Where does the clot go? (products include the HeRO graft) Back - PowerPoint PPT Presentation

4/17/2015 DISCLOSURES • Speaker and consultant to Cryolife Where does the clot go? (products include the HeRO graft) Back table or the pulmonary • Speaker for Gore (products included circulation - an argument for dialysis access grafts and stents) commonsense Neither of these will be discussed in this presentation Stephen E. Hohmann, MD FACS Vascular Surgeon Baylor University Medical Center Dallas, Texas AUDIENCE SURVEY Dr. Robert Kerlan UCSF Radiology_ Interventional Radiology Embolization Therapy for A. Pulmonary emboli are bad Colon Cancer B. Pulmonary emboli are good UCSF Radiologist Dr Robert Kerlan describes how interventional radiology C. Who cares, I am tired from lunch is utilized in embolization therapy to 76% treat colon cancer. D. I hate these type of questions “The family would like to thank Dr. Bowman, Reno Oncology, Dr. Kerlan, UCSF Medical Center, 18% Interventional Radiology 3% 3% Dept. for making Charles' Charles Gallegos (1947-2014) wish come true - seeing his Reno Gazette d d a o . . . . . http://www.legacy.com/obituaries/ b o r s son Charles turn 18 and g f e e d u r e q a r e a r f rgj/obituary.aspx?pid=170573181 i l i o o i t b o l m e p graduate. Many thanks to the #sthash.Z8mxC2mk.dpuf m b a m y e I t e , y s e r y e s a r r e n a a h o n t nurses and staff in the LSU c m o o e m h t u l a l W P u h P I at UCSF.” 1

4/17/2015 Clinical Professor Department of Radiology Can you really trust him? President-Elect, UCSF Medical Staff Dr. Robert Kerlan is the Chief of Interventional Radiology. He is particularly interested in the management of liver disease, including biliary disease, portal hypertension and hepatic malignancy. In his research, he is working to develop new procedures to diagnose and treat patients with problems related to living donor organ transplants. His UCSF campus-wide service memberships include the Surgical Case and Hospital Mortality Review Committee (SCHMRC), Allocation Committee, Patient Safety Committee, Clinical Vascular Access Committee and Executive Medical Board (EMB). Dr. Kerlan joined the UCSF Medical Staff in 1993 from La Jolla Radiology Medical Group, where he was a partner. Prior to that he was a staff radiologist at Scripps Memorial Hospital in Encinitas, CA, and Chief of Interventional Radiology at Scripps Memorial Hospital in La Jolla, CA. www.bloguin.com Education USC, School of Medicine, MD, 1977 UCLA, School of Medicine, Internship, Internal Medicine, 1978 UCSF, School of Medicine, Residency, Radiology, 1981 Assumptions • Clotted accesses are full of thrombus and an arterial plug made of platelet aggregate • Embolism to the lungs is bad, large or small and chronic small embolism may lead to pulmonary hypertension • Declotting is often done percutaneously for convenience NY Post 2

4/17/2015 Clearly there can be a problem S/P Percutaneous Thrombectomy K. Toosy, S. Saito, C. Patrascu, and R. Jean, “Cardiac arrest following massive pulmonary embolism during mechanical declotting of thrombosed hemodialysis fistula: successful resuscitation with tPA,” Journal of Intensive CareMedicine , vol.23, no. 2, pp. 143–145, 2008. L. A. Grebenyuk, R. J. Marcus, E. Nahum, J. A. Spero, N. S. Srinivasa, and R. L. McGill, “Pulmonary embolism following successful thrombectomy of an arteriovenous dialysis fistula,” Journal of Vascular Access , vol. 10, no. 1, pp. 59–61, 2009. Avni Shah, Naheed Ansari, and Zaher Hamadeh, “Cardiac Arrest Secondary to Bilateral Pulmonary Emboli following Arteriovenous Fistula Thrombectomy: A Case Report with Review of the Literature,” Case Reports in Nephrology, vol. 2012, Article ID 831726, 6 pages, 2012. doi:10.1155/2012/831726 Avni Shah, Naheed Ansari, and Zaher Hamadeh, “Cardiac Arrest Secondary to Bilateral Pulmonary Emboli following Arteriovenous Fistula Thrombectomy: A Case Report with Review of the Literature,” Case Reports in Nephrology, vol. 2012, Article ID 831726, 6 pages, 2012. doi:10.1155/2012/831726 Duck Some interesting numbers • Arterial emboli can occur in up to 6.3% of cases during percutaneous thrombolysis, although symptomatic cases are rare [1] • “Clinically significant pulmonary embolism during percutaneous thrombectomy procedures is an expected complication , yet it is rare, and the true incidence of PE is unknown” [2] [1} F. L. Weng and J. S. Berns, “Complications of percutaneous treatment of thrombosed hemodialysis access grafts,” Seminars in Dialysis , vol. 16, no. 3, pp. 257–262, 2003. [2] F. L. Weng and J. S. Berns, “Complications of percutaneous treatment of thrombosed hemodialysis access grafts,” Seminars in Dialysis , vol. 16, no. 3, pp. 257–262, 2003. 3

4/17/2015 Yes, Indeed Are there any studies J. D. Petronis, F. Regan, G. Briefel, P. M. Simpson, J. M. Hess, and C. S. Contoreggi, “Ventilation-perfusion scintigraphic evaluation of pulmonary clot burden after percutaneous examining thrombolysis of clotted hemodialysis access grafts,” American Journal of Kidney Diseases , vol. 34, no. 2, pp. 207–211, 1999. T. L. Swan, S. H. Smyth, S. J. Ruffenach, S. S. Berman, and G. D. Pond, “Pulmonary embolism following hemodialysis pulmonary embolism access thrombolysis/thrombectomy,” Journal of Vascular and Interventional Radiology , vol. 6, no. 5, pp. 683–686, 1995. T. B. Kinney, K. Valji, S. C. Rose et al., “Pulmonary embolism after percutaneous from pulse-spray pharmacomechanical thrombolysis of clotted hemodialysis grafts: urokinase versus heparinized saline,” Journal of Vascular and Interventional Radiology , vol. 11, no. 9, pp. 1143–1152, 2000. thrombectomy? H. F. M. Smits, P. P. Van Rijk, J. W. Van Isselt, W. P. T. M. Mali, H. A. Koomans, and P. J. Blankestijn, “Pulmonary embolism after thrombolysis of hemodialysis grafts,” Journal of the American Society of Nephrology , vol. 8, no. 9, pp. 1458– 1461, 1997. Interesting Conclusions Silent pulmonary emboli? Hsieh MY, Lai CL, Wu YW, Lin L, Ho MC, Wu CC. Impact • The radiographic incidence of on pulmonary arterial pressures after repeated endovascular thrombectomy of dialysis grafts: a prospective follow-up study. J pulmonary embolism ranged from Vasc Interv Radiol. 2014 Dec;25(12):1883-9. doi: 0-59% of cases. 10.1016/j.jvir.2014.07.018. Epub 2014 Aug 23. • Most did not experience any Cardiovasc Intervent Radiol. 2005 Jan-Feb;28(1):17-22. Pulmonary hypertension among end-stage renal failure patients symptoms following hemodialysis access thrombectomy. Harp RJ 1 , Stavropoulos SW, Wasserstein AG, Clark TW. • Of the four studies, only a few sympomatic PEs were identified but Cases (ie those with previous declot) were slightly more likely to have pulmonary hypertension than group 2 controls (OR = 1.5), noted that “silent” pulmonary emboli although this failed to reach statistical significance (p = 0.14). occurred frequently 4

4/17/2015 Journal of Vascular Surgery 2009:50, 953-6 CONCLUSION: Endovascular and surgical intervention for thrombosed dialysis prosthetic graft fistulae results in comparable early success and long-term primary and secondary patency rates. Surgery yields a better outcome for autogenous arteriovenous fistulae, in particular in the long-term. 5

4/17/2015 Why to declot surgically? The Choice is Clear • At present, you can have the best of Surgery WINS!! both worlds #1 Clot does not go to lungs or arterial bed #2 You can angioplasty or stent or surgically revise the inflow or outflow #3 If it is a fistula, you have better short and particularly long term outcomes, leading to less morbidity and $$$$$ 6