Strategy for surgical treatment of access related hand Strategy for - - PowerPoint PPT Presentation

C Sessa MD, PhD , O Pichot C Sessa MD, PhD , O Pichot Strategy for surgical treatment of access related hand Strategy for surgical treatment of access related hand ischemia and high flow : an algorithm ischemia and high flow : an algorithm

Groupe Hospitalier Mutualiste de Grenoble Groupe Hospitalier Mutualiste de Grenoble i i-

• VAS Paris september 14th 2018

VAS Paris september 14th 2018

Ischemia Ischemia and high flow are 2 different pathophysiogical and and high flow are 2 different pathophysiogical and clinical situations clinical situations

Introduction Introduction

Accurate diagnosis and strategy Accurate diagnosis and strategy Optimal techniques : specific, well codified, standardized, Optimal techniques : specific, well codified, standardized, reproducible reproducible ……… ………without jeopardizing the angioaccess without jeopardizing the angioaccess

High flow High flow

cardiac symptoms cardiac symptoms WITHOUT WITHOUT ischemia ischemia > > 2 L/min 2 L/min with ischemia (rare) with ischemia (rare)

Ischemia Ischemia

WITHOUT high flow WITHOUT high flow with high flow (rare) with high flow (rare) Zanow Zanow : 658 ml/min : 658 ml/min Thermann Thermann : 1.38 L/min : 1.38 L/min Sessa : < 1.5 ( L/min (1 case : 2.5 L/min) Sessa : < 1.5 ( L/min (1 case : 2.5 L/min)

Hemodynamics of AVF and pathophysiology of hand Hemodynamics of AVF and pathophysiology of hand ischemia ischemia

Hemodynamic of hand ischemia Hemodynamic of hand ischemia

Wixon 2000 Wixon 2000

Critical points for hand ischemia : below the AVF Critical points for hand ischemia : below the AVF severe distal arteriopathy +++ severe distal arteriopathy +++ high peripheral resistances high peripheral resistances lack of collaterals lack of collaterals Critical points for high flow : above the AVF Critical points for high flow : above the AVF diameter of artery +++ diameter of artery +++ vein vein AV anastomosis AV anastomosis

Wrist Wrist

(*) DRIL (*) DRIL Bandings Bandings (*) specific techniques for hand ischemia (*) specific techniques for hand ischemia Patent ulnar artery Patent ulnar artery with digital arteriopathy with digital arteriopathy * Ligation or embolization * Ligation or embolization

• f the radial artery
• f the radial artery

below the AFV (Storey) below the AFV (Storey) Forearm and digital Forearm and digital arteriopathy arteriopathy

Surgical strategy at the wrist Surgical strategy at the wrist

Strategy and techniques of treatment at the wrist Strategy and techniques of treatment at the wrist

Patent ulnar artery Patent ulnar artery

Ligation (Storey technique) or embolization of the artery distal Ligation (Storey technique) or embolization of the artery distal to the AVF to the AVF Eliminates reversal of flow Eliminates reversal of flow Restores antegrade flow to the fingers Restores antegrade flow to the fingers Improvement of symptoms and increase in distal pressure and digi Improvement of symptoms and increase in distal pressure and digital blood flow tal blood flow by manual compression of the artery below the AVF or with ballon by manual compression of the artery below the AVF or with ballon occlusion

• cclusion

Elbow Elbow

Normal flow Normal flow Normal or high flow Normal or high flow RUDI RUDI PAVA ou PAI PAVA ou PAI Bandings Bandings (*) DRIL +++ (*) DRIL +++

Surgical strategies at the elbow Surgical strategies at the elbow

(*) specific techniques for hand ischemia (*) specific techniques for hand ischemia

Arterial bypass Arterial bypass 10 cm 10 cm above the AFV and above the AFV and below the AVF below the AVF Wixon 2000 Wixon 2000 Increases distal flow to the hand +++ Increases distal flow to the hand +++ No changes in AVF flow No changes in AVF flow

The DRIL technique The DRIL technique

Eliminates flow inversion Directs flow in the bypass to the distal arterial network Arterial ligation below the AVF Arterial ligation below the AVF

AV AV F F Interval ligation Interval ligation

The DRIL technique The DRIL technique

DRIL bypass with great saphenous vein DRIL bypass with great saphenous vein

The Banding techniques The Banding techniques

Zanow JVS 2006 Zanow JVS 2006

What is the What is the « « target target » » ? ? Which technique is the most appropriate and Which technique is the most appropriate and effective ? effective ? Empirical, not well codified, unreproducible Empirical, not well codified, unreproducible How much reduction in needed to decrease How much reduction in needed to decrease flow without compromising the angioaccess ? flow without compromising the angioaccess ? Is the banding for ischemia different from high flow ? Is the banding for ischemia different from high flow ?

Results of Bandings Results of Bandings

Gupta JVS 2011 Gupta JVS 2011 87 procedures in 70 patients (Dril, Rudi, Pava 87 procedures in 70 patients (Dril, Rudi, Pava… …) ) 22 bandings : 22 bandings : higher failure rate : 62% higher failure rate : 62% most frequent reason for most frequent reason for reintervention : 8/11 (73%) reintervention : 8/11 (73%)

Lenghtens the fistula to decrease AVF flow Lenghtens the fistula to decrease AVF flow Smaller distal artery as inflow Smaller distal artery as inflow Distal anastomosis : 2 Distal anastomosis : 2-

• 3 cm (10

3 cm (10-

• 15 cm) below the

15 cm) below the bifurcation bifurcation

RUDI (Revision Using Distal Insertion) RUDI (Revision Using Distal Insertion)

Optimal length and diameter of the conduit ? Optimal length and diameter of the conduit ?

Callaghan J Vasc Access 2011 Callaghan J Vasc Access 2011

7 patients with 3 failures 7 patients with 3 failures ” ”a high rate of failure was seen requiring a high rate of failure was seen requiring technical modifications and further experience technical modifications and further experience before becoming a valuable technique before becoming a valuable technique “ “

Zanow Zanow

PAVA Proximalization of the arteriovenous anastomosis PAVA Proximalization of the arteriovenous anastomosis

Proximal inflow from a larger artery to lower arterial Proximal inflow from a larger artery to lower arterial pressure drop distal to the AVF pressure drop distal to the AVF mid mid-

• brachial artery?

brachial artery? axillary artery? axillary artery? What lenght and diameter of the graft ? What lenght and diameter of the graft ? tapered 4 mm x 7 mm tapered 4 mm x 7 mm 4 mm or 5 mm PTFE 4 mm or 5 mm PTFE No ligation of the artery vs DRIL No ligation of the artery vs DRIL No reversed flow to the forearm arteries = DRIL No reversed flow to the forearm arteries = DRIL Improvement of distal artery pressure or velocity Improvement of distal artery pressure or velocity

How do I treat ischemia? How do I treat ischemia?

Wrist : distal radial artery Wrist : distal radial artery ligation ligation Elbow : Elbow : DRIL DRIL

Vascular access ligation Vascular access ligation

Ischemic monomelic neuropathy Ischemic monomelic neuropathy Severe arterial lesions, poor general conditions or extended tis Severe arterial lesions, poor general conditions or extended tissue sue loss in patients in whom revascularization is not feasible loss in patients in whom revascularization is not feasible No improvement of symptoms after revascularization No improvement of symptoms after revascularization Patients with kidney transplant Patients with kidney transplant

Consequences Consequences Symptoms of cardiac overload +++ Symptoms of cardiac overload +++ Hand ischemia : rare Hand ischemia : rare

High flow : Strategy and techniques of treatment High flow : Strategy and techniques of treatment

Main factors Main factors Diameter of Diameter of artery +++ artery +++ anastomosis ++ anastomosis ++ vein vein High flow : High flow : > > 2 L/min 2 L/min

Indications Indications for flow reduction for flow reduction Cardiac symptoms with flow Cardiac symptoms with flow ≥ ≥ 2000 mL/min 2000 mL/min Asymptomatic patients with flow Asymptomatic patients with flow ≥ ≥ 2500 mL/min 2500 mL/min High flow High flow Sessa, Pichot Sessa, Pichot : : 2.8 L/min (1.9 2.8 L/min (1.9 -

• 3.8 L/min )

3.8 L/min )

High flow : Strategy and techniques of treatment High flow : Strategy and techniques of treatment

Wrist Wrist

(*) Ligation of the artery (*) Ligation of the artery Abow the AVF Abow the AVF (Bourquelot) (Bourquelot)

Elbow Elbow

RUDI RUDI PAVA , PAI PAVA , PAI (*) PAVA (*) PAVA-

• like technique

like technique (personal technique) (personal technique) Banding Banding (*) Transposition of radial artery (*) Transposition of radial artery (Bourquelot) (Bourquelot) (*) specific techniques for high flow (*) specific techniques for high flow

Surgical strategies for hand ischemia Surgical strategies for hand ischemia

How do I treat high flow ? How do I treat high flow ?

Wrist : Proximal radial Wrist : Proximal radial artery ligation artery ligation Elbow : Elbow : PAVA PAVA-

• Like

Like

The higher the flow rate, the longer the The higher the flow rate, the longer the PTFE graft PTFE graft

Authors Authors’ ’ technique : the PAVA technique : the PAVA-

• like

like

PTFE 5 mm x PTFE 5 mm x 10 10 cm for flow cm for flow < < 3 l/min 3 l/min 5 mm x 5 mm x 15 15 cm for flow cm for flow > > 3 l/min 3 l/min Mean flow reduction : about 50% Mean flow reduction : about 50%

The PAVA The PAVA-

• like technique

like technique

Ischemia Ischemia and high flow are 2 different situations that require and high flow are 2 different situations that require accurate diagnosis and appropriate treatment accurate diagnosis and appropriate treatment

Conclusions Conclusions

Specific techniques for ischemia and high flow that are well cod Specific techniques for ischemia and high flow that are well codified, ified, standardized, reproducible with satisfactory results standardized, reproducible with satisfactory results Other techniques for both situations are not always well Other techniques for both situations are not always well codified with codified with “ “poor poor” ” results results

Conclusions Conclusions