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Doran Mix 1 Joseph Featherall 2 University of Rochester School of Medicine and Dentistry 1

Pulsatile Hemodynamic Circuit Simulation of Access-Related Distal Ischemia and a Potential Mechanism for the Distal Revascularization-Interval Ligation Corrective Procedure. Doran Mix 1 Joseph Featherall 2 University of Rochester School of Medicine and Dentistry 1

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Doran Mix 1 Joseph Featherall 2 University of Rochester School of Medicine and Dentistry 1

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  1. Pulsatile Hemodynamic Circuit Simulation of Access-Related Distal Ischemia and a Potential Mechanism for the Distal Revascularization-Interval Ligation Corrective Procedure Doran Mix1 Joseph Featherall2 University of Rochester School of Medicine and Dentistry1 Rochester Institute of Technology2

  2. Disclosure: • None

  3. Objectives: • Model physiologic pulsatile blood flow in a Brachial-Cephalic arterovenous fistula • Observe retrograde blood flow in the arterial segment distal to AVF as a surrogate of access related distal ischemia (ARI) • Observe effect of capacitance and resistance produced by the Distal Revascularization-Interval Ligation procedure (DRIL)

  4. Hypothesis: • Pulsatile retrograde blood flow in the arterial segment distal to the AVF is a function of arterial collateral resistance and capacitance. • Distal Revascularization will promote retrograde blood flow to the distal limb by decreasing collateral resistance and increasing capacitance. • Interval Ligation is needed to prevent retrograde blood flow.

  5. Clinical Application • May 2009: 179,113 patients used AVF for hemodialysis • 52.6% of RRT population • Rate of Distal Ischemia after fistula creation ~1.6-8% • Future reimbursement based on outcomes

  6. Limitations: • Retrograde blood flow in the arterial segment distal to the AVF is neither necessary nor sufficient for ARI.

  7. Method: • Convert pulsatile arterial blood flow into an electric circuit diagram of an upper arm AVF • Pressure  Voltage • Flow  Current • Vessel Radius and Length  Resistance • Vessel Volume  Capacitance • Fluid Inertia  Inductance • Change resistance and capacitance of collaters • Hemodynamics in segment distal to AVF

  8. Arterial Windkessel Model

  9. Bridge: Hemodynamic  Circuit Ohms Law: P = Q * R Poiseuille’s Equation : Vessel Capacitance: Fluid Inertia:

  10. The Wheatstone Bridge:

  11. The Wheatstone Bridge

  12. Balancing the Bridge Anterograde: No Flow: Retrograde:

  13. DRILing the Bridge Anterograde: No Flow: Retrograde:

  14. Objective#1: Circuit Model

  15. Objective #1: Pulsatile

  16. Objective#2: Distal Flow

  17. Objective#3: DRIL Effect Collateral Anterograde: No Flow: Retrograde:

  18. Conclusion: • Retrograde flow is promoted by Distal Revascularization: decreasing collateral resistance • Anterograde flow is promoted by Distal Revascularization: decreasing resistance of proximal segment • Interval Ligation removes the distal conduit and effectively removes retrograde flow • Collateral ligation supports anterograde flow

  19. Objectives: • Model physiologic pulsatile blood flow in a Brachial-Cephalic AVF • Observe retrograde blood flow in the arterial segment distal to AVF as a surrogate of access related distal ischemia (ARI) • Observe effect of capacitance and resistance produced by the Distal Revascularization-Interval Ligation procedure

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