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Presentation for: Tri-Service General Hospital July 22nd, 2008

Presentation for: Tri-Service General Hospital July 22nd, 2008. Flow-Based Vascular Access Management. A Quantitative approach to preserving access patency; A patient’s link to life. Flow-Based. Surgical Creation of the access Hemodialysis Surveillance Angioplasty or

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Presentation for: Tri-Service General Hospital July 22nd, 2008

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  1. Presentation for: Tri-Service General Hospital July 22nd, 2008

  2. Flow-BasedVascular Access Management A Quantitative approach to preserving access patency; A patient’s link to life

  3. Flow-Based • Surgical Creation • of the access • Hemodialysis • Surveillance • Angioplasty or • Surgical Revision

  4. Vascular Access Management Tools Intraoperative Flowmeter Endovascular Flowmeter Hemodialysis Monitor

  5. Flow-based Access Creation

  6. HT300-Series Flowmeters • Mean Volume Flow Digital Display • Wave-Form printer • FlowSound • Inversion button (+/-) Above - HT313 , Below -HT323

  7. Transonic (FMV) Vascular Flowprobes • Available in a wide range of sizes (1.5 to 14 mm) • Reusable • Steam, EtO and Sterrad Sterilizable

  8. Transit-Time Ultrasound (TTU)

  9. TTU Difference between T-1 and T-2 is a phase change proportional to volume Flow

  10. ValidationTransit-Time Ultrasound (r = 0.93–0.95) between Transonic TTU Flow measurements and True Flow in an experimental model Beldi G, Transit time flow measurement: experimental validation and comparison of three different systems. Ann Thorac Surg 2000;70:212–217.

  11. Clinical Technique • Skeletonize Vessel • Select Flowprobe for a loose fit. • Use Acoustic Gel • Vessel should fill 60-95% of probe lumen • Keep vessel perpendicular to the probe (Don’t Twist)

  12. Movies (If available) Applying Gel Applying Flowprobe to Vessel Flowsound Documenting Waveform

  13. End-to-side anastomosis Measure Venous Outflow

  14. Side-to-Side Anastomosis Measure Venous Outflow

  15. Clinical Results - Fistulas • Johson et al • 227 Fistulas over 4 years • Measured Flow 5-10 minutes after vascular anastomosis Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements in Vascular Access Surgery,” Surgery 124(4):729–738, 1998.

  16. Fistula Flow Patency Results Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements in Vascular Access Surgery,” Surgery 124(4) 729–738, 1998.

  17. AV Fistula Guidelines Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements in Vascular Access Surgery,” Surgery 124(4):729–738, 1998.

  18. Clinical Results - Fistula • Berman72 AV fistulas over 12 months Berman, SS et al, “Predicting Arteriovenous Fistula Maturation with INtraoperative Blood Flow Measurements” Western Vascular Socitey 22nd Annual Meeting, Sept, 8-11, 2007, Kohala Coast, Kona, HI.

  19. Fistula Guidelines Berman, SS et al, “Predicting Arteriovenous Fistula Maturation with INtraoperative Blood Flow Measurements” Western Vascular Socitey 22nd Annual Meeting, Sept, 8-11, 2007, Kohala Coast, Kona, HI.

  20. PTFE Grafts Air in the graft interstices block ultrasound transmission. Therefore, measure at the distal outflow of the graft.

  21. Clinical Results - Grafts • Johnson et al162 PTFE grafts Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements in Vascular Access Surgery,” Surgery 124(4):729–738, 1998.

  22. PTFE Graft Flow Guidelines cont. Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements in Vascular Access Surgery,” Surgery 124(4):729–738, 1998.

  23. Flow-QC Measurements • Quick, accurate, and easy to perform • May indicate corrections during surgery • Can predict the ultimate survival of an AV access

  24. Flow-based Surveillance during Hemodialysis

  25. K/DOQI National (USA) Kidney Foundation Kidney Disease Outcomes Quality Initiative • Promotes new standards of care in order to treat all forms of kidney disease and reduce the number of dialysis patients. http://www.kidney.org/PROFESSIONALS/kdoqi/guideline_upHD_PD_VA/index.htm

  26. K/DOQI Goal: • Detect access dysfunction prior to access thrombosis. http://www.kidney.org/PROFESSIONALS/kdoqi/guideline_upHD_PD_VA/va_guide4.htm

  27. K/DOQI Suggested Technology • Indicator dilution (Transonic) flow measurements are the preferred method of A-V graft and fistula surveillance.

  28. Indicator Dilution Flow Measurements

  29. Transonic Flow-QC® Hemodialysis Monitor The Standard of Care for the ESRD patient

  30. HD Monitor Parameters • Dialysis Adequacy • Delivered Blood Flow • Recirculation • Vascular Access Flow • Cardiac Output

  31. Access Flow Measurement (Blood Lines are Reversed)

  32. K/DOQI Guidelines

  33. K/DOQI Guidelines for Monitoring AV Grafts and Fistulas • Access flow < 600 ml/min, the patient should be referred for fistulagram. • Access flow < 1000ml/min that has decreased by > 25% over 4 months should be referred for fistulagram.

  34. Monthly Access Flow Trending K/DOQI Guideline: <600 ml/min Documented Intervention

  35. Clinical Results • Gambro Study • McCarley Study

  36. Gambro Study An 18-month Gambro Study of 254 patients using a multidisciplinary approach to vascular access care resulted in: • 44% decrease in thrombosis. • Significant improvements in clinical outcomes. • Decrease in hospitalizations. Reference: Duda, CR, Spergel, LM, Holland, J, Tucker, T, Bosch JP, Bander, SJ. “A Multidisciplinary Vascular Access Care Program (VACS) Enables Implementation of Dialysis Outcomes Quality Initiative (DOQI)”, JASN Abstracts, Vol. 10, p. 206A, 1999.

  37. Vascular Access Blood Flow Monitoring Reduces Access Morbidity and Costs Patricia McCarley, Rebecca L. Wingard, Yu Shyr, William Pettus, Raymond M. Hakim, and T. Alp Ikizler Vanderbilt University Medical Center, Dialysis Clinics, Inc., Renal Care Group, Inc. Kidney International, Vol. 60 (2001), pp. 1164-1172

  38. Three-Phase Study 132 Hemodialysis Patients with A-V grafts or fistulas.

  39. Europe • “Objective monitoring of access function should be performed regularly by measuring access flow.” European best practice guidelines on hemodialysis Guideline 5. Surveillance of Vascular Access. ERA/EDTA. Nephrol Dial Transplant, 2007; 22(Suppl 2): ii99. Transonic Reference # HD7450A

  40. Japan • “Regular monitoring of shunt flow in haemodialysis patients has become extremely important.” “Clinical Evaluation of New Non-Invasive Shunt Flow Measurement Device.” Satoshi YAMAGUCHI1, Noriko OKUMURA1, Izumi AMANO1 Department of Blood Purification, Tenri Hospital. 42nd Annual Meeting of the Japanese Society for Artificial Organs; October 6, 2004

  41. Flow-QC in HD Preserve an Access - Save a Live

  42. Flow-based AV Access Intervention

  43. Why measure flow during Angioplasty? • Intra-access blood flow fails to normalize after angioplasty in 20-30% of patients. Vesely, T.M., et al, "Use of a catheter-based system to measure blood flow in hemodialysis grafts during angioplasty procedures," J Vasc Interv Radiol, 13(4) 371-378, 2002.

  44. HVT100 Endovascular System • HVT100 system provides quantitative assessment during angioplasty • The data allows the Radiologist to make adjustments before the patient leaves the IR suite. HVT100 Endovascular Flowmeter and ReoCath Flow Catheter

  45. Flow-Guided Angioplasty • Measure baseline flow before • Angioplasty • Measure flow after angioplasty to confirm success.

  46. Catheter Types Antegrade Retrograde

  47. K/DOQI Guidelines

  48. Clinical Results • Post-angioplasty blood flow is predictive of subsequent graft patency • Murray, BM et al, “Access Flow after Angioplasty Predicts Subsequent Arteriovenous Graft Survival,” J Vasc Interv Radiol 17:303-309, 2006. HD2020A • Success achieved in restoring flow,as measured during the intervention usually predicts good immediate outcomes in the HD unit. • Krivitski , NM “Access Flow Measurement during Surveillance and Percutaneous Transluminal Angioplasty Intervention,” Sem Dial 16(4): 304-308, 2003.

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