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Arteriovenous Fistulas Types, Trends, Physical Examination & Treatment

Arteriovenous Fistulas Types, Trends, Physical Examination & Treatment. B. Karenko, DO January 25, 2014. I have no disclosures. Objectives. Identify types of vascular access Evaluate trends of vascular access Physical examination of AV Fistulas Normal When to refer Treatment.

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Arteriovenous Fistulas Types, Trends, Physical Examination & Treatment

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  1. Arteriovenous FistulasTypes, Trends, Physical Examination & Treatment B. Karenko, DO January 25, 2014

  2. I have no disclosures

  3. Objectives • Identify types of vascular access • Evaluate trends of vascular access • Physical examination of AV Fistulas • Normal • When to refer • Treatment

  4. Type of Hemodialysis Access Synthetic AV Graft Central Venous Catheter AV Fistula

  5. Radiocephalic Fistula • Radial Artery to Cephalic Vein • Forearm • Preferential

  6. Brachiocephalic Fistula • Brachial Artery to Cephalic Vein • Antecubital Fossa

  7. Brachiobasilic Fistula • Brachial Artery to Basilic Vein • Upper Arm • +/- transposition

  8. AV Fistula Advantages Disadvantages Long Maturation Time More Difficult Cannulation High Primary Failure with Difficult Vasculature • Smaller Surgery • Decreased Infection • Decreased Thrombosis • Longer Lifespan • 68% AVF • 49% AVG Allon & Robbin, Kidney Int. 62:1109-1124, 2002. Nassar & Ayus. Kidney Int. 60:1-13, 2001 Pisoni RL, et al., Kidney Int. 61:305-306, 2002

  9. Best to Worst AVG AVF CVC

  10. Vascular Access Use & Outcomes; An International Perspective from the Dialysis Outcomes & Practice Patterns Study • Prospective Observational Study • >300 Hemodialysis Sites • 12 Countries • >35,000 patients Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

  11. AV Fistula Use 1996-2007 Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

  12. Referral Timeframe Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

  13. Creation to Cannulation Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

  14. Successful Fistula Adequate Vessels Good Pump >0.4 cm Robbins Radiology 225; 59-64, 2002

  15. Monitoring/Surveillance New AVF Established AVF Early Detection Thrombosis Inadequate Flow • Identify 1° Failures • Plan for Early Interventions • Plan for Surgical Revision

  16. Physical Examination • Look • Listen • Feel

  17. Look Radiocephalic Brachiobasilic (transposed) Brachiocephalic

  18. Look

  19. Aneurysm & Hematoma

  20. Steal Syndrome

  21. Central Vein Stenosis • Extremity Swelling • Collateral Veins

  22. Arm Elevation Test

  23. Auscultation • Normal Bruit • High Pitched (stenosis)

  24. Feel (Palpation) • Inflow Assessment • Outflow Assessment • Augmentation Test • Absence of Thrill • Pulsitile

  25. Outflow Obstruction

  26. Treatment of Stenosis • Venous Anastomosis/Outlet • Significant Lesions • <600 ml/min flow • >50% stenosis on angiogram

  27. Endovascular Angioplasty • First Line Treatment • 7-8mm peripheral • 12-14mm central • Poor long term patency • 50% require repeat treatment within 6-12 months Am. J Kidney Disease 2001; 37 (5); 1029

  28. Stents • Three Indications • Angioplasty Failure • Rapid Recurrence of Lesion • Vessel Rupture J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

  29. Patency 92% 80% 69% 35% 24% 3% 30 90 180 Clin J Am Soc Nephrol. 2008, 3(3);699

  30. Surgical Revision of Stenosis • Advantage • Elimination of the lesion • Disadvantage • Frequent new lesion development • Loss of venous access sites • Post surgical pain/recovery time

  31. Thrombosis • Percutaneous/Surgical Thrombectomy • Thrombolytic Agents

  32. Percutaneous Thrombectomy J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

  33. Surgical Thrombectomy J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

  34. Thrombectomy • Percutaneous/Surgical Thrombectomy • Primary Patency • 3 months: 30-60% • 6 months: 10-40% • Elective Angioplasty vs Thrombectomy J. Vasc. Interv. Radio. 1999; 10 (2pt1):129

  35. Thrombolysis (local) • Agents • Contraindications • Pulse Spray • Mechanical Clot Disruption • 50% patent at 1 yr

  36. Major Concern • Development of Clinically Significant PE • 650 Thrombectomy Cases • 1 Clinically Significant PE Kidney Int. 1994; 45(5) 1401

  37. Questions?

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