1 / 56

Gregg A. Miller MD Assistant Clinical Professor, Columbia P S Chief Medical Officer, American Access Care

dwayne
Download Presentation

Gregg A. Miller MD Assistant Clinical Professor, Columbia P S Chief Medical Officer, American Access Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    2. Percutaneous Flow Reduction Embolization Modification of resistances True percutaneous procedures Banding Modification of anastomosis resistances Percutaneous-assisted surgical procedures

    3. High Flow Access

    5. Ischemic Limb

    6. High Flow Access High flow access can manifest a spectrum of disease from high output heart failure with a mega-fistula to Dialysis Associated Steal Syndrome (DASS) with severe ischemic symptoms.

    7. High Flow Access Determine what you are Treating Steal (modify resistance) High Flow (modify anastomosis and resistance) High Flow with Steal Forearm AVF, or Upper Arm AVF Four Basic Treatments Proximalize Arterial Anastamosis (surgery) Distalize Arterial Anastamosis (surgery/embolization) Band the Inflow (minimally invasive surgery) Block Retrograde Flow (embolization)

    8. High Flow AVF’s: Forearm Treat Steal Goal: Modify Resistance Block retrograde flow Revascularize distally Treat High Flow Goal: Modify Anastomosis and Add Resistance

    9. Forearm Flow Reduction with MILLERBanding

    11. Minimally Invasive Coil Embolization

    12. Forearm Arteriogram

    13. High Velocity Ulnar Artery Flow

    14. Palmar Arch Shunt

    15. Retrograde Flow in DRA

    16. Embolized DRA with Enhanced Finger Perfusion

    17. High Flow AVF’s Forearm AVF GOAL:ADD RESISTANCE by Distalizing inflow

    18. Proximal Radial Artery Ligation (PRAL)

    19. Hypertrophic Radial Artery

    20. Proximal and Distal AVF Flow

    21. High Velocity Ulnar Flow

    22. Arterial Collaterals

    23. Proximal Radial Artery Embolization Tips for success Perform a full extremity arteriogram Understand anatomy Flow measurements with / without PRA occlusion

    24. Embolize Proximal Radial Artery

    25. High Flow AVF’s: Upper Arm Upper Arm AVF GOAL: ADD RESISTANCE High Flow -alter anastamosis Steal – change resistances RUDI / Distalization Proximalization Banding /Plication MILLER Banding Transonic flow measurement >4 l/min

    26. Proximal Arterial Hypertrophy with Distal Arterial Atrophy

    27. Proximalization – Surgical Option

    28. Flow Reduction by Distalization RUDI

    29. DRIL Distal Revision with Interval Ligation

    30. DRIL

    31. Retrograde Flow in Distal Brachial Artery

    32. Steal Treated with Interval Ligation

    33. Know the Anatomy

    34. Run-off with Distal Brachial Artery Occlusion

    35. Embolization Plug Deployed

    36. Embolize Brachial Artery

    37. Banding: Who is it not for….? Banding is not for patients with low flow accesses with Steal Low Flow< 800 cc/min DRIL, Proximalization

    38. T-banding

    39. Sizing is a problem

    41. Figure 3: A 68 y/o female with right upper arm brachial artery to cephalic vein fistula presented with DASS. She was referred to her vascular surgeon who placed a clip proximally attempting to correct the steal syndrome. The patient then returned with persistent severe steal symptoms and underwent a MILLER procedure which sized the flow restricting band to 4mm. The patient had an immediate resolution of symptoms.Figure 3: A 68 y/o female with right upper arm brachial artery to cephalic vein fistula presented with DASS. She was referred to her vascular surgeon who placed a clip proximally attempting to correct the steal syndrome. The patient then returned with persistent severe steal symptoms and underwent a MILLER procedure which sized the flow restricting band to 4mm. The patient had an immediate resolution of symptoms.

    42. MILLER Procedure Minimally Invasive Limited Ligation Endoluminal-assisted Revision MILLER procedure will treat all patients with a high flow accesses and are clinically symptomatic with Steal Syndrome Pathologically High Flow Inflow-Outflow Mismatch AVF, AVG

    43. Standardized Minimally Invasive Banding

    44. Standardized Minimally Invasive Banding

    47. MILLER Banding Statistics 183 Patients 12 of 183 required one or more bandings to achieve clinical efficacy 4 Technical failures due to bleeding complications and an inability to complete the dissection 114 patients underwent repair of steal 69 patients underwent flow reduction 58% banded to 4mm 24% banded to 3mm Range 3-6mm Average Flow reduction 54% (3300 – 1500cc/min)

    48. Procedure Failures 2 Patients had severe arteriopathy and flow reduction was not successful 4 Patients with difficult anatomy and were referred for surgical evaluation 2 Proximalization 1 DRIL 1 Banding with open dissection

    49. Shunt - Upper Arm Access

    50. Upper Arm Access after MILLER

    52. Conclusions Treatment of pathologically shunting accesses can performed percutaneously by adding resistances to the access circuit Resistance can be added through Banding Embolization

    53. Conclusions Flow reduction using percutaneous techniques and percutaneous assisted techniques are used to reduce flow and treat steal. Percutaneous Flow Reduction Techniques Effective Safe Do not require special equipment Can be done in the angiography suite (outpatient) Can be used as a first line treatment for pathologically shunting accesses

    54. High Flow AVF’s Forearm AVF High Flow vs. Steal DRA Coil/Ligation PRAL Ligation Banding/Plication MILLER Banding Upper Arm AVF High Flow vs. Steal DRIL RUDI / Distalization Proximalization Banding /Plication MILLER Banding

    55. High Flow AVF’s Forearm AVF High Flow vs. Steal Upper Arm AVF High Flow vs. Steal

    56. Upper Arm Flow Reduction Proximalization

More Related