Strategy for surgical treatment of access related hand Strategy for surgical treatment of access related hand ischemia and high flow : an algorithm ischemia and high flow : an algorithm C Sessa MD, PhD , O Pichot C Sessa MD, PhD , O Pichot Groupe Hospitalier Mutualiste de Grenoble Groupe Hospitalier Mutualiste de Grenoble i- -VAS Paris september 14th 2018 VAS Paris september 14th 2018 i
Introduction Introduction Ischemia and high flow are 2 different pathophysiogical and and high flow are 2 different pathophysiogical and Ischemia clinical situations clinical situations Accurate diagnosis and strategy Accurate diagnosis and strategy Optimal techniques : specific, well codified, standardized, Optimal techniques : specific, well codified, standardized, reproducible ……… ………without jeopardizing the angioaccess without jeopardizing the angioaccess reproducible
Hemodynamics of AVF and pathophysiology of hand Hemodynamics of AVF and pathophysiology of hand ischemia ischemia Ischemia Ischemia WITHOUT high flow WITHOUT high flow with high flow (rare) with high flow (rare) Zanow : 658 ml/min : 658 ml/min Zanow Thermann : 1.38 L/min : 1.38 L/min Thermann Sessa : < 1.5 ( L/min (1 case : 2.5 L/min) Sessa : < 1.5 ( L/min (1 case : 2.5 L/min) High flow High flow cardiac symptoms WITHOUT WITHOUT ischemia ischemia cardiac symptoms > 2 L/min 2 L/min with ischemia (rare) > with ischemia (rare)
Hemodynamic of hand ischemia Hemodynamic of hand ischemia Critical points for high flow : above the AVF Critical points for high flow : above the AVF diameter of artery +++ diameter of artery +++ vein vein AV anastomosis AV anastomosis Critical points for hand ischemia : below the AVF Critical points for hand ischemia : below the AVF severe distal arteriopathy +++ severe distal arteriopathy +++ Wixon 2000 Wixon 2000 high peripheral resistances high peripheral resistances lack of collaterals lack of collaterals
Surgical strategy at the wrist Surgical strategy at the wrist Wrist Wrist Patent ulnar artery Patent ulnar artery Forearm and digital Forearm and digital with digital arteriopathy with digital arteriopathy arteriopathy arteriopathy * Ligation or embolization * Ligation or embolization of the radial artery of the radial artery Bandings Bandings (*) DRIL (*) DRIL below the AFV (Storey) below the AFV (Storey) (*) specific techniques for hand ischemia (*) specific techniques for hand ischemia
Strategy and techniques of treatment at the wrist Strategy and techniques of treatment at the wrist Patent ulnar artery Patent ulnar artery Ligation (Storey technique) or embolization of the artery distal to the AVF Ligation (Storey technique) or embolization of the artery distal to the AVF Eliminates reversal of flow Eliminates reversal of flow Restores antegrade flow to the fingers Restores antegrade flow to the fingers Improvement of symptoms and increase in distal pressure and digital blood flow tal blood flow Improvement of symptoms and increase in distal pressure and digi by manual compression of the artery below the AVF or with ballon occlusion occlusion by manual compression of the artery below the AVF or with ballon
Surgical strategies at the elbow Surgical strategies at the elbow Elbow Elbow Normal or high flow Normal or high flow Normal flow Normal flow RUDI RUDI (*) DRIL +++ (*) DRIL +++ PAVA ou PAI PAVA ou PAI Bandings Bandings (*) specific techniques for hand ischemia (*) specific techniques for hand ischemia
The DRIL technique The DRIL technique Arterial bypass 10 cm 10 cm above the AFV and above the AFV and Arterial bypass below the AVF below the AVF Increases distal flow to the hand +++ Increases distal flow to the hand +++ No changes in AVF flow No changes in AVF flow Arterial ligation below the AVF Arterial ligation below the AVF Eliminates flow inversion Directs flow in the bypass to the distal arterial network Wixon 2000 Wixon 2000
The DRIL technique The DRIL technique Interval ligation Interval ligation DRIL bypass with great saphenous vein DRIL bypass with great saphenous vein AV AV F F
The Banding techniques The Banding techniques What is the « « target target » » ? ? What is the Which technique is the most appropriate and Which technique is the most appropriate and effective ? effective ? Empirical, not well codified, unreproducible Empirical, not well codified, unreproducible How much reduction in needed to decrease How much reduction in needed to decrease flow without compromising the angioaccess ? flow without compromising the angioaccess ? Is the banding for ischemia different from high flow ? Is the banding for ischemia different from high flow ? Zanow JVS 2006 Zanow JVS 2006
Results of Bandings Results of Bandings Gupta JVS 2011 Gupta JVS 2011 87 procedures in 70 patients (Dril, Rudi, Pava… …) ) 87 procedures in 70 patients (Dril, Rudi, Pava 22 bandings : higher failure rate : 62% 22 bandings : higher failure rate : 62% most frequent reason for most frequent reason for reintervention : 8/11 (73%) reintervention : 8/11 (73%)
RUDI (Revision Using Distal Insertion) RUDI (Revision Using Distal Insertion) Lenghtens the fistula to decrease AVF flow Lenghtens the fistula to decrease AVF flow Smaller distal artery as inflow Smaller distal artery as inflow Distal anastomosis : 2 Distal anastomosis : 2- -3 cm (10 3 cm (10- -15 cm) below the 15 cm) below the bifurcation bifurcation Optimal length and diameter of the conduit ? Optimal length and diameter of the conduit ? Callaghan J Vasc Access 2011 Callaghan J Vasc Access 2011 7 patients with 3 failures 7 patients with 3 failures ”a high rate of failure was seen requiring a high rate of failure was seen requiring ” technical modifications and further experience technical modifications and further experience before becoming a valuable technique “ “ before becoming a valuable technique
PAVA Proximalization of the arteriovenous anastomosis PAVA Proximalization of the arteriovenous anastomosis Proximal inflow from a larger artery to lower arterial Proximal inflow from a larger artery to lower arterial pressure drop distal to the AVF pressure drop distal to the AVF mid- -brachial artery? brachial artery? mid axillary artery? axillary artery? What lenght and diameter of the graft ? What lenght and diameter of the graft ? tapered 4 mm x 7 mm tapered 4 mm x 7 mm 4 mm or 5 mm PTFE 4 mm or 5 mm PTFE No ligation of the artery vs DRIL No ligation of the artery vs DRIL No reversed flow to the forearm arteries = DRIL No reversed flow to the forearm arteries = DRIL Improvement of distal artery pressure or velocity Improvement of distal artery pressure or velocity Zanow Zanow
How do I treat ischemia? How do I treat ischemia? Wrist : distal radial artery Wrist : distal radial artery Elbow : Elbow : ligation ligation DRIL DRIL
Vascular access ligation Vascular access ligation Ischemic monomelic neuropathy Ischemic monomelic neuropathy Severe arterial lesions, poor general conditions or extended tissue sue Severe arterial lesions, poor general conditions or extended tis loss in patients in whom revascularization is not feasible loss in patients in whom revascularization is not feasible No improvement of symptoms after revascularization No improvement of symptoms after revascularization Patients with kidney transplant Patients with kidney transplant
High flow : Strategy and techniques of treatment High flow : Strategy and techniques of treatment High flow : > > 2 L/min 2 L/min High flow : Main factors Main factors Diameter of artery +++ artery +++ Diameter of anastomosis ++ anastomosis ++ vein vein Consequences Consequences Symptoms of cardiac overload +++ Symptoms of cardiac overload +++ Hand ischemia : rare Hand ischemia : rare
High flow : Strategy and techniques of treatment High flow : Strategy and techniques of treatment High flow High flow Sessa, Pichot : : 2.8 L/min (1.9 - - 3.8 L/min ) 3.8 L/min ) Sessa, Pichot 2.8 L/min (1.9 Indications for flow reduction for flow reduction Indications Cardiac symptoms with flow ≥ ≥ 2000 mL/min 2000 mL/min Cardiac symptoms with flow Asymptomatic patients with flow ≥ ≥ 2500 mL/min 2500 mL/min Asymptomatic patients with flow
Surgical strategies for hand ischemia Surgical strategies for hand ischemia Wrist Wrist Elbow Elbow (*) Ligation of the artery (*) Ligation of the artery Abow the AVF Abow the AVF RUDI RUDI (Bourquelot) (Bourquelot) PAVA , PAI PAVA , PAI (*) PAVA- -like technique like technique (*) PAVA (personal technique) (personal technique) Banding Banding (*) Transposition of radial artery (*) Transposition of radial artery (Bourquelot) (Bourquelot) (*) specific techniques for high flow (*) specific techniques for high flow
How do I treat high flow ? How do I treat high flow ? Wrist : Proximal radial Wrist : Proximal radial Elbow : Elbow : artery ligation artery ligation PAVA- -Like Like PAVA
Authors’ ’ technique : the PAVA technique : the PAVA- -like like Authors PTFE 5 mm x 10 10 cm for flow cm for flow < < 3 l/min 3 l/min PTFE 5 mm x 5 mm x 15 15 cm for flow cm for flow > > 3 l/min 3 l/min 5 mm x The higher the flow rate, the longer the The higher the flow rate, the longer the PTFE graft PTFE graft Mean flow reduction : about 50% Mean flow reduction : about 50%
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