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

Jan Tordoir Maastricht, the Netherlands

Surgical vs endovascular intervention for vascular access maturation failure

Jan Tordoir Maastricht, the Netherlands

I have no disclosures

What do guidelines recommend?

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

• n an AV-access to enhance maturation postoperatively (2C)

2 ERBP (2019): We suggest there is insufficient evidence to support

• pen surgical over endovascular interventions as the preferred

treatment for non-maturing arteriovenous fistulas in adults with end-stage kidney disease (2D)

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)

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

juxta-anastomotic arterial inflow proximal vein venous outflow

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- anastomotic ++ Proximal neo- anastomosis + PTA Stent Proximal vein + Patchplasty Graft interposition ++ PTA BAM Stent Stent-graft Venous outflow + Patchplasty Graft interposition ++ PTA Stent Stent-graft Accessory veins ++ Ligation + Coiling

Surgical intervention for arterial inflow

Proximal graft interposition (Oakes procedure)

Prosthetic graft Vein ligation

• utcome

N

Patients 14 PTA graft-vein anastomosis 8 (5 patients) Trombectomy 8 (6 patients) Modality switch to PD 1 Failure 9

J Vasc Surg 2019;70:853-7

Endovascular intervention for arterial inflow

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 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. Long segment

• bstruction

Short segment

• bstruction

J Vasc Surg 2009;49:995-9 Nephrol Dial Transplant (2009) 24: 3782–3788

Endovascular intervention for arterial inflow

82 % (Raynaud) 66 % (Turmel Rodrigues)

Surgical intervention for juxta-anastomotic stenoses

Proximal neo-anastomosis

Surgical intervention for juxta-anastomotic stenoses

Secondary patency for RCAVFs (n=81) is substantially improved by PNA formation Primary patency of PNA performed on immature AVF is significantly poorer than PNA for already matured AVF

J Vasc Surg 2011;54:168-73

all AVF secondary patency PNA primary patency mature AVF (n=31) primary patency immature AVF (n=50)

Endovascular intervention for juxta-anastomotic stenoses

J Vasc Surg 2011;53:108-14

PNA PTA

Angioplasty and surgery have similar results to treat juxta-anastomotic stenoses Repeat procedures were more frequent with angioplasty

Endovascular intervention for proximal/outflow vein stenosis

Fluoroscopic-guided angioplasty

The Journal of Vascular Access 2019, Vol. 20(4) 397–403

secondary patency primary patency assisted-primary patency

Ultrasound-guided angioplasty/ Balloon-assisted maturation (BAM)

Endovascular intervention for proximal/outflow vein stenosis

Balloon-assisted maturation (BAM)

1 Ann Vasc Surg 2017; 41: 41–45 2 Ann Vasc Surg 2014; 28: 1275–1279

To BAM or not to BAM

These data suggest the role of BAM did not decrease maturation times of AVF BAM warrants further scrutiny before further adoption

technique

• no. patients1

functional

• no. procedures

time to maturation

BAM+ 54 76% (6 mts) 125 (range 1-8) 119 ds BAM- 114 79% (6 mts)

• 146 ds

complications

212 (62%)

• wall hematoma 136
• rupture

32

• spasm

26

• thrombosis

5

type of AVF

RCAVF 63 % BCAVF 21 % BBAVF 13 % Bbrachial 2 % Uceph 1 %

• no. procedures

336 (range 1-6)

technique

• no. patients2

BAM+ 94

Endovascular intervention for proximal vein stenoses

• Front. Surg. 2017;4:13

Type AVF N Previous intervention (all AVF) N Primary patency (all AVF) Secondary patency (all AVF)

Brachiocephalic 6 PTA 9 91% (6 mts) 100% (6 mts) Brachiobasilic 3 BAM 3 65% (12 mts) 72% (12 mts Brachiobrachial 3

Stent-graft

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

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 Summary

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
• n stenosis location
• Arterial inflow obstruction best treated by endovascular means
• Surgical proximal neo-anastomosis should be recommended for

juxta-anastomotic stenosis Surgical vs endovascular intervention for vascular access maturation failure