Use of ultrasound for AVF angioplasty. Time to get rid-off the C-arm? Olivier Pichot - Carmine Sessa Grenoble
Disclosure I do not have any potential conflict of interest for this presentation
Fluoroscopic guidance ▪ Dedicated equipment • X Ray room • C-arm ▪ Radiation exposure • Patient • Medical team ▪ Radiation protection • Lead apron • Shielding booth • Film badges ▪ Contrast agent injection
Is it possible to resolve these issues? ▪ Radiation exposure: ▪ An ideal technology ? • ALARA (As Low As Reasonably • No radiation Achievable) • No contrast ▪ Contrast agents: • Good flux visualisation • Hemodynamical information • CO2 • Flow • Contrast dilution • Velocities • Anatomical information • Vein wall • Surrounding tissues • Continuous monitoring of the procedure
Ultrasound ✔ No radiation ✔ No contrast ✔ Good flux visualisation ✔ Hemodynamical information ✔ Flow ✔ Velocities ✔ Anatomical information ✔ Vein wall ✔ Surrounding tissues ✔ Continuous monitoring of the procedure
In practice: Preoperative duplex examination ▪ AVF DU analysis ▪ Mapping ▪ Choice of the vascular access site Preoperative DUS and PTA management: Doelman 2005) • Optimize the choice of the cannulation site in 38% of cases • Reduce the number of access punctures • Avoid extra session to perform PTA and shorten examination time • Avoid extra burden for the patient ▪ Choice of the appropriate balloon
« Surgery like » set-up & Sterilized supplies
1. Vascular access ▪ Non systematic EG ▪ Mandatory (very useful) • Drainage vein access • Maturation delay • Retrograde catheterization • Obesity • Brachial artery access
2. Introducer tip positioning ▪ Mandatory (very useful) if the distance between the vein access site & the stenosis is short 2 cm
3. Catheterization
4. Balloon positioning
4. Balloon positioning
5. Balloon inflation
6. Results evaluation
6. Results evaluation
▪ 131 PTA in 86 patients: ▪ Echo guidance: 81.7% • Distal AVF • Forearm 72.9% 61% • Arm 27.1% • Cephalic vein 82.4% ▪ Fluoroscopic guidance: 18.3% • Ceph. arch or prox. v. 75% • EG unavailable 25% EG PTA Results n= 107 (%) 93,5 3,7 3,7 1,9 0,9 Catheterization failure Stenosis relief (n=100) RX conversion (n=1) Residual stenosis (n=2) or (n=2) thrombosis (n=2)
Complications ▪ Cephalic v. rupture 1.9 % (n= 2) ▪ Compressive perivenous hematoma 2.8 % (n= 3)
▪ Extended dissection: 19.6% (n=21) • Successful prolonged compression 17.8 % 19 • Residual stenosis 1.8 % 2 ▪ Recoil (vein stenosis) 9.3 % (n=10) ▪ Vein spasm (access site) 1.8 % (n=2)
Echoguidance pro and cons ▪ No radiation no contrast ▪ “In office” practice ▪ Reduction of the duration (and cost) of the procedure
Echoguidance pro and cons ▪ Limitations: • Cephalic arch • Arteries calcifications • Central veins Cephalic arch Radial artery Brachio cephalic vein
Echoguidance pro and cons ▪ Intrinsic improvements: • Security and accuracy of the vascular access • Real time monitoring of all the procedure steps • Real time monitoring of all the procedure outcome • Anatomical • Hemodynamic +++ • Vein (or catheter) mobilization maneuver
The future: to convince… KDOQI CLINICAL PRACTICE GUIDELINE FOR VASCULAR ACCESS: 2018 AJKD SUBMISSION DRAFT April 2019
The future: to educate… New practice New semiology Training phantoms Fellowship
Echoguidance is already a routine practice for the new medical generation 😊 ▪ Anesthesiologist: Local anesthesia ▪ Nephrologist: CVC insertion ▪ Carcinologist: PICC-Line insertion ▪ Nurse: Peripheral IV catheter insertion ▪ Vascular surgeon and radiologist: Arterial and venous access ▪ Phlebologist: Endovenous treatment guidance Echoguidance for AVF PTA is the next step !
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