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Surgical solutions for high flow and hemodialysis access- induced - - PowerPoint PPT Presentation
Surgical solutions for high flow and hemodialysis access- induced - - PowerPoint PPT Presentation
Surgical solutions for high flow and hemodialysis access- induced distal ischemia (HAIDI): an algorithm C Sessa MD, PhD , O Pichot MD Groupe Hospitalier Mutualiste de Grenoble i-VAS 2019 Paris - Friday, 13th september 2019 Hemodynamics of AVF
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Hemodynamic of hand ischemia
Wixon 2000
Critical points for hand ischemia : below the AVF severe distal arteriopathy +++ high peripheral resistances lack of collaterals Critical points for high flow : above the AVF diameter of artery +++ vein AV anastomosis
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Specific techniques for ischemia DRAL : wrist DRI L: wrist, elbow , lower limbs
Introduction
Specific techniques for high flow PRAL : wrist PAVA LIKE technique (personnal technique): elbow Techniques for both Banding : wrist, elbow PAVA or PAI technique : elbow RUDI : elbow
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Wrist
(*) DRIL Bandings (*) specific techniques for hand ischemia Patent ulnar artery with digital arteriopathy * Ligation or embolization
- f the radial artery
below the AFV (Storey) Forearm and digital arteriopathy
Surgical strategy at the wrist
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Elbow
Normal flow Normal or high flow RUDI PAVA ou PAI Bandings (*) DRIL +++
Surgical strategies at the elbow
(*) specific techniques for hand ischemia
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Arterial bypass : > 10 cm above the AFV and immediately below the AVF Wixon 2000 Increases distal flow to the hand +++ No changes in AVF flow
The DRIL technique
Eliminates flow inversion Directs flow in the bypass to the distal arterial network Arterial ligation : right below the AVF
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AVF Interval ligation
The DRIL technique
DRIL bypass with great saphenous vein
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The Banding techniques
Zanow JVS 2006
What is the « target » ? Which technique is the most appropriate and effective ? Empirical, not well codified, unreproducible How much reduction in needed to decrease flow without compromising the angioaccess ? Is the banding for ischemia different from high flow ?
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Results of Bandings
Gupta JVS 2011 87 procedures in 70 patients (Dril, Rudi, Pava…) 22 bandings : higher failure rate : 62% most frequent reason for reintervention : 8/11 (73%)
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Lenghtens the fistula to decrease AVF flow Smaller distal artery as inflow Distal anastomosis : 2-3 cm (10-15 cm) below the bifurcation
RUDI (Revision Using Distal Insertion)
Optimal length and diameter of the conduit ?
Callaghan J Vasc Access 2011
7 patients with 3 failures ”a high rate of failure was seen requiring technical modifications and further experience before becoming a valuable technique “
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Zanow
PAVA Proximalization of the arteriovenous anastomosis
Proximal inflow from a larger artery to lower arterial pressure drop distal to the AVF mid-brachial artery? axillary artery? What lenght and diameter of the graft ? tapered 4 mm x 7 mm 4 mm or 5 mm PTFE No ligation of the artery vs DRIL No reversed flow to the forearm arteries = DRIL Improvement of distal artery pressure or velocity
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How do I treat ischemia?
Wrist : distal radial artery ligation (Storey) Elbow : DRIL
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Vascular access ligation
Ischemic monomelic neuropathy Severe arterial lesions, poor general conditions or extended tissue loss in patients in whom revascularization is not feasible No improvement of symptoms after revascularization Patients with kidney transplant
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Consequences Symptoms of cardiac overload +++ Hand ischemia : rare
High flow : Strategy and techniques of treatment
Main factors Diameter of artery +++ anastomosis ++ vein High flow : > 2 L/min
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Indications for flow reduction Cardiac symptoms with flow ≥ 2000 mL/min Asymptomatic patients with flow ≥ 2500 mL/min High flow Sessa, Pichot : 2.8 L/min (1.9 - 3.8 L/min )
High flow : Strategy and techniques of treatment
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Wrist
(*) Ligation of the artery Abow the AVF (Bourquelot)
Elbow
RUDI PAVA , PAI (*) PAVA-like technique (personal technique) Banding (*) Transposition of radial artery (Bourquelot) (*) specific techniques for high flow
Surgical strategies for hand ischemia
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How do I treat high flow ?
Wrist : Proximal radial artery ligation Elbow : PAVA-Like
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The higher the flow rate, the longer the PTFE graft
Authors’ technique : the PAVA-like
PTFE 5 mm x 10 cm for flow < 3 l/min 5 mm x 15 cm for flow > 3 l/min Mean flow reduction : about 50%
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The PAVA-like technique
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Ischemia and high flow are 2 different situations that require accurate diagnosis and appropriate treatment
Conclusions
Specific techniques for ischemia ( DRAL , DRIL) and high flow (PRAL, PAVA LIKE) that are well codified, standardized, reproducible with satisfactory results Other techniques for both situations (PAVA or PAI, banding, RUDI) are not always well codified with “poor” results
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