Surgical vs endovascular intervention for vascular access maturation - PowerPoint PPT Presentation

Surgical vs endovascular intervention for vascular access maturation failure Jan Tordoir Maastricht, the Netherlands

I have no disclosures Jan Tordoir Maastricht, the Netherlands

What do guidelines recommend? 1 ESVS (2018): The most common causes of non-maturation are venous, arterial or anastomotic stenosis , competing veins or large patent branches, and excessive depth from the skin. Depending on the cause, open or endovascular repair can be performed , although in general no significant differences have been found between the two modalities (2C) 2 ERBP (2019): We suggest there is insufficient evidence to support open surgical over endovascular interventions as the preferred treatment for non-maturing arteriovenous fistulas in adults with end-stage kidney disease (2D) 3 KDOQI (2019): There is inadequate evidence to make a recommendation on the preferred use of surgical or endovascular techniques for postoperative maturation. It is reasonable to consider a careful individualized approach for using either surgical techniques or endovascular techniques when needing to intervene on an AV-access to enhance maturation postoperatively (2C) 1 Eur J Vasc Endovasc Surg. 2018 Jun;55(6):757-818 2 Nephrol Dial Transplant. 2019 Jun 1;34(Supplement_2):ii1-ii42 3 In press

Location of stenoses in vascular access maturation failure venous outflow arterial inflow proximal vein juxta-anastomotic Nephrol Dial Transplant. 2001 Dec;16(12):2365-71

Surgical vs endovascular intervention for vascular access maturation failure Target lesion Surgical Technique Endovascular Technique Arterial inflow + Graft interposition ++ PTA Juxta- ++ Proximal neo- + PTA anastomotic anastomosis Stent Proximal vein + Patchplasty ++ PTA Graft interposition BAM Stent Stent-graft Venous outflow + Patchplasty ++ PTA Graft interposition Stent Stent-graft Accessory veins ++ Ligation + Coiling

Surgical intervention for arterial inflow Proximal graft interposition (Oakes procedure) outcome N Patients 14 Prosthetic graft PTA graft-vein anastomosis 8 (5 patients) Trombectomy 8 (6 patients) Modality switch to PD 1 Vein ligation Failure 9 J Vasc Surg 2019;70:853-7

Endovascular intervention Long segment obstruction for arterial inflow Raynaud A, Novelli L, Bourquelot P, Stolba J, Beyssen B, Franco G. Low-flow maturation failure of distal accesses: Treatment by angioplasty of forearm arteries. J Vasc Surg. 2009 Apr;49(4):995-9. Short segment obstruction Turmel-Rodrigues L, Boutin JM, Camiade C, Brillet G, Fodil-Chérif M, Mouton A. Percutaneous dilation of the radial artery in nonmaturing autogenous radial-cephalic fistulas for haemodialysis. Nephrol Dial Transplant. 2009 Dec;24(12):3782-8

Endovascular intervention for arterial inflow 66 % (Turmel Rodrigues) 82 % (Raynaud) J Vasc Surg 2009;49:995-9 Nephrol Dial Transplant (2009) 24: 3782 – 3788

Surgical intervention for juxta-anastomotic stenoses Proximal neo-anastomosis

Surgical intervention for juxta-anastomotic stenoses primary patency mature AVF (n=31) secondary patency PNA all AVF primary patency immature AVF (n=50) Primary patency of PNA performed on Secondary patency for RCAVFs (n=81) is substantially improved by PNA formation immature AVF is significantly poorer than PNA for already matured AVF J Vasc Surg 2011;54:168-73

Endovascular intervention for juxta-anastomotic stenoses PNA PTA Angioplasty and surgery have similar results to treat juxta-anastomotic stenoses Repeat procedures were more frequent with angioplasty J Vasc Surg 2011;53:108-14

Endovascular intervention for proximal/outflow vein stenosis Fluoroscopic-guided angioplasty secondary patency assisted-primary patency primary patency The Journal of Vascular Access 2019, Vol. 20(4) 397 – 403

Endovascular intervention for proximal/outflow vein stenosis Ultrasound-guided angioplasty/ Balloon-assisted maturation (BAM)

Balloon-assisted maturation (BAM) To BAM or not to BAM no. patients 1 technique functional no. procedures time to maturation BAM+ 54 76% (6 mts) 125 (range 1-8) 119 ds BAM- 114 79% (6 mts) -- 146 ds no. patients 2 technique type of AVF no. procedures complications BAM+ 94 RCAVF 63 % 336 (range 1-6) 212 (62%) -wall hematoma 136 BCAVF 21 % -rupture 32 BBAVF 13 % -spasm 26 Bbrachial 2 % -thrombosis 5 Uceph 1 % These data suggest the role of BAM did not decrease maturation times of AVF BAM warrants further scrutiny before further adoption 1 Ann Vasc Surg 2017; 41: 41 – 45 2 Ann Vasc Surg 2014; 28: 1275 – 1279

Endovascular intervention for proximal vein stenoses Stent-graft Type AVF N Previous intervention N Primary patency Secondary patency (all AVF) (all AVF) (all AVF) Brachiocephalic 6 PTA 9 91% (6 mts) 100% (6 mts) Brachiobasilic 3 BAM 3 65% (12 mts) 72% (12 mts Brachiobrachial 3 Front. Surg. 2017;4:13

Surgical & endovascular intervention for accessory veins Accessory vein ligation Accessory vein coiling

Surgical vs endovascular intervention for vascular access maturation failure Summary Surgical intervention Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults. Nephrol Dial Transplant. 2019 Jun 1;34(Supplement_2):ii1-ii42

Surgical vs endovascular intervention for vascular access maturation failure Summary Endovascular intervention Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults. Nephrol Dial Transplant. 2019 Jun 1;34(Supplement_2):ii1-ii42

Surgical vs endovascular intervention for vascular access maturation failure Conclusion • Intervention for AVF early thrombosis and failure to mature is worth-wile • Guidelines report similar outcomes from endovascular and surgical intervention • However, there are distinct differences in outcome depending on stenosis location • Arterial inflow obstruction best treated by endovascular means • Surgical proximal neo-anastomosis should be recommended for juxta-anastomotic stenosis