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

Proximal radial artery AVFs: The best access for the majority of patients William Jennings, MD FACS PARIS - Friday, September 14th 2018 Institut Mutualiste Montsouris Department of Surgery Department of Surgery

DISCLOSURE POLICY It is the policy of The University of Oklahoma Health Sciences Center College of Medicine to ensure balance, independence, objectivity and scientific rigor in all its educational programs. All faculty participating in these St. John Medical Center programs are expected to disclose to the program audiences any real or apparent conflict of interest related to the content of their presentation. DaVita: Speaker Gore: Speaker University of Oklahoma, Tulsa Avenu Medical: Consultant

Vascular access for prevalent hemodialysis patients (2002) Dialysis Outcomes and Practice Patterns Study (DOPPS) % of patients 4 100 9 3 Catheters 24 10 93 80 81 Grafts 52 60 40 20 24 Fistulas 0 Europe Japan United States

U.S. Vascular Access Prevalence 63.3% AV Grafts AV Fistulas in use Catheters Fistula First start date 2018 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

A radiocephalic AVF remains the first choice for vascular access….. New England Journal of Medicine, Nov 17, 1966; 275(20) 1089-1092

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

Many PRA-AVF venous outflow opportunities Cephalic V. Median Cephalic V. Median Antebrachial 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.

Proximal radial artery AVF Proximal radial artery AVF Consider ligation Cephalic v. Deep communicating V. Basilic v. Median antebrach. V. Radial art. Hand 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

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 operative sites

Hand Ischemia Risk • Brachial artery inflow has as much as a ten fold higher risk of 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 often 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 only 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

1396 1048 729 480 303 181 102 57 25 Percent Functional Patency 673 Proximal radial artery-AVF Patency 333 149 59 29 10 year experience with PRA inflow Jennings WC. Mallios A, Mushtaq N. Proximal radial artery arterovenous fistula for hemodialysis access. J Vasc Surg, 2018, Jan;6(1):244-253.

Proximal radial AVFs vs Brachial cephalic AVFs 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

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

Cephalic v. Median. Antebrachial V. PRA-AVF Bi-directional flow…..

Cephalic vein End-to-side PRA anastomosis with the deep communicating vein Deep communicating vein Brachial artery Radial artery 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.

Deep communicating vein Proximal radial artery Brachial artery Venous branch patch readied for the anastomosis Jennings WC, et al. Seminars in Vascular Surgery: Contemporary Issues in Hemodialysis Access. Alternative Autogenous Access Options. 2011 .