No disclosures Warren Gasper MD UCSF Vascular Surgery 4/15/2016 2 - PowerPoint PPT Presentation

Cannulation Related Complications Delay the Use of AVFs In a Significant Number of Patients Can anything be done about it? No disclosures Warren Gasper MD UCSF Vascular Surgery 4/15/2016 2 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 � 47 patients with AVFs had a Arteriovenous Fistula Maturation Cannulation complications major infiltration between � Initiating hemodialysis with an arteriovenous fistula has superior 2000-2004 outcomes, largely due to avoiding catheter-related infections, � All events required new or complications and death prolonged catheter use � Fistula maturation is a major hurdle: it takes time, yet it’s unpredictable � Incidence was 5.2% per • Non-maturation rates are 20-60% patient-year � Odds ratio for a major needle � Tools have been developed to predict whether a fistula is mature: infiltration in new (<6 mo) vs • Rule of 6’s: ≥ 6mm diameter, ≤ 6mm deep, ≥ 600ml/min flow established (>6 mo) AVF was 2.98 (95% CI 1.61 - 5.54) • Bandyk “5-minute AVF protocol”: ≥ 600ml/min flow, brachial artery P<.0004) EDV/PSV >0.4, ≥ 6mm diameter, ≤ 6mm deep, >10cm length Am J Kidney Dis 2006 47: 1020-1026 KDOQI Am J Kid Dis 2006 | Semin Vasc Surg 2013 26:120–126 3 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 1 4/15/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Is this fistula mature? Mean velocity: (PSV-EDV)/3 + EDV � 72 year old man with HTN, DM, CKD stage 4 with deteriorating renal function (eGFR 28) who had a left brachiocephalic AVF placed in Mean velocity: 194 cm/s anticipation of hemodialysis Brachial artery diameter: 6mm � Over the next 7 months his renal function declines and hemodialysis is recommended Volume flow: >2000ml/min � He has a strong thrill over the AVF � Fistula cannulation is attempted twice but is unsuccessful due to infiltration � Arm is now bruised, painful and swollen… 5 AVF Cannulation Complications | UCSF Vascular Symposium 2016 6 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 Pre-cannulation ultrasound 11mm 6mm Flow <600ml/min? Diameter <6mm? Depth >6mm? Fistula diameter is 6mm – adequate Fistula depth is 11mm – too deep Fistulagram / Fistulagram / Superficialize Revision Revision 7 AVF Cannulation Complications | UCSF Vascular Symposium 2016 8 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 2 4/15/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Open Fistula Elevation Lipectomy 9 AVF Cannulation Complications | UCSF Vascular Symposium 2016 10 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 Brondor J Am Coll Surg 2008;206:1069–1075 J Vasc Surg 2009;50: 369-74. Venous Window Needle Guide Ultrasound-guided liposuction (VWING) 11 AVF Cannulation Complications | UCSF Vascular Symposium 2016 12 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 Causey J Vasc Surg 2010;52:1397-400 Jennings J Vasc Surg 2014;60:1024-32 3 4/15/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

ReTAP patch Pseudoaneurysm 13 AVF Cannulation Complications | UCSF Vascular Symposium 2016 14 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 Re-TAP patch Avoiding cannulation-related complications � 3 weeks later the patient successfully initiated dialysis � Never needed a catheter � Fistula has been functioning without intervention for the past year 15 AVF Cannulation Complications | UCSF Vascular Symposium 2016 16 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 4 4/15/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Summary � Cannulation-related complications cause significant delays in fistula access and are most likely to occur in new fistulas (<6mo) � Cannulation-related complications may be predicted 17 AVF Cannulation Complications | UCSF Vascular Symposium 2016 18 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 4/15/2016 J Vasc Surg 2009;50: 369-74. Summary � Cannulation-related complications cause significant delays in fistula access and are most likely to occur in new fistulas (<6mo) � Cannulation-related complications may be predicted • Physical exam • Pre-cannulation ultrasound � A proactive, preventative management strategy of deep and/or small fistulas may reduce cannulation complications and reduce catheter days 19 AVF Cannulation Complications | UCSF Vascular Symposium 2016 4/15/2016 5 4/15/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]