, Thoracic Outlet, and Lower Extremity Procedures. Ch.16, p.151-163. Philadelphia: Wolters Kluwer; 2015.

Bi-directional flow may be established with forearm access sites when feasible.

PRA-AVF

• Median. Antebrachial V.

Cephalic v.

Bi-directional flow…..

Brachial artery Radial artery Cephalic vein Deep communicating vein Radial vein is opened adjacent to the radial artery Radial vein branches create a broad flair or” branch patch” for anastomosis to the radial artery

• Jennings WC. Mallios A, Mushtaq N. Proximal radial artery arterovenous fistula for hemodialysis
• access. J Vasc Surg, 2018, Jan;6(1):244-253.
• Gracz KC, et al.Proximal forearm fistula for maintenance haemodialysis.Kidney Int. 1977;11:71-74.
• Bender MH, et al. The Gracz arteriovenous fistula evalu- ated: results of the brachiocephalic elbow

fistula in haemodialysis angio-access. Eur J Vasc Endovasc Surg. 1995;10:294-297.

• Konner K. How can the use of arteriovenous fistulas be increased? Semin Dial. 2003;16:217-219.

End-to-side PRA anastomosis with the deep communicating vein

Deep communicating vein Brachial artery Venous branch patch readied for the anastomosis Proximal radial artery

Jennings WC, et al. Seminars in Vascular Surgery: Contemporary Issues in Hemodialysis Access. Alternative Autogenous Access Options. 2011 .

Ellipsys Ellipsys Vascular Access System Vascular Access System

Venous Micropuncture Proximal Radial Artery Puncture

• Hull J, Jennings WC, Cooper R, Waheed U, Schaefer M, Narayan R. The Pivotal Multicenter Trial of

Ultrasound Guided Percutaneous Arteriovenous Fistulae creation for Hemodialysis. J Vasc Inter Radiol 2017 Dec02. .

• Mallios A, Jennings WC, Boura B Costanzo A, Bourquelot P, Combes M. Initial Results of

Percutaneous Arteriovenous Fistula Creation with the Ellipsys Vascular Access System. J VascSurg 2018. April 18.

Ellipsys proximal radial artery AVF

44 months post Ellipsys PRA-AVF No interventions or complications (Columbian patient, Original human trial) Creating a secure PRA anastomosis with the Ellypsys AVF device.

New PRA AVF Site of excised graft segment Failed (and ulcerated) upper arm AVG

SECONDARY ARTERIOVENOUS FISTULAS: CONVERTING PROSTHETIC AV GRAFTS TO AUTOGENOUS DIALYSIS ACCESS. Semin Dial. 2008 Sep-Oct;21(5):474-82.

Converting eroded graft to PRA-AVF

Dialysis in older patients- Technical points:

• Condition of skin and soft tissue
• f the forearm is often poor.
• Selection of a single targeted

upper arm outflow vein for prompt maturation and cannulation

• - Proximal Radial artery inflow

when feasible

• All access options considered

Jennings WC, Landis L, Taubman KE, Parker

• DE. Creating Functional Autogenous Vascular

Access in Older Patients. J Vasc Surg. 2011 Mar;53(3):713-9

Conclusions

• A radiocephalic AVF remains the first

access option but only in selected patients with adequate vessels.

• PRA-AVFs offer lower flow access when

compared to brachial inflow, with markedly fewer risks and complications.

• PRA-AVFs are feasible for the majority of

patients and are often the preferred access in older patients.

Bridge of Life (BOL) is a non-profit organization working with renal failure and dialysis care since 2006 with 127 missions in 25 countries worldwide. Starting in 2012, 14 vascular access surgery missions and > 600 operations, creating arteriovenous fistulas for dialysis. We work with local surgeons, nephrologists, and nurses to leave a sustained impact at each site and maintain lines of communication for teaching and support. https://www.bridgeoflifeinternational.org/about-us/