Program Book - Keck School of Medicine of USC - University of ...

Program Book

TABLE OF CONTENTSNeeds Assessment 2Course Description and Learning Objectives 3Acknowledgement of Commercial Support & Exhibitors 4Program Faculty & Disclosures 5Program Schedule and Contents 7Cultural and Linguistic Competency Policy & Resources 1501

Needs AssessmentOver 370,000 patients in the United States require hemodialysis to sustain life. 1 Growth in theincident hemodialysis population has been driven by a linear increase since 1980. 1 In 2009, therewere 106,333 new hemodialysis patients. 1 Kidney Disease Outcomes Quality Initiative (K-DOQI)Clinical Practice Guidelines for Hemodialysis Adequacy have stated since 2006 that patients shouldhave a functional permanent access at the initiation of dialysis therapy. 2 However, 81% of patientsstill dialyze through a catheter at initiation of hemodialysis. 3 This may be related to the fact thatmany patients have challenging anatomy that make traditional arteriovenous fistulas or graftsdifficult to create.Advancements in biomedical engineering have accelerated the technological development andapplication of vascular access grafts. With the explosion of endovascular technology in vascularsurgery, many new grafts have been developed which use a combination of an open andendovascular approach to treating patients with challenging anatomy. This has resulted in morenon-catheter based hemodialysis access options.In 2003, the Fistula First Breakthrough Initiative was created with a goal of achieving a 70%prevalent fistula rate. 4 While the prevalent fistula rate has nearly doubled from 32% in 2003, as ofJanuary 2012, the prevalent national fistula rate is still only 60%. 5 One contributing factor to thefailure to achieve the 70% goal is that improvements in overall management of end-stage renaldisease patients have decreased the annual mortality almost 18% from 2000 to 2008. 1 However,during that same period, the prevalence of patients wait-listed for a kidney transplant increasednearly 33%. 1 As a result, the survival of this patient population increases at a rate that outpaces theavailability of kidney transplants. As survival increases without kidney transplantation, the availablesites for hemodialysis access creation become exhausted, increasing the challenge to the surgeon.In addition, with increasing patient survival, access complications also become more common.Advanced surgical techniques and endovascular technology have been increasingly applied totreatment of dialysis access complications so that the life of the hemodialysis access can beprolonged.Advances in technology combined with failure to meet national guidelines and the increasingprevalence of hemodialysis patients who pose a dialysis access challenge makes “Controversiesand Challenges in Hemodialysis Access” a timely topic for discussion and the subject of thisyear’s symposium. This course has been designed to update physicians and surgeons on themany new developments in vascular access grafts and techniques and to provide guidance as tohow these new management strategies should modify current practice patterns and achievenational guidelines.References1. U S Renal Data System, USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage RenalDisease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and KidneyDiseases, Bethesda, MD, 2011.2. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: HemodialysisAdequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 2006;48:S1-S322 (suppl 1).3. Slinin Y, Gui H, Gilbertson DT, et al. Meeting KDOQI Guideline Goals at Hemodialysis Initiation and Survival during theFirst Year. Clin J Am Soc Nephrol 5:1574-1581,2010.4. Neumann ME. “Fistula first” initiative pushes for new standards in access care. Nephrol News Issues 18:47-8,2004.5. Fistula first data. Available at http://www.fistulafirst.org/AboutFistulaFirst/FFBIData.aspx. Accessed .6.2012.2

Course DescriptionMax R. Gaspar, M.D., was an attending surgeon at the Los AngelesCounty + University of Southern California Medical Center for over fiftyyears, and served as Chief of Vascular surgery at LAC+USC for twentyfiveyears. His teaching and scholarly accomplishments have had alasting impact on vascular surgery in Southern California. This annualsymposium, which honors Dr. Gaspar, addresses a specific topic of interest to physicians andsurgeons who care for the patient with vascular disease. The topic of the 2012 GasparSymposium is “Controversies and Challenges in Hemodialysis Access”. A distinguishedfaculty has been assembled for the symposium which is designed to update the attendee on thecurrent status of the evolving field of hemodialysis access. This year we are delighted to have Dr.Samuel Eric Wilson, Professor of Surgery at the University of California at Irvine, as the GasparVisiting Professor. Dr. Wilson has been a leader in vascular surgery for over four decades. Hehas been the editor of the textbook “Vascular Access: Principles and Practice” since 1980, whichis now in its fifth edition. His symposium address on September 27 is titled, “Three Rules toBreak in Vascular Access Surgery”. His Gaspar Lecture “Maintaining Best Practices in theEndovascular Revolution” will be delivered the following day, September 28, at the USC HealthSciences CampusLearning ObjectivesUpon successful completion of this activity, participants will be able to:1. Be familiar with the principles of hemodialysis and access planning.2. Describe techniques for vascular access in the upper and lower extremity and thepediatric population.3. Discuss the complications of vascular access surgery and the treatment options forthose complications.Desirable Physician Attributes: In alignment with the CME mission of the Keck School of Medicine, programs are planned in thecontext of desirable physician attributes as designated by the ACGME/ABMS and the Institute of Medicine: 1) Patient Care andPatient-centered Care, 2) Medical Knowledge, 3) Practice-based Learning, 4) Interpersonal and Communication Skills, 5)Professionalism, 6) Systems-based Practice, 7) Work in Interdisciplinary Teams, 8) Apply Quality Improvement, 9) UtilizeInformatics, and 10) Employ Evidence-based practice. This program and the objectives have been developed in the context ofattributes 1, 2, 3, 5, and 10.Professional Credit: The Keck School of Medicine of the University of Southern California is accredited by theAccreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.The Keck School of Medicine of the University of Southern California designates this live activity for a maximum of 6.75AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participationin the activity.The California State Board of Registered Nursing accepts courses approved for AMA PRA Category 1 credits as meeting thecontinuing education requirements for license renewal. Nurses from states other than California must check with their local stateboard for specific continuing education policies.3

ACKNOWLEDGEMENTSWe would like to thank the following companies for their educational support of this meeting:Abbott VascularBoston Scientific CorporationCovidienEndologixMedtronicW.L. Gore & AssociatesWe gratefully acknowledge the following companies participating as exhibitors at this event:Abbott VascularAngioScoreAtrium Medical CorporationBaxter HealthcareBoston Scientific CorporationCook MedicalCovidienCryoLifeDynamics Orthotics & Prosthetics, Inc.Edward LifeScienceEKOS CorporationEndologixFundacion PadrinoGrifols U.S. IncHarvest Technologies Corp.KCIMedtronicOsborn MedicalPhilips HealthcareSIGVARIS, Inc.Spectrum HealthcareTerumo Cardiovascular SystemsTransonicVascular Solutions, IncVeritas InterventionalW.L. Gore & AssociatesZymoGenetics

PROGRAM FACULTY AND DISCLOSURESCourse DirectorFred A. Weaver, MD, MMMProfessor of SurgeryChief, Division of Vascular Surgery and Endovascular TherapyCo-Director, USC Cardiovascular Thoracic InstituteKeck School of Medicine of USCConsultant/Grant/Research: WL GoreMax R. Gaspar Visiting ProfessorSamuel Eric Wilson, MDProfessor of SurgeryUniversity of California - IrvineSchool of MedicineNo relevant financial relationships to disclose.Guest FacultyAhmed Abou-ZamZam, MDAssociate Professor of SurgeryChief, Division of Vascular SurgeryDepartment of Cardiovascular and Thoracic SurgeryLoma Linda UniversityNo relevant financial relationships to disclose.Scott Berman, MD, FACSVascular & Endovascular SurgeryRegistered Vascular TechnologistCarondelet Vascular Specialist GroupTucson Special Group, ArizonaNo relevant financial relationships to disclose.Christian deVirgilio, MDVice Chair of EducationProfessor of SurgerySurgery - VascularHarbor UCLA Medical CenterNo relevant financial relationships to disclose.Alik Farber, MD, FACSAssociate Professor of Surgery and RadiologyChief, Section of Vascular & Endovascular SurgeryBoston Medical CenterNo relevant financial relationships to disclose.Robert Hye, MDKaiser Foundation Hospital – San DiegoGrant Research: WL Gore,Inc; Proteon Therapeutics, Inc; BTG InternationalJuan Carlos Jimenez, MDAssistant ProfessorDivision of Vascular SurgeryUCLA5

No relevant financial relationships to disclose.Joseph Mills, MDChief, Division of Vascular and Endovascular SurgeryProfessor, Department of SurgeryUniversity of ArizonaNo relevant financial relationships to disclose.Keck School of Medicine of USC FacultyWilliam M. Lee, MDAssistant Professor of SurgeryDivision of Vascular Surgery & Endovascular TherapyNo relevant financial relationships to disclose.Mitra Nadim, MDAssociate Professor of MedicineDirector, Hypertension Center & Renal Disease CenterDivision of Nephrology, Department of MedicineNo relevant financial relationships to disclose.Christian Ochoa, MDAssistant Professor of SurgeryDivision of Vascular Surgery & Endovascular TherapyNo relevant financial relationships to disclose.Vincent L. Rowe, MDAssociate Professor of SurgeryProgram Director, Vascular Surgery Residency ProgramDivision of Vascular Surgery& Endovascular TherapyNo relevant financial relationships to disclose.David Shavelle, MDAssociate Professor of Clinical MedicineDivision of Cardiovascular MedicineGrant Research: Abiomed, Inc; GlaxoSmithKline; Maquet, Inc; St. Jude Medical, IncKaren Woo, MDAssistant Professor of SurgeryDivision of Vascular Surgery & Endovascular TherapyNo relevant financial relationships to disclose.Faculty Disclosure: Current guidelines state that participants in continuing medical education activities should beaware of any affiliation or financial interest that could affect the speaker’s presentation(s). The Accreditation Council forContinuing Medical Education policy mandates that the provider adequately manages all identified potential conflicts ofinterest prior to the program. Faculty members have completed disclosure forms and potential conflicts of interest havebeen reviewed and resolved prior to the program. All disclosures must be listed in the course syllabus.Cultural and Linguistic Competency: This activity is in compliance with California Assembly Bill 1195, which requires that allCME activities address cultural and linguistic competency in patient care delivery to meet the concerns of a diversepopulationthrough effective and appropriate professional development.6

PROGRAM AGENDA7:00 am Registration and Continental Breakfast8:00 am Course OverviewFred A. Weaver, MD, MMMSession I: Basic ConceptsModerator: Vincent L. Rowe, MD8:10 am ESRD in 2012: Socio-Economic ImpactJuan Carlos Jimenez, MD8:30 am Principles of Hemodialysis and Access CannulationMitra Nadim, MD8:50 am Vascular Access Planning and Pre-Op EvaluationFred A. Weaver, MD, MMM9:10 am What’s New in Vascular Grafts?Scott Berman, MD9:30 am Panel Discussion9:50 am BreakSession II Vascular Access TechniquesModerator: Fred A. Weaver, MD, MMM10:10 am Options and Strategies for Upper Extremity Arteriovenous Fistula CreationChristian deVirgilio, MD10:30 am Lower Extremity Dialysis AccessAhmed AbouZamZam, MD10:50 am Pediatric Vascular AccessVincent L. Rowe, MD11:10 am Options for End Stage Dialysis AccessWilliam M. Lee, MD11:30 am Panel DiscussionInvited Lecture11:50 am Three Rules to Break in Vascular Access SurgerySamuel Eric Wilson, MD- Gaspar Visiting Professor12:30 pm LunchSession III Vascular Access Complications IModerator: Karen Woo, MD1:45 pm Vascular Access Surveillance, Is It Worth It?Christian Ochoa, MD2:05 pm Management of the Non-Maturing Arteriovenous FistulaAlik Farber, MD7

2:25 pm Vascular Access Infections, Medical, Surgical ManagementRobert Hye, MD2:45 pm Panel Discussion3:05 pm BreakSession IVModerator:Vascular Access Complications IIFred A. Weaver, MD, MMM3:25 pm Ischemic Steal, Diagnosis and ManagementJoseph Mills, MD3:45 pm The Management of Thrombosed and Failing Fistulas/GraftsDavid Shavelle, MD4:05 pm Aneurysmal Fistula Reduction and ReconstructionKaren Woo, MD4:25 pm Panel Discussion4:45 pm Adjourn8

Juan Carlos Jimenez, MD September 27, 2012Assistant Professor8:10 am – 8:30 amDivision of Vascular SurgeryUCLAESRD IN 2012:Socio-Economic ImpactLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Understand the cardiovascular changes that accompany mild thyroiddisease.2. Diagnose and Treat Cardiovascular Risk Factors associated withsubclinical hypothyroidism.3. Recognize that Statin Induced Myopathy may result fromhypothyroidism.4. Use best practice principles when using levothyroxine to treathypothyroidism and coexistent cardiac disease.9

ESRD in 2012: Socio-economicImpactJuan Carlos Jimenez MD, FACSAssistant ProfessorDivision of Vascular SurgeryDavid Geffen School of Medicine at UCLAUSRDS• United States Renal Data System• National data registry that collects, analyzes,and distributes information on ESRDpopulation in U.S.• Funded by NIH, and National Institute ofDiabetes and Digestive and Kidney Diseases(NIDDKD)• 2011 Annual Report contains data up to 200910

ESRD- U.S. Demographics• Total treated ESRDpopulation- > 570,000• Prevalent population on HD-370,274• Prevalent population on PD-27,522• Incidence HD patients-113,636– 3.3 % increase from prior year• Medicare: Primary payor for83% of HD patientsUSRDS 2011 ADRIncident & prevalent patientcounts (USRDS), by modalityUSRDS 2011 ADRAdjusted incident rates of ESRD& annual percent changeUSRDS 2011 ADR11

Geographic variations in adjustedincident rates of ESRD per millionpopulation, 2009Incident counts &adjusted rates ofESRD, by ageUSRDS 2011 ADRIncident counts &adjusted rates ofESRD, by raceUSRDS 2011 ADR12

Incident counts &adjusted rates ofESRD, by HispanicethnicityUSRDS 2011 ADRIncident counts &adjusted rates ofESRD, by primarydiagnosisUSRDS 2011 ADRESRD-Mortality• Alive three years after thestart of ESRD therapy– Dialysis patients-50%– Pre-emptive transplant-82%• Adjusted rates of all-causemortality– 6.5-7.4 times greater fordialysis patients comparedwith general populationUSRDS 2011 ADR13

Adjusted all-cause & cause specificmortality (from day one) in thefirst year of hemodialysisUSRDS 2011 ADRAdjusted all-cause mortality in the ESRD& general populations, by age, 2009Adjusted survival probabilities,from day one, in the ESRD population14

ESRD-Cost• In 2009, total medicare spending rose 8.2% to491 billion dollars• Costs for non-Medicare population were 13.5billion dollars• Costs for ESRD rose 3.1% to 29 billion dollarsUSRDS 2011 ADRTotal Medicare ESRD expendituresper person per year, by modalityIncident patient distribution,by first modality & payorUSRDS 2011 ADR15

ESRD-International ComparisonsPrevalence of ESRD Incidence of ESRD• Taiwan and Japan highestrates of prevalent ESRD• Lowest rates Bangladeshand Phillipines• Highest incident rates inMorelos and Jalisco(Mexico)USRDS 2011 ADRPrevalent rates offunctioning grafts,2009Greatest reported prevalent ratesof functioning grafts in Norway,United States and France16

Percent distribution ofprevalent dialysis patients,by modality, 2009• In Hong Kong, four of five prevalentdialysis patientstreated with peritoneal dialysis• New Zealand and Australia 16.3 and9.3% use home hemodialysisUSRDS 2011 ADRTransplant rates, 2009Highest functioning transplant ratesin Canada, Norway, Jalisco (Mexico),and United StatesESRD-Transplantation• On 2009, 17,736 kidney transplantsperformed in U.S.• Number of patients on wait-list grew by 6% in2009– 71, 975 total• Survival following renal transplant– 1 yr-Deceased donor-92%, Living Related-96%– 5 yr-Deceased donor-70%, Living Related-83%17

Outcomes for first-time wait-listedpatients three years after listing, 2006,by age, race, & PRAUSRDS 2011 ADRConclusions:• Incidence of patients with ESRD requiringdialysis continues to increase• Rate in Hispanic population 1.5 greatercompared with Non-Hispanics• Medicare continues to be primary payor for83% of patients requiring HD• Despite relative increase in recent years,transplant rates lag far behind incident ESRDcases• Effects of Affordable Care Act and MedicareCuts?18

Mitra Nadim, MD September 27, 2012Associate Professor of Medicine8:30 am – 8:50 amDirectorHypertension Center & Renal Disease CenterDivision of NephrologyDepartment of MedicinePRINCIPLES OF HEMODIALYSIS ANDACCESS CANNULATIONLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Understand the principles of clearance.2. Access the adequacy of dialysis.3. Compare the various modalities of hemodialysis.

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Fred A. Weaver, MD, MMM September 27, 2012Professor of Surgery8:50 am – 9:10 amChiefDivision of Vascular Surgery andEndovascular TherapyCo-Director, USC CardiovascularThoracic InstituteKeck School of MedicineVASCULAR ACCESS PLANNINGAND PRE-OP EVALUATIONLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Identify arterial and venous anatomy that is necessary for creation ofa vascular access.2. Choose the most efficacious vascular access that can be created.3. List the factors that go into the successful planning for vascularaccess.21

Vascular Access Planning andPreoperative EvaluationFred A Weaver MD, MMMProfessor and ChiefVascular Surgery and Endovascular TherapyKeck Medical Centerwww.surgery.usc.eduInitial Evaluation: History• General health• Age• Atherosclerotic riskfactors• Coagulation disorders– Systemic lupus– Cancer (multiplemyeloma …)– Prior DVT’s• Pacemaker• CHF (output)• CAD or malignancy (lifeexpectancy)• Arm or neck surgery• Anticipated transplant• Hospitalization recentand remote• Previous vascularaccess• Vascular Procedureswww.surgery.usc.eduEvaluation-Physical Exam• Dominant hand• Skin lesions• Prior dialysis grafts• Visible veins• Arm swelling• Existing indwelling catheters, pacemakers• Chest wall collateralswww.surgery.usc.edu22

Arterial Evaluation• Blood pressure measurement in both arms• Pulse exam brachial, radial, digit– Calcified arteries• Allen test• Duplex scan, luminal diameter > 2 mm• Angiogram if necessarywww.surgery.usc.eduVenous Work-upWho?– Prior failed access– No visible veins– Everyone?Why?– Increase fistula placement– Decrease failure ratewww.surgery.usc.edu• Non-invasive• Excellent fordistal extremities• Proximal vesselswell imaged• Will demonstrateoccluded arteriesand veinswww.surgery.usc.edu23

• Veins not circular but ovoid, min and max diameters• Higher venous pressure more circular• Patient supine, warm room and gel• Proximal tourniquet, pressure cuff• B mode venous diameters should be determined atvenous pressure >40 mm Hg• Reproducibility with higher with pressure >40 mmHgwww.surgery.usc.eduRelation between the outcome of surgery and preoperativeultrasound assessment. The ultrasound scan is defined asabnormal if the vessel is of diameter less than 1.5 mm and/or astenosis is detected in the cephalic veinUltrasoundAssessmentOutcomeFailed Successful TotalAbnormalNormalTotal1791603838174754Wong Eur J Vasc Endovasc Surg 1996; 12:207-213www.surgery.usc.eduRelative frequencies of each access type placed during the twoperiodsBeforeinstitutionNoninvasiveprotocolof protocolAutogenous fistula* 14% 63%Bridging grafts 62% 30%Permanent catheter 24% 7%Prevalence significantly different in each group (p < 0.05). From June1992 to August 1994, 183 procedures were performed before institutionof protocol. From September 1994 to April 1996, 172 procedures wereperformed with noninvasive protocol.Silva J Vasc Surg 1998;27:302-8www.surgery.usc.edu24

Vascular UltrasonographyPrior to Dialysis Access Surgery• Arterial and venous duplex studies prior toaccess placement• 47 patients• 52% had at least one prior access• Venous occlusions and arterial lesions (forearmportion of radial artery)• Post US: 97% fistula formation rateAm J Surg 2002;184:568www.surgery.usc.eduNoninvasive criteria for selection of upperextremity arteries and veins for dialysis accessproceduresVenous ExaminationVenous luminal diameter 2.5 mm for AFVenous luminal diameter 4.0 mm for BGAbsence of segmental stenoses or occluded segmentsContinuity with the deep venous system in the upper armAbsence of ipsilateral central venous stenosis or occlusionArterial ExaminationAbsence of pressure differential 20 mm Hg between armsArterial lumen diameter 2.0 mmPatent palmar archSilva J Vasc Surg 1998;27:302-8www.surgery.usc.eduVenography• Excellent forproximal veins• Invasive• Contrast agent• More expensive• Redo access• Exhausted accesswww.surgery.usc.edu25

VENOGRAM+ -CFDI+ 17(true positive)- 4(false negative)1(false positive)33(true negative)Sensitivity = 17/21 x 100 = 81.0% Positive Predictive Value = 17/18 x 100 = 94.4%Specificity = 33/34 x 100 = 97.1% Negative Predictive Value = 33/37 x 100 = 89.2%Overall diagnostic accuracy of color flow duplex imaging (CFDI) compared withoverall diagnostic accuracy of venography for proximal upper extremity venousoverflow obstruction (N = 55). Passman M, JVascSurg 1998; 28:869-75www.surgery.usc.eduVenous occlusion secondary tocatheters• 15-50% incidence• Hemodynamicmonitoring• TPN• Pacemaker• Hemodialysiswww.surgery.usc.eduSubclavian Stenosis Following Subclavian Dialysis CatheterizationPatient characteristics of normal, abnormal andequivocal subclavian venogramsNormal Equivocal AbnormalNumberSexAge (years)Race:CaucasianAsianBlackDays of catheterizationDays since catheter removedSide of catheterization112F/8M54.5 + 3.983028 ±6*143 + 565L/6R*P

Anticipating Steal• Incidence 2-20%, Most studies 4%• Calcified arteries, digital arteries• Decreased digital pressure• Digital-brachial index < 1.0-0.6• Brachial inflow, autogenous fistulawww.surgery.usc.eduCLINICAL GUIDELINES ARTERIOVENOUS HEMODIALSYSIS ACCESSTHE SOCIETY FOR VASCULAR SURGERYTiming of referral to surgeon and timing of placement of permanent vascular accessAdvanced chronic renal disease, creatinine >4 mg/dl (late stage 4, glomerular filtration rate

• Thorough preoperative assessmentessential to successful vascular access andoptimizing AVF rate• Noninvasive assessment has changed theparadigm for vascular access planning• Use venography liberally particularly forprior subclavian cannulation and redoaccess• Autogenous Access preferred, distal toproximal• Anticipate Stealwww.surgery.usc.edu28

Scott Berman, MD September 27, 2012Vascular & Endovascular Surgery9:10 am – 9:30 amRegistered Vascular TechnologistCarondelet Vascular Specialist GroupTucson Special Group, ArizonaWHAT’S NEW IN VASCULAR GRAFTS?LECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Incorporate new dialysis graft technology into their current practice2. Choose the appropriate dialysis graft to fit their individual patientneeds.29

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Christian deVirgilio, MD September 27, 2012Vice Chair of Education10:10 am – 10:30 amProfessor of SurgerySurgery – VascularHarbor UCLA Medical CenterOPTIONS AND STRATEGIES FOR UPPEREXTREMITY ARTERIOVENOUS FISTULACREATIONLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Identify optimal strategies for creation of an arterial venous fistula.2. List order of preference for arterial venous fistula.31

Options and Strategies forUpper Extremity ArteriovenousFistula CreationChristian de Virgilio MDDivision of Vascular SurgeryHarbor-UCLA Medical CenterObjectivesTo discuss options for upper extremityhemodialysis– AV fistula– AV graftDiscuss ethnic differences in arm vein diametersTo provide an optimal access creation strategy– Timing– LocationTiming of Access PlacementAV fistula– At least 6 months prior to anticipated dialysis– Needs time to mature– May need revisionAV Graft– Only 3-6 weeks prior to anticipated dialysis– If placed too early, may thrombose before useGoals– Avoid central catheter– Minimize duration of central catheter32

2006 NKF-KDOQI GuidelinesPreferred: FistulaeWrist/forearmradiocephalicradiobasilicElbowbrachiocephalicbrachiobasilicbrachiobrachial?Acceptable: Synthetic or biological graftForearm loop graftUpper-arm graftSource: NKF-KDOQI Vascular Access Clinical Practice Guidelines. 2006 UpdateRadial Artery Cephalic Vein(Cimino Fistula)First choice for most surgeons if :Cephalic vein > 2.5 mmAt least 10 cm vein lengthStrong radial pulseAdvantagesSimple to createPreserves proximal vesselsFew complicationsOperative Technique:Cimino (radiocephalic) AVFLocal anesthesiaEnd of vein to side of arteryDilate vein with dilutepapaverine1-time dilator proximally? HeparinPre-emptive division oftributaries33

Cimino (radiocephalic) AVFPotential disadvantages– Smaller artery and vein, less flow– Unrecognized radial artery atherosclerosis– Unrecognized vein stenosis from priorphlebotomy– Lower functional patencyBrachial artery-Cephalic vein AVFat ElbowAdvantagesHas higher blood flowEasy to cannulateCosmetic benefitBetter functional patency (in some studies)DisadvantagesSlightly more difficult to createIn obese pt, may need superficializationIncreased incidence of stealGreater incidence of cephalic arch stenosis(narrowing at deltopectoral groove)Brachial artery-Basilic vein AVF(BBAVF)AdvantageUsually larger than cephalicLess likely to be damaged by priorphelbotomy34

Potential Problems with BBAVFSignificant rate of early thrombosis (1 stage)Technically more demandingInjury to medial antebrachial cutaneous nerveInadequate length (if enters brachial vein early)Inadequate superficializationNot moved anterior enough– Brachial artery injuryControversies with BBAVFOne or two stageSuperficialization with or withouttranspositionOne Stage BBAVFVein is completely dissected out anddividedNew tunnel created more anterolaterallyAnastomosis made to brachial artery atelbow35

Two Stage BBAVFStage 1 anastomosis made to brachial arteryat elbowStage 2 6 weeks later, matured vein isSuperficialized +/- transposed1 vs 2-Stage BBAVFOnly one prospective, randomized trial– 40 patientsEarly Failure (prior to four weeks)– One-stage 40%– Two-stage 10% (p

1 vs 2-Stage BBAVFOne-stage(n=60)Two-stage(n=30)p-valuePrimary failure 22.9% 9.1% 0.17Primary patencyOne yearTwo yearSecondary patencyOne yearTwo yearPrimary functional patencyOne yearTwo yearSecondary functional patencyOne yearTwo year78%34%82%41%61%34%80%41%84%84%89%89%88%88%94%94%0.0460.010.0470.0151 vs 2-Stage BBAVFPatency for one-stage BBAVF proceduresmay be decreased due to– Extensive mobilization– Tunneling of a non-matured, thin-walled basilicvein– Unseen vessel injury– Kinking of a thin-walled veinBrachial Vein-Brachial Artery AVFDeeper than basilic veinMore thin walledMoretributaries37

Brachial Artery-Brachial Vein AVFSuperficialization is moredemanding/tediousNeeds more time to matureBrachial Artery-Brachial Vein AVFAngle and Chandra JVS 200520 pts brachial vein-brachial artery AVFFistula functional in 19/20Arm swelling in 1No stealBrachial Artery-Brachial Vein AVFDorobantu et al J Vasc Access 200633 pts6 (20%) occluded in 30 days33% forearm edema38

Brachial Artery-Brachial Vein AVFTorina et al J Vasc Access 200811 one-stage, 2 two-stage73% of one stage had complicationsOnly 24% 1 year patency (worse than AVgraft)Problems with Fistula First at AllCost ApproachA high proportion of new fistulas do not matureadequately for useUp to 60% AVF unsuitable for dialysis even after4-5 monthsTaking a “shot” at a fistula that fails hasconsequences– Indwelling catheterCatheter related infectionsCentral vein stenosis– Veins in arm may be thrombosed precludingsubsequent graft placementDember et al. JAMA May 14, 2008 Vol 299 No 18 2164-2171Trends in Central Venous Catheter Usage39

Forearm AV GraftsLarge surface area to cannulateEasy to cannulateUsable within 2 weeksEasy to handle and implantEasy to declotAV Graft OptionsStandard PTFEHeparin bonded PTFEBovine graftHeparin Bonded PTFE Graft:Propatenend-point attachment mechanismheparin molecules anchored to the luminalsurfacemaintains heparin’s bioactive propertiesthromboresistant BioActive graft surface thatis not consumed40

Heparin Bonded vs. StandardPTFE for HemodialysisTexas Southwestern Study J Vasc Access2009 Davidson et al.83 heparin bonded AVG (mainly 4-7 mm)67 standard PTFEOverall clot free survival 69% at 1 year78% at 1 year for heparin bonded58% at 1 year for standard PTFEP = 0.007Bovine ArtegraftBovine carotid arteryEasy to handle/sewDiameter sometimes too big for nativeartery (taper)Patency similarto PTFELess infection riskComparison of AVG with AVFProblems with comparisons:– Not all patency comparisons include primaryfailures (much more likely with AVF)– AVG often used when veins too small for AVFor after AVF failures– Need for prolonged central lines whileawaiting AVF maturation not factored in– Better secondary patency of AVG not alwaysconsidered41

Comparison of brachial-basilic AVfistula and prosthetic forearm graft• 105 patients were randomized for a BBAVF orloop AVG (non heparin bonded)• Primary and assisted-primary 1-year patencywere significantly higher in the BBAVF group• Secondary patencies were comparableKeuter et al JVS 2008Comparison of transposed brachiobasilic fistulas toupper arm grafts and brachiocephalic fistulasOliver et al Kidney Int 2001Compared with BBAVF– BCAVF less likely to failRR 0.3 (95% CI, 0.1 to 1.0)– BCAVF trend for less thrombosisRR 0.3 (95% CI 0.1 to 1.1)– Upper arm AVG more likely to thromboseRR 2.6 (95% CI, 1.3 to 5.3) excluding primary failuresRR 1.6 (95% CI, 1.0 to 2.7) when accounting for the lower risk ofprimary failure of AVGConfidence interval includes 1.0No significant difference in cumulative patency (failurefreesurvival) among 3 types of access if primary failureincluded (median follow-up:594 days)Racial differences in AVfistula ratesStudies have reported thatAfrican American patients:– Fewer first time AVF– Lower fistula primary patency rates– Higher fistula complication rates3342

34Racial differences in AVfistula rates249 male patients– 95 African American (AA)Median age: 63 yearsCephalic Vein DiametersProximalupper armDistalupper armProximalforearmDistalforearmAfricanAmericanNon-AfricanAmericanP value2.6 2.8 0.12.4 3.0 0.022.0 2.5 0.031.7 2.1 0.0535Basilic Vein DiametersBasilicveindiameter(mm)Proximalupper armDistalupper armProximalforearmDistalforearmAfricanAmericanNon-AfricanAmericanP value3.5 4.0 0.0042.9 3.5 0.00021.8 2.5 < 0.00011.4 2.1 < 0.00013643

Racial differences in AVfistula ratesAVF– AA patients: 82%– Non-AA patients: 93%AVG– AA patients: 18%– Non-AA patients: 7%– P = 0.009Fistula Patency RatesOne yearPrimarypatencyPrimaryfunctionalpatencyAfricanAmerianNon-AficanAmericanP value80.8% 76.2% 0.473.1% 69.2% 0.538ConclusionsIf good vein and good artery– Radiocephalic 1 st choice– Brachio-cephalic 2 nd choice44

ConclusionsBrachial artery-basilic vein AVFExcellent option for AV access in patientswho are not candidates for radiocephalic orbrachiocephalic AVFPrimary, secondary, and functional patencyrates higher for 2-stage– method of choiceTiming and technique for the second stageneed further refinementConclusionsBrachial Artery-Brachial Vein AVFTechnically more difficultBest if done in 2 stagesProbably better to wait longer (3 months)for 2 nd stage than Brachial Basilic AVFPatency data limitedConclusions– Decision between brachiobasilic, brachiobrachialvs AVG debatabledepends on vein diameterurgency of accessage, life expectancy of patient– AVG if veins marginal and particularly ifalready has central venous access, shorterlife expectancy45

THANK YOU!46

Ahmed Abou-ZamZam, MD September 27, 2012Associate Professor of Surgery10:30 am – 10:50 amChiefDivision of Vascular SurgeryDepartment of Cardiovascular andThoracic SurgeryLoma Linda UniversityLOWER EXTREMITY DIALYSIS ACCESSLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Manage the complex hemodialysis patient who has exhausted allupper extremity access options.2. List the different types of permanent lower extremity access options.3. Choose the best lower extremity access type based on specificpatient indications such as obesity and the presence of peripheralarterial disease.4. Incorporate the K-DOQI guidelines into their practice.47

Lower ExtremityDialysis AccessAhmed M. Abou-Zamzam, Jr.Associate Professor of SurgeryChief, Division of Vascular SurgeryLoma Linda University Medical CenterLower Extremity Dialysis Access• Vascular surgeons -“will operate anywhere”Lower Extremity Dialysis Access• Vascular surgeons -“will operate anywhere”(except thigh access)XXX48

Lower Extremity Dialysis AccessKDOQI Clinical Practice Guidelines:2.1 The order of preference for placement of fistulae in patients with kidneyfailure who choose HD as their initial mode of KRT should be (in descendingorder of preference):2.1.1 Preferred: Fistulae (B)2.1.1.1 A wrist (radiocephalic) primary fistula.2.1.1.2 An elbow (brachiocephalic) primary fistula.2.1.1.3 A transposed brachial basilic vein fistula.2.1.2 Acceptable: AVG of synthetic or biological material, such as:2.1.2.1 A forearm loop graft, preferable to a straight configuration.2.1.2.2 Upper-arm graft.2.1.2.3 Chest wall or “necklace” prosthetic graft or lower-extremityfistula or graft; all upper-arm sites shouldbe exhausted.Lower Extremity Dialysis AccessWho needs lower extremity access?2.1.2.3 Chest wall or “necklace” prosthetic graft or“lower-extremity fistula or graft; all upper-arm sites should beexhausted.”Lower Extremity Dialysis AccessWork up prior to lower extremity access:Review all prior sitesDocument lack of upper extremity access optionsVenogram of upper extremitiesLower extremity pulse examination, ABI's(non-invasive arterial study when any doubt)Venous duplex of lower extremity veinssize, patency, duplicity, prior occult dvt - both legssconsider ascending venogram if prior femoral lines49

Lower Extremity Dialysis AccessWhat are the options for lower extremity access?Analogous to upper extremitiesFistulae -Based on femoral vein or greater saphenous veinAVG -Thigh loops – from common femoral or superficial femoral arteriesLower Extremity Dialysis AccessTechniques: AVFGSV loop first described in 1969Pierre-Paul, et al AVS 2004Lower Extremity Dialysis AccessTechniques: AVFTransposed femoral vein (tFV)Initial description: The Superficial Femoral-Popliteal Vein TranspositionFistula: Description of a New Vascular Access Procedure Jackson, JACS2000Two patientsJackson noted high flows and decreased ABI50

Lower Extremity Dialysis AccessTechniques: Transposed femoral vein (tFV)Lower Extremity Dialysis AccessTechniques: AVGMost commonly CFA-CFV loopKhadra, et al, Am J Surg, 1997Lower Extremity Dialysis AccessData: Saphenous Vein loop AVFSaphenous vein loop to femoral artery arteriovenous fistula: a practicalalternative Pierre-Paul, et al Annals Vasc Surg, 2004Seven patients40% patency at 3 yearsLow flow57% wound complicationsAll developed stenoses in GSVMean secondary patency 16 monthsOther reports range ~40% two yearAll low flow, aneurysms, woundcomplications51

Lower Extremity Dialysis AccessData: tFVArteriovenous fistula construction in the thigh with transposed superficialfemoral vein: our initial experience Gradman, et al JVS 200125 patients28% major complications, 32% ischemic complicationsCumulative patency at one year 86%One limb loss, 8 steal (all over 40)Lower Extremity Dialysis AccessData: tFVFemoral vein transposition for arteriovenous hemodialysis access:improved patient selection and intraoperative measures reducepostoperative ischemia Gradman, et al JVS 2005Updated with more selective patient selection46 adults – 22 more than initial seriesExclusion of older patients with PADTapering of anastomosis (14 of 22 adults),Measurement of distal pressuresResults:94% secondary patency at 1 and 2 yearsNo ischemic complications4.5-5mmLower Extremity Dialysis AccessData: tFVLong-term results of femoral vein transposition for autogenousarteriovenous hemodialysis access Bourquelot, et al JVS 2012Largest series of tFV - 72 accesses (27 years)Average time on dialysis prior to leg access 10 years82% successful dialysis within 2 monthsPrimary patency 91% 1 year, 45% 9 yearsSecondary patency 84% 1 year and 56% at 9 years11% delayed healing, hematoma, lymphocele(no tapering of anastomosis)0 serious infections13 patients (18%) with complications requiring ligation –5 ischemic, 1 amputation52

Lower Extremity Dialysis AccessData: tFVSmall skin incision and fistula elevation for hemodialysis using the femoralvein Alcocer, et al JVS 201225 patients; most recent technique in the last 13Smaller incision; Fistula elevationResults: reduced wound dehiscence/complicationsSimilar patencyStandard approachSmall incision; superficializationLower Extremity Dialysis AccessData: AVGProsthetic thigh arteriovenous access: outcome with SVS/AAVS reportingstandards Cull, et al, JVS 2004125 grafts in 100 patients2 year primary patency 19%, secondary patency 54%41% infection rate, 11% limb ischemia, 9% major amputation1.68 interventions/yearLower Extremity Dialysis AccessData: AVGThe mid-thigh loop arteriovenous graft: patient selection, technique, andresults Scott, et al Am Surg 2006Attempt to avoid infection – mid-thigh access SFA-FV46 graftsPrimary patency 40% one year, 18% 2 yearSecondary patency 68% 1 year, 43% 2 yearInfection 21% requiring graft excisionIschemia 13%Felt this option preserves more proximal vesselsand longer outflow vein for secondary procedures.53

Lower Extremity Dialysis AccessData: AVGProsthetic lower extremity hemodialysis access grafts have satisfactorypatency despite a high incidence of infection Geenen, et al JVS 2010Largest series of thigh AVGs – 153 (15 years)Primary patency 54% 1 year, 40% 2 year, 19% 5 yearSecondary patency 75% 1 year, 64% 2 year, 50% 5 year27% infectious complications; 17% graft loss1% ischemic complicationsMean AVG function 31 months(Standard CFA-CFV)Conclude: AVGs are alrightLower Extremity Dialysis AccessData: AVG vs. AVFLower-extremity arteriovenous access for haemodialysis: a systematic reviewAntoniou, et al Eur J Vasc Endovasc Surg, 2009Systematic Literature Review of upper thigh AVG, mid-thigh AVG and tFVWeighted mean primary patency rates: 1 year: 48%, 43% and 83%Weighted mean secondary patency rates: 1 year: 69%, 67% and 93%Access loss due to infection: 18%, 18% and 2% (

Lower Extremity Dialysis AccessOther Options?HeRO (Hemodialysis Reliable Outflow)Limited data• Outcomes Comparison of HeRO and Lower-Extremity ArteriovenousGraft in Patients with Long-Standing Renal Failure Steerman, et al JVS 2012(SVS abstract)62 HeRO and 23 thigh AVGsPrimary patency 1 year 26% vs. 60% (HeRO vs. AVG) (0.01)Secondary patency 1 year 61% vs. 66% (0.56)Similar infection rates (30%) and mortality (20-30%)Reinterventions 6.2 per year in HeRO and 3.7 in AVGEarly information, but not promising for HeROLower Extremity Dialysis AccessOther Options?long-term catheters ? – NO!Lower Extremity Dialysis AccessSummary:Lower extremity access is an important option in dialysis accessPatency rates are good to excellent when performed appropriatelyTransposed femoral vein is best AVF –select in younger patients without PADwatch for ischemiabeware of high rate of wound complicationsAVG option for others –watch for infections55

Thank You!LLUMC56

Vincent L. Rowe, MD September 27, 2012Associate Professor of Surgery10:50 am – 11:10 amProgram DirectorVascular Surgery Residency ProgramDivision of Vascular Surgery &Endovascular TherapyPEDIATRIC VASCULAR ACCESSLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Manage pediatric patients that require dialysis access.2. Identify the barriers to providing care to pediatric dialysis patients.3. Identify the differences of in the management of pediatric dialysisfrom adult patients.57

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William M. Lee, MD September 27, 2012Assistant Professor of Surgery11:10 am – 11:30 amDivision of Vascuar Surgery &Endovascuar TherapyOPTIONS FOR END STAGE DIAYSISACCESSAt the time of printing lecture objectives were unavailable.59

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Samuel Eric Wilson, MD September 27, 2012Professor of Surgery11:50 am – 12:30 amUniversity of California - IrvineSchool of MedicineMAX R. GASPAR INVITED LECTURE:THREE RULES TO BREAK IN VASCULARACCESS SURGERYLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Formulate plans for vascular access in the ESRD patient to allowmaximum duration of hemodialysis.2. Identify specific patient presentations in which changes in standardguidelines maybe necessary.3. Evaluate patients’ hemodynamic parameters in order to intervenebefore an access fails.61

When to Break the Guidelines in Vascular Access SurgerySamuel Eric Wilson, MD, FACSAt least eight national and professional organizations have given “Ex-Cathedra”guidelines for the performance of vascular access surgery. The Dialysis OutcomeQuality Initiative of the National Kidney Foundation, the Society of Vascular Surgery, theCanadian Society of Nephrology, Caring for Australians with Renal Insufficiency, TheBritish Renal Association and others have all issued recommendations. Theseguidelines are for the most part sensible, and as far as possible evidence based, butcannot conceivably provide the answer to every clinical situation. I will outline someimportant clinical presentations in which the patient will better be served by breakingthese guidelines.Over the last decade, the number of hospital admissions for end stage renal disease inNorth America has remained fairly stable at approximately 20,000 per year but thenumber of hospital days has dropped in half from 175,000 to approximately 60,000. Thedecreased duration of hospitalization is probably due to the shift in vascular accesssurgery to an outpatient basis and also because of better coordination of vascular carerather than a specific technical advance.Even so, one must give credit to the level of interest raised in access surgery by theattention of these various committees. In at least five situations, however, I think it is tothe patient’s benefit to vary from the guidelines.First, the brachiocephalic A V fistula should be constructed before a radiocephalic fistulawhen the success of the latter is in doubt. In a review of 155 AV fistula procedures, we62

found that failure to mature occurred in 35% of radiocephalic procedures versus only5% of brachiocephalic and the mean time to successful hemodialysis was 13 weeks forthe radiocephalic compared to only 6 weeks for the brachiocephalic (J Vasc Access2007; 8:275-280). The only caveat to this approach is that the patient with thebrachiocephalic fistula may develop a late symptomatic steal as the venous outflowcontinues to develop. Accordingly, in patients for whom you cannot predict at least 75%successful functional patency for the radiocephalic fistula I suggest turning first to thebrachiocephalic construction.Second, an AV graft may be placed in the forearm which will allow dialysis with carefulpuncture within 48 hours. This approach is preferable to the uncertain function of an AVfistula and avoids the complications associated with prolonged central venouscatheterization (central venous occlusion and catheter infection). The radial artery toantecubital vein graft, useful in the absence of a satisfactory distal cephalic vein, hasthe added advantage of dilating both the upper arm basilic and cephalic outflow veins,allowing for an autogenous brachiocephalic AVF when the graft becomesunsalvageable.Third, in the patient over 65 years of age the secondary patency of a PTFE graft in thebrachioaxillary position is equal to that of a successful basilic vein transposition.Functional patency of the brachiobasilic transposed vein occurs in only 75% patients atmost and requires approximately 3 to 5 months until it is first used. During this intervalthe patient is often maintained with a central venous catheter. Further, the primarypatency of the transposed brachiobasilic AV fistula at one year will vary between 35 and50%. Basilic vein transposition is optimal when the patient has approximately 3 months63

efore initiation of dialysis. It functions best in patients less than 65 years of age but stillhas significant complications such as hematoma, pseudoaneurysm, and fibrosis. Thebrachial axillary graft functions satisfactorily in the patient who has on- going dialysisand an urgent need for an access. With care, early puncture can usually be made safelyin standard wall thickness PTFE grafts within approximately 48 hours. Brachial artery toaxillary grafts form less venous myointimal hyperplasia in the older patient and canundergo outflow revision usually by short endovascular covered stents or occasionallyopen outflow revision in order to maintain patency. Whether the access is autogenousor a prosthetic construction, it is important to verify axillosubclavian vein patencypreoperatively.Fourth, it is unlikely that preemptive percutaneous transluminal angioplasty of thevenous outflow will prolong patency of the PTFE graft. In five of six randomized trials,the increased rate of PTA intervention did not result in any prolongation of graft survival.On the other hand, the AV fistula that is slow to mature or failing, will respond toaggressive PTA of strictures. PTA with or without a stent should be reserved forphysiological dysfunction in the AV graft specifically an increasing trend in venousreturn pressure, or a flow decrease to less than 600 mls/min in association with agreater than 50 % luminal diameter reduction. Remember, the median duration ofextended patency with PTA is approximately 3 months which is only half the patencythat can be obtained with open patch angioplasty although the former technique issimpler and now holds sway among most access surgeons.Fifth, central venous catheterization with a tunneled, cuffed catheter may be the onlytechnique necessary for the older patient with chronic renal failure requiring64

hemodialysis. In North America the life expectancy of the individual reaching 80 yearsold is another 7 years of life (a personally depressing statistic), but for the end stagerenal patient this drops to less than 18 months. Given this limited life expectancy andweighing up other risk factors, many elderly patients are best served with a simpletunneled catheter.A last consideration is the use of a lower extremity AV graft positioned from a superficialfemoral artery to the saphenous vein in female patients who have very small upperextremity arteries and veins. Although patency rates are good for this access, infectionrates are higher because of the proximity to contaminated areas. It should be avoided inincontinent patients.The general concepts of autogenous AVF before graft, distal vessels first, upper ratherthan lower extremity, and avoidance of percutaneous catheters are all sound, but ineach instance exceptions to the guidelines may better meet the patient’s needs.References1. KDOQI ( 2006) Vascular Access Guidelines AM J Kidney Disease(2006;48:S177-322)2. Society for Vascular Surgery Practice Guidelines J Vas Surg (2008;48:S1-80)3. Wilson, SE. Vascular Access: Principles and Practice. 5 th edition. Lippincott,Williams and Wilkins 200965

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Christian Ochoa, MD September 27, 2012Assistant Professor of Surgery1:45 pm – 2:05 pmDivision of Vascular Surgery &Endovascular TherapyVASCULAR ACCESS SURVEILLANCEIS IT WORTH IT?LECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Manage patients long term with vascular access and2. Formulate a plan on when to perform surveillance duplex scans onfunctioning fistulas.67

Vascular AccessSurveillanceIs it worth it?Christian Ochoa, MDVascular SurgeryKeck Hospital of USCVascular Access• End Stage Renal Disease and vascular accesscontinues to rise.• May 2011, the AVF rate reached 58.6%• Tunneled catheters can increase complicationsand mortality• Vascular access complications• Infection• Stenosis• Thrombosis• Access lossVascular Access• Problems with Vascular Access• Low flow rates• Inability to clear Urea and other metabolites• Extended treatment times• Frequent hospitalizations• A total of 8% of Medicare spending is used for theoptimization of vascular access• So what can we do?68

Vascular Access Failure• The majority of grafts fail due to thrombosissecondary to underlying stenosis• AVG->venous anastomosis• AVF->arterial anastomosis• Lumsden et al.• Followed 32 pts with ≥ 50% AVG stenosis• After 3 mos-23% thrombosed• 6 mos-30% thrombosedVascular Access Surveillance%Primary PatencyLily et al. Am J Kidney Dis 2001; 37: 945-953Access Surveillance• Rationale for Surveillance• The inferior patency of AVG following thrombosissuggests that a proactive strategy to prevent graftthrombosis would be prudent.• Centers for Medicare and Medicaid Services• National Kidney Foundation-Kidney DiseaseOutcomes Quality Initiative• Undue burden on dialysis centers69

Monitoring Vs. SurveillanceClinical MonitoringPhysical Examination•Inspection•Thrill•Edema•Abnormal (80%)Routine Laboratoryblood testDifficulties in access•Prolonged bleeding(76%)•Decrease in Kt/V (69%)Vascular Access SurveillanceAccess SurveillanceStatic Venous PressuresAccess flowmeasurementsDuplex USVascular Access SurveillancePaulson et al, 201270

Results of Access Surveillance forStenosisSurveillanceMethodClinicalMonitoring# of patients %PPVMaya et al. 358 69Cayco et al 68 93Static VenousPressureBesarb et al. 87 92Flow MonitoringSchwab et al. 28 100Moist et al. 53 87UltrasoundRobbin et al. 122 80Surveillance to Predict AccessThrombosisRef Qa Threshold %PPVMay et al 710 25McDougal et al 600 32Paulson et al 600 39Wang et al 500 43Surveillance for AVG stenosis may result in unnecessary interventionon grafts that may not fail.Does Angioplasty of AVGStenosis Detected bySurveillance ReduceThrombosis?71

Vascular Access Surveillance• Observational studies vs RandomizedControlled Trials• Obs-comparing against historical controls• Introduce bias• RCT reduce bias and causalityRefVascular Access SurveillanceObservational StudiesSurveillancemethodThrombosis rate (per graft years)Historical Surveillance % ReductionSchwab DVP 0.61 0.20 67Besarab Static VP 0.50 0.28 64Safa CM 0.48 0.17 64Allon CM 0.70 0.28 60Cayco CM 0.49 0.29 41McCarley Flow Monitoring 0.71 0.16 77Vascular Access SurveillanceRandomized Controlled Trials• Total of 12 RCT• AVG-8• AVF-4• Sample sizes ranged from 51-189 pts• Followup ranged from 6-28 months• They differ in sample sizes, method of surveillance,recruitment criteria72

Lumsden et al. (1997)Life table analysis of graft patency data.PTA does not result in prolonged patency in AVGJournal of Vascular Surgery Volume 26, Issue 3 1997 382 - 392Vascular Access SurveillanceRandomized Controlled Trials•Sands et al. (1999)103 PtsAVF-68AVG-35Monthly measurementQaMonthly measurementVPSNo monthlyMeasurement (CTL)Criteria for interventionQa < 800ml/min (AVG)Qa < 600ml/min (AVF)Or 25% decr in QaCriteria for interventionVPS >0.5Angioplasty occurred for stenosis > 50%73

Vascular Access SurveillanceRandomized Controlled Trials• Mean follow up 197 days• Monthly surveillance and intervention led todecrease in thrombosis p

Ram et al. Kidney Int 64:272-280, 2003Cumulative Graft SurvivalRam et al. Kidney Int 64:272-280, 2003Vascular Access SurveillanceRandomized Controlled TrialsRam et al. Kidney Int 64:272-280, 200375

Vascular Access SurveillanceRandomized Controlled TrialsWhat about AVF?AVF SurveillanceRandomized Controlled TrialsShetty et al 2011, Int J of NephrologyAVF SurveillanceRandomized Controlled TrialsTonelli, 2008; Am J Kid Dz76

Meta-Analysis of Access Surveillanceon the Rate of ThrombosisTonelli, 2008; Am J Kid DzMeta-Analysis of Access Surveillanceon the Rate of Access LossTonelli, 2008; Am J Kid DzMeta-Analysis of Access Surveillance• Screening measurement of access flow (Qa)decreases thrombosis in AVF• Screening does not affect access loss• Screening in AVG may not be beneficial andlead to unnecessary use of resources77

So why does preemptiveangioplasty not lead to improvedaccess survival?Lack of benefit of PTA in accesssurvival• Angioplasty causes neointimal hyperplasia andleads to restenosis.• The time to restenosis after PTA is shorter than% the initial stenosis• Elastic recoil also occurs• What about stents?• May improve freedom from restenosis and improvepatency of AVGWhat about surgical revision?78

Surgical Revision vs PTATessitore et al, Clin J Am Soc Nephrol; 2006Surgical Revision vs PTAAdjusted Primary PatencyTessitore et al, Clin J Am Soc Nephrol; 2006Surgical Revision vs PTAAdjusted Primary PatencyTessitore et al, Clin J Am Soc Nephrol; 200679

• ConclusionAccess Surveillance• Monthly Qa and is beneficial in showing stenosisand intervention leads to decrease thrombosis rates• Physical examination and clinical assessment are keyto maintenance of access• However, at present, surveillance does not appear toprolong AVF or AVG survival• Further larger RCT studies are needed80

Alik Farber, MD, FACS September 27, 2012Associate Professor of Surgery and2:05 pm – 2:25 pmRadiologyChiefSection of Vascular & Endovascular SurgeryBoston Medical CenterMANAGEMENT OF NON-MATURINGARTERIOVENOUS FISTULALECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Treat patients with non-maturing arteriovenous fistulae.2. Choose treatment algorithms for patients with non-maturingarteriovenous fistulae.3. Evaluate non-maturing arteriovenous fistulae.81

Management of the Non-MaturingArteriovenous FistulaAlik Farber MDChief of Vascular and Endovascular SurgeryBoston University Medical CenterArteriovenous Fistula (AVF) Maturation• Definitions• Biology• Associated factors• Reasons for non-maturation• Assessment of a non-maturing AVF• Treatment strategiesDefinition of AVF Maturation82

C SCedars-Sinai Medical CenterLos Angeles, CaliforniaBroad Definition• “… a series of processes that begins with thesurgical creation of an AVF and ends with itssuccessful and reproducible cannulation to achieveeffective hemodialysis…” Saad. Vascular 2010Specific Definitions• “… has discernible margins, measures 6 mm indiameter or greater, is 6 mm or less deep fromthe skin surface, and has a blood flow > 600cc/min” NKF-KDOQI Guidelines 2006• “… ability to use the fistula for dialysis with 2needles and maintain a dialysis machine flowrate optimal for dialysis (>300 cc/min) during 8of 12 dialysis sessions…” Dialysis Access Consortium (DAC). JAMA 200883

Specific Definition• “…use of AVF with 2 needles for 75% of dialysis sessions within a 4 week period and either Aor B:– A: 4 consecutive sessions in which the mean dialysis machine blood pump speed > 300cc/min…– B: a measured spKt/V>1.4 or URR>70%...• Failure to meet criteria during initial ascertainment period does not preclude thepossibility of meeting the criteria during a subsequent ascertainment period• In order to be classified as clinically mature the first clinical maturation use mustoccur by either:– 9 months after AVF creation for patients undergoing hemodialysis at 9 months afterAVF creation; OR– 4 weeks after initiation of hemodialysis for patients who begin dialysis more than 9months after AVF creationHemodialysis Fistula Maturation Consortium (HFMC), a NINDK-sponsored multicenter,observational cohort study designed to identify predictors and mechanisms of AVFmaturation and failureBiology of AVF Maturation• Fistula creation: AV anatomosis blood flow shear stressShear Stress = 4hQ/pr 3• Vascular response:• shear stress to original level by vascular diameter Dilatation• High shear stress venous remodelingEndothelial cells secrete NO, prostacyclin, other mediators…: Venous vasodilation Medial hypertrophy Arterial vasodilationMulvany. Hypertension 199684

Biologic Reasons for Non-maturation• Failure of arterial dilation– Endothelium of diseased, calcified donor arteries may notbe able to secrete mediators required for flow-mediatedvasodilation• Failure of venous dilation– Endothelium of scarred venous segments injured by priorvenipuncture may not be able to secrete mediators requiredfor flow-mediated vasodilation• Accelerated venous neointimal hyperplasia– Areas of low shear stress within the AVF caused by AVFconfiguration and differences in compliance may lead tofocal areas of neointimal proliferation– Vascular injury caused by vessel stretching, torsion, andskeletonization may result in neointimal hyperplasiaAsif A. Clin J Am Soc Nephrol 2006AVF Maturation in Clinical PracticeAVF Maturation in Clinical Practice• Assessment of literature is very difficult– Definitions of maturation are diverse– Studies are underpowered– Appropriate controls are lacking– Patient population not standardized85

AVF Maturation in Clinical Practice• Assessment of literature is very difficult– Definitions of maturation are diverse– Studies are underpowered– Appropriate controls are lacking– Patient population not standardized• AVF maturation failure rate:– 18 – 53% (Allon M. Kidney Int 2002)– 59.5% (Dember L. JAMA 2008)AVF Maturation in Clinical Practice• Assessment of literature is very difficult– Definitions of maturation are diverse– Studies are underpowered– Appropriate controls are lacking– Patient population not standardized• AVF maturation failure rate:– 18 – 53% (Allon M. Kidney Int 2002)– 59.5% (Dember L. JAMA 2008)• Push to increase the utilization of AVF in the US throughNKF-KDOQI Guidelines and FISTULA FIRST Initiative has ledto increase in maturation failure rates (Patel S. J Vasc Surg 2003;Biuckians A. J Vasc Surg 2008)Factors Associated with AVF Maturation• Clinical factors– AVF location, age, gender, race, diabetes, stroke, dialysisdependence at time of AVF placement• Pathologic factors– Matrix metalloprotease levels, arterial micro-calcification• Pre-operative hemodynamic factors– Vein diameter, artery diameter, routine venous/arterial mapping,venous distensibility, MAP> 90, large-caliber accessory veins• Intra-operative factors– AVF blood flow rates, heparin dose, surgeon experience• Post-operative hemodynamic factors– AVF diameter, AVF flow volume, radial artery resistive index86

Nonmaturation of arm arteriovenous fistulas forhemodialysis access: A systematic review of riskfactors and results of early treatmentEduard H. J. Voormolen, BSc,a,b Abdelkarime Khodadade Jahrome, MD,c Lambertus W. Bartels, PhD,bFrans L. Moll, MD, PhD,c Willem P. Mali, MD, PhD,a and Peter J. Blankestijn, MD, PhD,dUtrecht, The NetherlandsIntroduction: Arteriovenous fistula (AVF) nonmaturation increases reliance of hemodialysis patients on grafts andcatheters, exposing them to associated high complication risks. This systematic review assessed the success rates andcomplications of therapeutic interventions in arm hemodialysis AVFs experiencing nonmaturation. It also compared theefficacy of preoperative clinical factors (eg, age, gender, race), and preoperatively and postoperatively acquiredhemodynamicparameters (eg, arterial diameter or blood flow through the AVF) at stratifying risk of nonmaturation.Methods: Two independent researchers used a systematic strategy to search literature databases and extract data fromarticles judged relevant and valid. The evidence base for this review comprised 33 articles, 12 about treatment, and 21concerning risk stratification. A meta-analysis was performed to calculate summary measures for nonmaturationtreatment success and risk stratification efficacy (eg, excess risk and relative risk) of preoperative clinical, preoperativehemodynamic, and postoperative hemodynamic risk factors.Results: The success rate of early endovascular or surgical treatment, defined as the possibility of achieving adequatehemodialysis, averaged 86%, with 1-year primary patencies of 51%, 1-year secondary patencies of 76%, and complicationrates of 9.3%, with 5.5% minor complications. Overall, patients with preoperative clinical risk factors had excessnonmaturation risks of 21% (95% confidence interval [CI], 11%-30%) and a relative risk of 1.7 (95% CI, 1.3-2.1). Patientswith preoperative hemodynamic risk factors had average estimated excess risks of 24% (95% CI, 15%-33%) and a relativerisk of 1.7 (95% CI, 1.4-2.0). Patients with hemodynamic risk factors present shortly after operation had excessnonmaturation risks of 50% (95% CI, 42%-58%) and a relative risk of 4.3 (95% CI, 3.4-5.5).Conclusions: Patients can be treated effectively for AVF nonmaturation early on, and it is possible to identify thosepatients at risk of nonmaturation most effectively with an early postoperative assessment of hemodynamic risk factors.Additional research is needed that concentrates on adopting the strategy of early treatment of patients with postoperativerisk factors. ( J Vasc Surg 2009;49:1325-36.)Meta-analysis• 1794 articles 33 articles with 745 patients fit criteria• Summary measures for risk stratification efficacy• Methodological quality of studies evaluated• Excess risk and relative risk for non-maturation calculated– Excess risk: The difference between the absolutenonmaturation risk of patients considered at risk (ie, patientswith risk factors) and considered not at risk (ie,patientswithout risk factors). A measure of 0% means no risk isconferred by the risk factor.– Relative risk: The nonmaturation risk of a patient at riskdivided by the nonmaturation risk of a patient not at risk. Ameasure of 1.0 means no risk is conferred.Voormolen E. J Vasc Surg 2009Meta-analysis•Methodological quality for most studies was poorRisk FactorsExcess Non-maturationRiskRelative Non-maturationRiskPre-operative Clinical Risk Factors 21% (95% CI, 11%-30%) 1.7 (95% CI, 1.3-2.1)Pre-operative Hemodynamic Factors 24% (95% CI, 15%-33%) 1.7 (95% CI, 1.4-2.0)Post-operative Hemodynamic Factors 50% (95% CI, 42%-58%) 4.3 (95% CI, 3.4-5.5)Voormolen E. J Vasc Surg 200987

Hemodialysis Fistula MaturationConsortium (HFMC)• NINDK-sponsored prospective cohort study of 600 patients with new AVF• Goal: to better understand predictors and causes of AVF maturation• Standardized data collected in 4 domains which comprehensively addressfactors hypothesized to be associated with AVF maturation– Vascular Anatomy (pre- and post AVF creation)• Size, flow parameters, anatomical abnormalities of artery and vein as measured by US– Vascular Biology• Functional characteristics assessed by flow mediated dilatation, arterial pulse wavevelocity, and venous capacitance• Morphometric and molecular analyses of venous tissue• Plasma biomarker analysis– Clinical Patient Attributes• Demographics, dialysis history, comorbidities• Intra-operative and surgical factors– Processes of Care• Pre, intra, and post-operative factors• 485 patients enrolled as of 9/17Optimization of AVF MaturationPre-operative Maneuvers to OptimizeAVF Maturation• Arm veins need to preserved!– No PICC lines– Blood draws or IV from mid-forearm or hand (notantecubital fossa)• Duplex ultrasound needs to be considered … ifquality of vein is questionable on a tourniquetassisted physical exam• Potential central venous stenosis should beanticipated, interrogated if necessary, andavoided88

Duplex Ultrasound is a Useful Addition tothe Clinical Exam• Access patency higher in patients undergoing routineultrasound compared with PE aloneMihmanli et al. J Ultrsound Med 2001Zhang et al. Chin J Med Imaging Technol 2006• Ultrasound changed clinical plan in 30% of patientsRobbin et al. Radiology 2002• Ultrasound improves accuracy of predicting AVF failureWong et al. Eur J Vasc Endovasc Surg 1996Intra-operative Factors to OptimizeAVF Maturation• Surgeon experience with dialysis access plays a role(Feldman H. Am J Kidney Dis 2003; Dixon BS. Kidney Int 2006; Basile C. Kidney Int 2007; ErnandezT. Nephron Clin Pract 2005; FISTULA FIRST Initiative)– Technical maneuvers may be important• Onlay anastomotic technique for radiocephalic AVF that maydecrease torsional stess on cephalic vein and may lower juxtaanastomoticstenosis (Bharat A. J Vasc Surg 2012)• Intra-operative angioplasty of diseased donor artery(Napoli M. J Vasc Access 2007) and small vein in conjunction withpost-operative Balloon Angioplasty Maturation (BAM)(De Marco Garcia LP. J Vasc Surg 2010)Timing of AVF Maturation• Increase in AVF blood flow and diameter occur veryearly after AVF construction (Robbin M. Radiology 2002; Lin SL. Am JNephrol 1998)• Signs of successful maturation should be evident by 4weeks post-op (Robbin M. Radiology 2002)• AVF that fail to mature by 6-8 weeks do not mature (Asif A.Clin J Am Soc Nephrol 2006)• Physical examination needs to be performed at 4 weeksto assess for presence and cause of non-maturation(Concept 9, FISTULA FIRST Initiative)• Responsible anatomical derangements need to beidentified and expeditiously addressed (Concept 9, FISTULA FIRSTInitiative)89

Physical Exam of AVF• Has an accuracy of 80% in predicting maturation(Robbin M. Radiology 2002)• Normal mature AVF– easily compressible– soft pulse that quickly augments with AVF compression– prominent thrill at the anastomosis during systole anddiastole, thrill often extends over long segment of AVFPhysical Exam of AVF• Visible superficial branches– Accessory veins• Thrill that persists despite AVF occlusion– Significant upstream accessory veins• Enlarging segment near the anastomosis– Downstream venous stenosis• Weak pulse and weak thrill– Poor inflow due to arterial or anastomotic stenosis• Strong, abrupt pulse. Thrill absent or limited to systole.– Good arterial inflow and significant venous stenosis• Bounding pulse at the anastomosis. Pulse disappears within 5 cmdowstream.– Juxta-anastomotic stenosis• Contour of AVF hard to discern. Weak thrill.– AVF may be too deep• Arm swelling– Central venous stenosisAnatomical Derangements Responsiblefor AVF Non-maturation• Accessory veins• Arterial inflow stenosis• Arterial anastomotic stenosis• Juxta-arterial anastomosis stenosis• Venous stenosis in body/outflow tract of AVF• Central venous stenosis• Deep or excessively tortuous AVF90

Anatomical Derangements Responsiblefor AVF Non-maturation (119 patients)71.4% AVF had multiple derangements• Accessory veins 29.4%(3.4%)• Arterial inflow stenosis 5.1%• Arterial anastomotic stenosis 47.1%• Juxta-arterial anastomosis stenosis 63.9%• Venous stenosis in body/outflow tract 58.8%• Central venous stenosis 8.4%• Deep or excessively tortuous AVF 5.0%Nassar GM. Clin J Am Soc Nephrol 2006A simple algorithm for the evaluation of patients with early AVF failure©2006 by American Society of NephrologyAsif A et al. CJASN 2006;1:332-339Fistulography and Management• 21 G needle, 0.018” guidewire, 5F dilator/sheath• Orientation depends on location of suspected lesion• Angiography should include AVF, anastomosis, and central veins• Sheath is upsized to a 5 or 6 F short sheath as needed• Donor artery evaluation may require arterial access– femoral– Brachial• Endovascular revascularization is attempted if stenotic lesions are found• Treatment may need to be repeated• High Pressure Balloons and prolonged inflation times are used• Cutting balloons may be useful for recalcitrant lesions• Stents and stentgrafts are avoided• Open surgery is considered for those who do not respond to endovasculartherapy91

Significant Accessory VeinsSurgical Branch Ligation-infrequently reported among secondary procedures (

Juxta-arterial Anastomosis Stenosis (JAAS)• Defined as lesions close to the anastomosis• Reported prevalence 25-64% (Falk A. J Vasc Access 2011; Nassar GM. Clin J Am Soc Nephrol 2006;Beathard GA. Kidney Int 2003)• Often occurs at venous swing points• Angioplasty performed on 112 JAAS lesions in 73 patients 51%primary and 90% secondary patency at 1 year (Asif A. Semin Dialysis 2005)• Endovascular failures are treated with surgical revision– Proximal relocation of the anastomosis– Jump-graft– Patch repair• Retrospective comparison of PTA and surgical repair in 73patients with RC AVF and JAAS– Restenosis was higher in PTA group (69% vs 43%, p

Venous Stenosis in AVF Body/OutflowTract• Common lesion in poorly maturing AVF (33-59% of alllesions) (Falk A. J Vasc Access 2011)• Occurs in cephalic arch of BC AVF and in proximal veinswing point of BVT• Most likely to respond to PTA• Endovascular failures are treated with surgical revision– Patch repair– Jumpgraft to more proximal or different vein264233894

Central Venous Stenosis• Uncommon cause of maturation failure (3-9%) (Falk A. JVasc Access 2011; Nassar GM. Clin J Am Soc Nephrol 2006)• High pressure PTA is essential• Recurrence is common• Stents are deployed in recalcitrant lesions• Surgical revascularization such as jugular venousturndown or extra-anatomic central venous bypassseldom employed to support maturation• Limb abandonment is common95

Deep or Excessively Tortuous AVF• Prevalence depends on the posture of the surgeontoward superficialization and transpositionprocedures– Approach 1: Perform AV anastomosis and superficializeor transpose vein at a later time based on whethermaturation occurs• 295 fistula elevation procedures have 71% secondaryfunctional patency rates at 1 year (Bronder C. J Am Coll Surg 2008)– Approach 2: Transpose all veins that are judged to bedeep at the time of the first procedure96

Treatment Results (Meta-analysis)• 47% (95% CI 25%-70%) increase in maturation chance whenprimary failing AVFs were treated early (one study with controlgroup)• 85.5% of treated patients (range, 74%-98%) were able to usetheir AVF at least once for hemodialysis after treatment• Complications (8 articles, 508 patients)– 47 (9.3%) patients suffered complications• 28 (5.5%) hematoma• 11 (2.2%) venous rupture• 5 (1%) ischemic steal• 1 (

Robert Hye, MD September 27, 2012Kaiser Foundation Hospital –2:25 pm – 2:55 pmSan DiegoVASCULAR ACCESS INFECTIONS,MEDICAL, SURGICAL MANAGEMENTLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Manage catheter, prosthetic and autologous vascular accessinfections.2. Incorporate strategies to treat vascular access infection andpreserve access sites into practice.98

Vascular AccessInfection: Medical,Surgical ManagementRobert J. Hye, M.D.SCPMG, San DiegoDialysis Access Infection• Major Problem in Dialysis Population• Second leading cause of death aftercardiovascular disease• Leading cause of hospitalization• Often results in loss of access sites• May require temporary catheter use• Major driver of cost associated with vascularaccess• UremiaPre-disposing Factors forInfection in HemodialysisPatients• Directly impairs chemotaxis, phagocytosis and adherence ofneutrophils• Secondary metabolic changes also affect neutrophil function• Increase neutrophil apoptosis• Cell-mediated immunity depressed• Diabetes• Loss of natural barriers due to invasive procedures• Surgery, cannulation, IR procedures• Changes in bacterial flora• Markedly higher rates of S. aureus colonization99

Influence of Access Type onInfection Risk• Prospective multi-center Canadian studyof access related blood stream infection• AVF – 0.2 per 1000 dialysis procedures• AVG – RR – 2.5• Tunneled catheter – RR – 15.5• Non-tunneled catheter – RR 22.5Taylor et al, Infect Control HospEpidemiol, 2002; 23:716-20.Influence of Access Type onInfection RiskTaylor et al, Infect Control HospEpidemiol, 2002; 23:716-20.Survival Based on Access Type,SCPMG 2000 - 2009Red - AVFBlue - AVGGreen - CATHAVFWoo et al, Permanente Journal,2012; 16: 4-9.100

Bacteriology of Access Infection• Staph aureus• Coag (-) Staph• Enterococcus• Gram –negative organisms• Candida• MRSA and VRE are both increasing• 2005, CDC reported 15.4% of all MRSA infectionsoccur in dialysis population and estimated 100X riskof colonization versus non-dialysis patients*Varies by access typeBacteriology of Access InfectionTaylor et al, Infect Control HospEpidemiol, 2002; 23:716-20.Prevention of HemodialysisAccess Infection• Construct fistulas whenever possible• Minimize duration of catheter use• May be some benefit to antimicrobialimpregnated catheters and antimicrobial“lock” solutions but limited data• Meticulous surgical technique, perioperativeantibiotics, avoidance ofhematomas• Education and training of patients, dialysisunit staff101

Prevention of HemodialysisAccess InfectionsCDC MMWR 3/16/12Tunneled Catheter InfectionsCatheter Related Bacteremia (CRB)• Three types, may co-exist• Exit-site infection• Erythema, induration, purulence at exit site• Tunnel infection• Systemic signs of infection: fever, chills (on dialysis),erythema over tunnel• Catheter/Fibrin Sheath Infection• Biofilm• Diagnostic criteria by Infectious Disease Societyof North America• Based on timed quantitative cultures• Decision usually made empiricallyManagement of CRB• Blood cultures, peripheral and catheter• Initiate broad spectrum antibiotics (Vancomycinand aminoglycoside or 3 rd gen Cephalosporin)• Consideration of access site preservationimportant• Five strategies:• Antibiotic Therapy and Preservation• Exchange of catheter over guidewire via existingtunnel• Exchange of catheter over guidewire via new tunnel• Catheter removal/immediate replacement at new site• Catheter removal/delayed replacement102

Replacement of InfectedCatheters over Guidewire• Beathard, J AM Soc Nephrol, 1999• 123 cases, three groups: Catheter exchange withnew tunnel, without new tunnel, or removal anddelayed re-insertion• 75 – 85% cure at 45 days, no diff between groups• Tanriover, et al, Kidney Intl, 2000• 69 cases without overt sepsis• 31 immediate guidewire exchange, 38 delayed• No difference between groups in Infection freesurvival ~ 60% @ 50 days• KDOQI 2006 Guidelines• Recommended exchange over guidewire in absenceof gross infection/sepsisManagement of CRB• Mokrzycki, et al, Am Journal of Kidney Diseases, 2006• Compared outcomes of CRB in 223 cases in 7dialysis units w/wo dedicated catheter infectionmanagement team• Dedicated team associated with 73% (p < .02)decrease in combined endpoint of recurrentbacteremia and septic death• Guttman et al, J Vasc Interv Radiol, 2011• 61 cases, 25 guidewire exchange, 35 same dayremoval/replacement at new site• Infection rate 4.4 vs 2.3 per 1000 cath days (p = .49)Management of CRB• Mokrzycki et al, NephrolDial Transplant, 2006• Multivariate analysis in226 patients• Guidewire exchange vsremoval / delayedreplacement equivalent• Predictors of treatmentfailure were cathetersalvage (OR 5.4, p =.003) and S. aureusinfection (OR 4.2, p=.002)103

Summary of CatheterManagement in CRB• Catheter preservation does not work• CRB with sepsis, obvious tunnel or exit siteinfection best managed with removal anddelayed replacement at new site• CRB without overt signs of infection can bemanaged with guidewire exchange withcomparable results to remove/replacement• S. aureus may be an exception and remove/replaceshould be considered• 3 – 6 week course of culture directed antibioticsin all casesDialysis Graft Infection• Two categories• Peri-operative• Operative wound infections• Entire graft more likely to be infected• Less likely to be treatable with partial excision• Late• Related to dialysis unit punctures• Present with exposed or eroded graft, infectedpseudoaneurysm, infected hematoma, drainingsinus tract• Infection more likely to be limitedTherapy for Dialysis GraftInfections• Culture and initiate broad spectrum antibiotics• General principle is to excise all infectedprosthetic material• Total excision requires temporary access and mayrequire complex arterial reconstruction• More likely to be required for peri-operative infections• Subtotal excision preserves cuff to allow arterialclosure, also requires temporary access• Partial excision & reconstruction can eliminate theneed for a catheter and preserve the access site• Many graft patients have limited available access sites104

Technique of Partial GraftExcision• Expose arterial and venous limb of graft atuninfected, incorporated site• Divide graft, resect portion of incorporatedsegment of infected graft to be removed• Tunnel new segment of PTFE and performanastomoses• Close old tunnel to “wall off” anastomoses andclose wounds• Remove infected graft and either pack wound orclose over drains• Antibiotic Rx for 6 weeksPartial Graft ExcisionPartial Graft ExcisionPOD # 10105

Partial versus Total GraftExcision for Infection• Ryan, et al, J Vasc Surg, 2004• 51 graft infections treated with total excision (13),subtotal excision (15) or partial excision &preservation (23)• Management determined by extent of infection• Total and subtotal excisions all healed w/o recurrence• 74% (17/23) of partial excisions healed and remainedpatent• 6 failures required later total excision• Concluded selective management strategy wassuccessfulPartial versus Total GraftExcision for Infection• Walz & Ladowski, Ann Vasc Surg, 2005• 84 cases, total excision(26), subtotal excision(28), partial excision & preservation(30)• 46.7% (14/30) partially excised groupdeveloped recurrent infection• 44.4% of recurrences occurred within 6months• Concluded that partial excision preserves site,graft patency and avoids catheter but withsignificant recurrent infection ratePartial versus Total GraftExcision for InfectionSchutte et al, Am J Surg, 2007, 193:385 -388106

Dialysis Graft InfectionSummary• Management strategy determined by:• Extent and timing of infection• Severity of systemic sepsis• Availability of other access sites• Total and subtotal excision most effective ineradicating infection but require catheter andnew access site• Partial excision & preservation preserves accesssites, avoid catheters but is associated with 20 –25% recurrence rate• Requires close monitoring• 6 weeks of culture directed antibioticsInfected Autogenous DialysisFistulas• Rare, S. aureus pre-dominant organism• Usually due to erosion of aneurysmthrough skin or necrosis at puncture site• Contamination vs Infection• Excision/reconstruction with or withoutinterposition graft preferred treatment• Recent reports of covered stents inabsence of gross infectionEndovascular Therapy ofAneurysmal AV fistulas• Shemesh, et al, J Vasc Surg,2011• 20 patients with aneurysmsand graftpseudoaneurysms, 6erosions (Viabahn)• 87% patency at 1 year withno infections• Shah, et al, J Vasc Surg, 2012• 24 patients, 8 witherosions, 3 failed due toinfection (Viabahn)107

Infected Autogenous DialysisFistulas• Fistula reduction andreconstruction• Wound closure overdrains• Depending on extentof resection, cathetermay be requiredSummary• Vascular access infection is a major causeof morbidity and expense in the dialysispopulation• Prevention is effective and should be apart of every institution’s program• Therapy should be individualized with thegoals of treating infection with minimalmorbidity while preserving access sitesand avoiding catheter usage whenpossible108

Joseph Mills, MD September 27, 2012Chief3:25 pm – 3:45 pmDivision of Vascular andEndovascular SurgeryProfessorDepartment of SurgeryUniversity of ArizonaISCHEMIC STEAL, DIAGNOSIS ANDMANAGEMENTLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Manage ischemic steal syndrome and differentiate it from physiologicsteal.2. Diagnose ischemic by history, physical examination and simplenoninvasive tests.3. Identify patients at greatest risk for ischemic steal syndrome.109

Ischemic Steal Syndrome due to Hemodialysis Access ProceduresJoseph L. Mills, Sr., MDProfessor of SurgeryChief, Division of Vascular and Endovascular SurgeryUniversity of Arizona Health Sciences CenterTucson, Arizona 85724jmills@u.arizona.eduThis summary is based in large part on previously published work by the author and theUniversity of Arizona (see references).Background:An estimated 340,000 individuals with end stage renal disease are currentlymaintained on hemodialysis. Due to the Fistula First Initiative and improvements insystems of care, an increasing percentage of patients are dialyzed via an autogenousarteriovenous fistula (nearly 70% in our region). The remainder are dialyzed via cathetersor AV grafts. Both hemodialysis fistulae and grafts are associated with the developmentof ischemic steal syndrome (ISS), with a reported incidence of 1.6-8%. The purpose ofthis presentation is to review the risk factors for and hemodynamics of ischemic stealsyndrome and to detail effective techniques for diagnosis and management.Incidence and Presentation:The reported incidence of ISS ranges from 1.6 – 8%, although the true incidencemay be a bit higher due to lack of recognition and reluctance of clinicians to recognize allbut the most severe forms of the ISS spectrum. Preoperative factors that place individualsat increased risk for the development of ISS include: female gender, age > 60 years,diabetes, multiple operations on the same limb, construction of an autogenous fistula, andthe use of the brachial artery as the donor vessel. Mean patient age in the largest reportedseries is approximately 60 years and diabetes is present in about ¾ of patients with ISS.The development of ischemic symptoms distal to an arteriovenous (AV) fistulacan occur early (< 30 days) or late (>30 days) postoperatively. Although most symptomsoccurring acutely are self-limiting and resolve with observation, symptoms that occur lateare frequently progressive and demand more aggressive medical attention. Mostcommonly patients present with extremity coolness and vague neurosensory changes -often incorrectly diagnosed as diabetic neuropathy. In more severe cases, patients mayreport ischemic rest pain, ischemic ulceration of the digits, or intrinsic muscle weakness.Physical examination usually reveals diminished peripheral pulses, pallor, and evidenceof sensory or motor neuropathy. Because many of the signs and symptoms are rather nonspecific,clinicians should maintain a high index of suspicion in all patients with afunctioning AV fistula or graft who have distal extremity complaints.1101

The simplest confirmatory, noninvasive test is a hemodynamic one. Digitalphotoplethysmography (PPG) should be performed in the vascular laboratory with thefistula patent and then repeated after manual compression of the fistula. Although it isquite normal to have a reduction in the amplitude of digital waveforms distal to a patentproximal fistula, in pure ISS, the non-ischemic hand should demonstrate normal pulsatilewaveform contours. Patients with severe ISS have monophasic, flat, waveform contoursin the affected hand that augment with the compression of the fistula. Examples of digitalwaveforms in a patient with ISS and ischemic finger ulcers with and without compressionare in Figure 1 below, where A shows diminished pulsatility with blunted waveformswith fistula patent, and B shows marked improvement after fistula compression.Figure 1.Hemodynamics:The hemodynamics of AV fistulae have long interested surgeons, and a thoroughunderstanding of the physiologic sequelae of an AV fistula are important to diagnose andtreat patients with ISS. The magnitude of blood flow through an AV fistula is a functionof diameter of both the fistula and the donor artery. Fistulas have been classicallyclassified based on the fistula diameter relative to that of the donor artery. Small fistulasare defined as having a diameter less than 75% of the diameter of the inflow artery. Insuch fistulas the primary determinant of the magnitude of fistula flow is fistula resistance,which varies with the fourth power of fistula diameter. The natural history of smallfistulas is that the relatively sluggish flow through the fistula eventuates in thrombosis.Large fistulas have a diameter greater than 75% of that of the donor artery and themagnitude of blood flow tends to be independent of fistula resistance and diameter (seeFigure 2). In large fistulas flow is primarily determined by the relative resistances at thelevels of the peripheral vascular bed, the donor artery, and the collateral circulation.Because most surgically created fistulas are necessarily of the large variety to providesufficient blood flow to support hemodialysis (400 to 600 mL/min), the discussion thatfollows pertains only to this group. Fistula blood flow in large fistulae (beyond thevertical line in Figure 2) is no longer dependent on fistula diameter, but rather on relativeresistances of the fistula components (inflow, peripheral arterial bed and collateralcirculation).1112

Figure 2: (From JACS 2000: Wixon et al)Figure 3: Basic components of an AV fistula1123

A fistula consists of a donor artery (inflow), outflow vein, a low flow - highresistance connection (the peripheral vascular bed); the fistula itself (a low resistanceconnection); and a parallel set of inflow and outflow conduits (the arterial and venouscollaterals). Creating an AV fistula (high flow, low resistance) causes a transient drop inproximal arterial pressure that is quickly compensated by an increase in the heart rate andcardiac output. Temporary occlusion of an AV fistula by manual compression results in atransient increase in blood pressure and a fall in heart rate and cardiac output (Branham-Nicoladoni sign). After AV fistula creation, both the proximal arterial and proximalvenous flow increase several fold. In all cases, the direction of blood flow in the proximalartery remains centrifugal (toward the periphery) and the direction of blood flow in theproximal vein remains centripetal (toward the heart). The direction of blood flow in thearterial and venous collaterals remains predictable with arterial collateral flow directedperipherally and venous collateral flow directed centrally. The direction of blood flow inthe artery distal to the fistula varies and may be antegrade, retrograde, or bidirectional.The reversal of blood flow in the artery just distal to the fistula is common, and NOTsufficient to diagnose ISS.Pressure gradients govern the direction and magnitude of blood flow in the arterydistal to the fistula and are related, in complex ways, to the hemodynamic resistances ofthe proximal artery, the arterial collaterals, the fistula, and the peripheral vascular bed(ddP = QR, where ddP is the pressure gradient, Q is the flow, and R is the resistance).Sumner’s description of the relationship using a simple electrical analogue (Ohm’s Law)provides the best conceptual understanding. In this model the artery immediately distal tothe fistula is represented by the cross arm of a Wheatstone bridge (Fig. 3B). The problemof flow through the cross arm of the Wheatstone bridge was first solved by CharlesWheatstone in 1843. Traditional methods of solving the equation require solving sixsimultaneous loop equations. A more recent technique, Maxwell’s method, uses both ofKirchoff ’s rules and reduces the number of simultaneous equations to three. The solutiondemonstrates that the pressure gradient between the two points is dictated by theresistance ratios of inflow to fistula and collateral to peripheral vascular bed. Thepressure in the artery at the level of the fistula (Fig. 3A, point C) is a function of the ratiobetween the resistance of the proximal artery (Fig. 3A, segment BC) and the fistula (Fig.3A, segment CE). The pressure in the artery distal to the fistula (Fig. 3A, point D) is afunction of the ratio of resistance of the arterial collaterals (Fig. 3A, segment BD) to thedistal vascular bed (Fig. 3A, segment DE). The importance of these relationships cannotbe overemphasized because the pressure gradient between these two points will dictatethe direction and magnitude of the blood flow in the artery distal to the fistula.Using this model, one can predict the effect of varying individual portions of thecircuit. For example, the model correctly predicts that increasing the peripheral vascularresistance favors the development of steal; increasing fistula resistance would favorantegrade flow in the distal artery. From a practical standpoint, deprivation of adequatedistal perfusion by the presence of either retrograde flow or low magnitude antegradeflow in the artery distal to the fistula defines ischemic steal syndrome.1134

Theoretically the presence of a large arteriovenous fistula always reduces the perfusion tomore peripheral tissues. This is evidenced by the fact that the perfusion pressure isalways lower distal to an arteriovenous fistula. Under usual circumstances arterialcollaterals and compensatory peripheral vasodilatation are sufficient to maintainperipheral perfusion at adequate levels. The relevance and magnitude of steal becomesclinically important only if distal arterial perfusion pressure is insufficient to satisfy distalmetabolic requirements. Simply stated, although the direction and magnitude of bloodflow in the artery just distal to the fistula is of academic interest it is the adequacy ofmore distal perfusion that is of practical interest.Various Ischemic Steal Syndrome Clinical Scenarios:The model discussed above readily allows one to explain and evaluate different scenariosof ISS as they may present.Ischemic symptoms during dialysis:Problem: hand numbness or pain occurring only during dialysisMisconception: symptoms are due to increase in fistula flow during dialysis andincreased brachial shunt fraction.Actual mechanism: marked reduction in myocardial preload and systemic blood pressureduring dialysis, especially likely if patient’s baseline BP is low prior to initiating dialysis.Additive effect of reduced systemic blood pressure plus chronically reduced distalperfusion pressure may exceed compensatory mechanisms of vascular bed producingglobal and accentuated distal ischemiaSolution: if symptoms are mild-moderate and occur only during dialysis, hold BPmedications the morning of dialysis.Ischemic steal in longstanding fistulas/grafts (Changes with chronicity):Background hemodynamics and compensatory mechanisms:The establishment of an AV fistula for hemodialysis produces several importantphysiologic consequences. The increased flow velocity in both the donor artery andoutflow vein serves as a potent long term stimulus for these vessels to dilate to normalizetransmural shear stress. The chronic distal ischemia tends to maximize peripheralvasodilation and stimulate the maturation of a rich collateral network. To predict howthese changes will interact, one must recall the relationship that exists between the vesselradius and resistance (Poiseuille’s Law). Although the principles of Poiseuille’s Law (i.e.,ideal fluid, laminar flow, rigid tube of fixed diameter) cannot be strictly satisfied by thecurrent model we must recognize that the resistance offered by a conduit varies inverselywith the fourth power of the radius: R = 8hL/pr4 where h = viscosity constant, L = lengthof stenosis, and r = radius of stenosis. The consequences of these changes in resistancecan then be predicted by reexamining the ratios in Table 1. The model predicts that both1145

lower fistula resistance and decreased collateral resistance are likely to augmentretrograde flow in the artery distal to the fistula. These factors are partially compensatedby the decrease in the resistance of the inflow artery. More peripherally there must be apoint (presumably at the entrance of a large collateral artery) at which the flow becomesantegrade (Figure 3A, point D). In truth, a strict boundary between antegrade andretrograde flow does not exist; there is bidirectional flow with each systole and diastole.Physiologically the location of this point is arbitrary, but anatomically this location mayrepresent an area of low shear stress at increased risk for accelerated atherogenesis aspreviously described in the particle resonance theory of carotid plaque formation. Thiscurious observation was previously made in a published report that described substantialocclusive disease in this segment of the artery in all 11 patients in whom the ischemicsyndrome developed chronically after arteriovenous fistula construction. Despite thehemodynamic changes that favor the development of steal at the level of the artery distalto the fistula, most individuals remain entirely asymptomatic. In fact augmentedcollateral circulation may account for the gradual improvement of distal perfusionpressure noted by Lazarides and others. Surgical intervention cannot be recommended forthe mere presence of reversal of flow, but rather is reserved for patients withsymptomatic, disabling, or limb-threatening ischemia.The following situations can lead to ISS in longstanding AV accesses:Inflow stenosis:Problem: may occur in 20-30% of patients with ISS and should be excluded beforepursuing other treatment options.Mechanism: any process that increases the resistance of the inflow artery changes theresistance ratios in Table 1 to increasingly favor steal. It is for this reason that selectivearteriography of the donor artery remains a critical portion of the evaluation beforeembarking on surgical revision to correct symptomatic steal syndrome.Solution: Pressure gradients across any suspicious lesions should be measured.Correction of a hemodynamically significant inflow stenosis by angioplasty and/or stentmay relieve ISS symptoms.1156

Treatment of Ischemic Steal Syndrome:Unreliable techniques that are often ineffective –BandingPlicationReason for lack of reliability and efficacy:Based on premise that increasing resistance in the circuit can improve distal perfusion.Generally unreliable, insufficient, and often result in fistula thrombosisEffective procedures:Distal Revascularization Interval Ligation (DRIL):First suggested by Schanzer and colleagues in 1988, this procedure works on theperipheral circulation aspect of the fistula equation rather than on the resistance side.Although these authors also recognized that the ischemic steal syndrome resulted from adiscordant relationship between the resistance in the fistula and periphery, they suggestedworking the equation from the side of the peripheral circulation. They suggested that apotential mechanism of inadequate peripheral circulation resulted from a poorly formedcollateral network. In an attempt to reduce the resistance in the peripheral circuit, abypass graft (in essence, a low-resistance collateral) was created between the arteryproximal to the fistula and the artery distal to the fistula. This reduced the resistance ratiobetween the peripheral circulation and the fistula, reduced the brachial shunt fraction, anddirected a greater proportion of blood flow toward the periphery. To prevent retrogradeflow back up the native artery distal to the fistula, the artery distal to the fistula wasligated (Fig. 4A).Since this initial report, patients in whom this technique has been utilized haveexperienced excellent access patency and relief of ischemic symptoms. DRIL has the besttrack record in achieving these dual goals of ISS therapy.DRIL: mechanism of actionOne must remember that surgically created fistulas are of the large variety and that theprimary determinant of magnitude of blood flow through the fistula remains a function ofthe diameter of the donor artery. By definition the process of banding, or plication, mustnarrow the fistula sufficiently to convert a large, flow-independent fistula to a small, flowdependent fistula, the natural history of which is to eventually thrombose. Because theplication technique increases the resistance of the fistula it necessarily increases theresistance of the total circuit. In the face of a fixed inflow pressure the result is a globalreduction in circuit blood flow, of which a smaller fraction is shunted through the fistula.Although sometimes sufficient to improve peripheral perfusion, it creates a low-flowstate in the fistula and induces thrombosis. The resultant graft thrombosis, which usuallyoccurs subsequent to banding, remains predictable.In contradistinction the DRIL procedure (Fig. 4A) reduces resistance not only1167

within the peripheral circulation, but also within the total system. In the simplest termsthe bypass graft functions as a low-resistance collateral in parallel circuitry (Fig. 4B).Recalling that the inverse of the total resistance of a parallel circuit is the sum of theinverse of the individual resistors, 1/Rtotal = 1/R1 1 1/R2 the total resistance of the parallelcircuit is always lower than that of each individual resistor. By reducing the ratios ofresistance between the systemic circulation and the fistula, the brachial shunt fraction isdecreased and peripheral perfusion is augmented. The overall reduction in resistance inthe system augments the total blood flow in the extremity such that fistula blood flowsare maintained. If a distal bypass graft were performed without concomitant ligation ofthe artery distal to the fistula, it could certainly augment the retrograde flow in the distalbrachial artery. In the face of ligation the blood flow is left with no other choice but tofollow the pressure gradient downstream to the peripheral vascular bed. Some vascularsurgeons remained concerned about ligating the artery below the fistula origin, but inpractice, this component of the procedure rarely leads to significant adverse sequelae.Figure 4.Key points to DRIL procedure:1. Use autogenous vein whenever possible2. Exclude inflow stenosis before proceeding with DRIL procedure3. Originate the bypass well proximal to the pressure sink zone near the AVF origin.In practice, this might need to be at least 5-10 cm. In an upper extremity fistula,there is a continuous drop off in arterial pressure from the origin of the ipsilateralsubclavian artery to the large pressure sink zone at the origin of the fistula itself.If the bypass is originated too close to the pressure sink zone, the inflow will beinadequate to restore adequate distal perfusion (somewhat analogous to1178

performing a femoral-femoral bypass without first correcting an inflow iliacstenosis with a 30 mm Hg gradient). In practice, if the bypass graft origin isplaced at a sufficient distance proximal to the fistula origin, persistent steal willnot be a problem.Illustrations of DRIL procedure: Figures 5 (left) and 6 (right)Other procedure to correct ISS:RUDI (Revision Using Distal Inflow): Minion et al Ann Vasc Surg 2005;19:625-28.This procedure seems to be fairly effective (mechanism – reducing donor artery diameterwithout need for banding). It is most applicable to elbow level fistulae where inflow tofistula can be transposed from brachial to radial artery. Long-term effectiveness versusDRIL has not been established, and hemodynamic results compared to DRIL are unclear.1189

PAI ( Proximalization of Arterial Inflow):Physiologic mechanism: adds fistula lengthAvoids arterial ligation. The illustration below is from Zanow and associates, JVS 2006.A recent series from the University of Pittsburgh (JVS 2011) depicts the relative efficacyof various procedures to treat ISS. The largest experience in this report, and in the overallliterature, is with DRIL. PAI and RUDI also appear effective, but experience andduration of follow-up are more limited than with the DRIL procedure. Banding, and ofcourse ligation, are ineffective. The approach of banding should likely be abandoned.11910

Ligation may still be an option for early severe ISS, especially when the fistula has notbeen accessed and does not have a proven track record of successful access performance.Other options can then be reconsidered before committing to a more complex procedureto correct ISS.Conclusions:The development of the ischemic steal syndrome remains an important complication afterthe creation of an AV fistula. Before the description of the DRIL procedure attempts atsurgical correction often failed to correct the distal ischemia or resulted in fistulathrombosis. As a result there was a general reluctance for clinicians to fully recognize thesyndrome. In many centers this reluctance banding continue to disappoint both the patientand the surgeon. The innovative design of the DRIL procedure uniquely provides areliable means to reestablish distal perfusion without compromising fistula patency and isstrongly recommended as the procedure of choice in treating ischemic steal syndrome.PAI and RUDI procedures also hold promise for treatment of ISS in appropriatelyselected patients.12011

REFERENCES:1. National Institute of Diabetes and Digestive and Kidney Diseases, NIH, HHS. UnitedStates Renal Data System annual data report; 2010.2. Health Care Financing Administration, HHS. End stage renal disease programhighlights [fact sheet]; August 1997.3. Haimov M, Baez H, Neff M, Slifkin R. Complications of arteriovenous fistulas forhemodialysis. Arch Surg 1975;110:708– 712.4. Zibari GB, Rohr MD, Landreneau MD, et al. Complications from permanenthemodialysis access. Surgery 1988;104:681-686.5. Kwun KB, Schanzer H, Finkler N, et al. Hemodynamic evaluation of vascularangioaccess procedures for hemodialysis. Vasc Surg 1979;13:170-177.6. Ballard J, Blunt TJ, Malone J. Major complications of angioaccess surgery. Am J Surg1992;164:229–232.7. Berman SS, Gentile AT, Glickman MH, et al. Distal revascularization-interval ligationfor limb salvage and maintenance of dialysis access in ischemic steal syndrome. J VascSurg 1997;26:393–404.8. Morsy AH, Kulbaski M, Chen C, et al. Incidence and characteristics of patients withischemia after hemodialysis access procedure. J Surg Res 1998;74:8–10.9. Lazarides MK, Staamos DN, Panagopoulos GN, et al. Indications for surgicaltreatment of angioaccess-induced arterial “steal.” J Am Coll Surg 1998;187:421–426.10. DeCaprio JD, Valentine RJ, Kakish, et al. Steal syndrome complicating hemodialysisaccess. Cardiovasc Res 1997;5: 648–653.11. Strandness DE Jr, Gibbons GE, Bell JW. Mercury strain gauge plethysmography:evaluation of patients with acquired arteriovenous fistulas. Arch Surg 1962;85:215–219.12. Byrne JP, Stevens LE,Weaver DH, et al. Advantages of surgical arteriovenousfistulas for hemodialysis. Arch Surg 1971;102: 359–362.13. Strandness DE, Sumner DS. Arteriovenous fistula. In: Hemodynamics for surgeons.1st ed. New York: Grune & Stratton, Inc; 1975:621–663.14. Sumner DS. Arteriovenous fistula. In: Strandness DE Jr, ed. Collateral circulation inclinical surgery. Philadelphia: WB Saunders; 1969:[section 2]27–90.15. Zarins CK, Giddens DP, Bharadvaj BK, et al. Carotid bifurcation atherosclerosis.Quantitative correlation of plaque localization with flow velocity profiles and wall shearstress. Circ Res 1983;53:502–514.16. Shemesh D, Mabjeesh NJ, Abramowitz HB. Management of dialysis access -associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimalflow reduction. J Vasc Surg 1999;30:193–195.17. Fillinger MF, Reinitz ER, Schwartz RA, et al. Beneficial effects of banding onvenous intimal-medial hyperplasia in arteriovenous loop grafts. Am J Surg 1989;158:87–94.18. Schanzer H, Schwartz M, Harrington E, Haimov M. Treatment of ischemia due to“steal” by arteriovenous fistula with distal artery ligation and revascularization. J VascSurg 1988;7:770–773.19. Ingebrigtsen R, When PS. Local blood pressure and direction of flow in experimental12112

arterio-venous fistula. Acta Chir Scand1960;120:142–150.20. Wixon CL, Mills JL, Berman SS. Distal revascularization - interval ligation formaintenance of dialysis access and restoration of distal perfusion in ischemic stealsyndrome. Semin Vasc Surg 2000;13:1–7.21. Wixon CL, Hughes JD, Mills JL. Understanding Strategies for the treatment ofIschemic Steal Syndrome after Hemodialysis Access. JACS 2000;191(3):301-310.22. Knox RC, Berman SS, Hughes JD, Gentile AT, Mills JL. Distal revascularizationintervalligation: a durable and effective treatment for ischemic steal syndrome afterhemodialysis access. J Vasc Surg 2002;36;250-6.23. Minion DJ, Moore E, Endean E. Revision using distal inflow: a novel approach todialysis-associated steal syndrome. Ann Vasc Surg 2005;19:625-28.24. Zanow J, Kruger U, Scholz H. Proximalization of the arterial inflow: A newtechnique to treat access-related ischemia. J Vasc Surg 2006;43:1216-1221.25. Gupta N, You TH, Konig G, Dillavou E, Leers SA, Chaer RA, et al. Treatmentstrategies of arterial steal after arteriovenous access. J Vasc Surg 2011;54(1):162-167.12213

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David Shavelle, MD September 27, 2012Associate Professor of Clinical3:45 pm – 4:05pmMedicineDivision of Cardiovascular MedicineTHE MANAGEMENT OF THROMBOSED ANDFAILING FISTULAS/GRAFTSLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Treat thrombosed and failing fistulas/grafts.2. Identify treatment options for thrombosed and failing fistulas/grants.3. Define various endovascular treatment options for thrombosed andfailing fistulas/grants.124

Endovascular Management ofThrombosed/Failing FistulasDavid M. Shavelle MD FACC FSCAIAssociate Clinical ProfessorKeck School of Medicine at USCDirector, Interventional Cardiology FellowshipDirector, Cardiac Catheterization LaboratoryLos Angeles County + USC Medical CenterDisclosures/Conflict of Interest• Abiomed, Inc.• Abbott Vascular, Inc.• Glaxo Smith Kline (GSK)• St Jude Medical, Inc• Maquet, Inc.Speaker’s BureauSpeaker’s BureauResearch Grant SupportResearch Grant SupportSpeaker’s HonorariumResearch Grant SupportOutline: Endovascular Management ofThrombosed/Failing Fistulas• Pathophysiology of access failure• Signs of access failure• Endovascular therapy• ‘cross-sheath’ technique• 4-step approach• PTA vs stents vs covered stents• Success rates• Complications• Medical therapy125

Definitions• Early (Primary) Failure• Access than never provided reliablehemodialysis after surgical creation• Prevalence: ~50% 1-3• More common in diabetics and elderly• Inflow stenosis at juxta-anastomotic site• Late Failure• Access that initially worked• Outflow stenosis• Stasis of blood flow thrombosis1 Asif A, et al. Clin J AM Soc Nephrol 2006;1:33209; 2 Patel ST, et al. J Vas Surg 2003;38:439-45;3 Berman SS, et al. J Vasc Surg 2002;34:866-71Pathogenesis of Access FailureEarlyLateInflow StenosisFailure to MatureOutflow StenosisStasisThrombosisCommon Indications forEndovascular Intervention1. Early failure of fistulas (BAM)• Inflow stenosis• Outflow stenosis2. Late failure of fistulas• Access thrombosis• Venous/outflow stenosis3. Arm edema (central stenosis)4. Prolonged bleeding following cannulation5. Poor flow during dialysis – fistula flow

Pre-emptive Invasive Evaluation• Early angiography and PTA may preventsubsequent access thrombosis• Intervention on an open (non–thrombosed)access has longer patency than intervention ona closed (thrombosed) access• Some studies suggest benefit• Other studies suggest no benefit• Dember et al Kidney Int 2004• Moist LM J Am Soc Nephrol 2003• Bittl JA Cath Cardiovasc Intervent 2009p 0.16• Static venous pressure/Systolic blood pressureratio (SVPR)• 64 patients with ↑SVPR• >0.4 Intervention• Observation groupfollowed for graftthrombosis• Primary endpoint: graftabandonment4-step Approach1. Thrombectomy of outflow, fistula/graftand inflow segments2. PTA of venous outflow stenosis3. Fogarty thrombectomy of adherentclot at arterial inflow anastomosis4. Angiography of fistula/graft, centralveins and inflow region127

Dual-Sheath TechniqueStep 1: ThrombectomyMultiple Devices• Pulse-spray infusion catheters• Mechanical thrombectomy devices• Amplatz device (Microvena)• Arrow-Treotola (Arrow Int)• Gelbfish Endo-vac (Neovascular)• Rheolytic thrombectomy (Medrad)• Balloon - aspiration techniqueVenous limb 1 stBittl J J Am Coll Cardiol Intv 2010:3;1-11Step 2: Angiography and PTA• PTA using balloons sized 6–8mm in diameter• Occasionally non-compliantballoons (conquest, dorado)and cutting balloons (bostonsci) may be required (↑vesselrupture)• Use of stents for flow limitingdissections, perforation andphysician preferenceBittl J J Am Coll Cardiol Intv 2010:3;1-11128

Step 3: Re-establish inflow• Fogarty thrombectomy ofarterial inflow• Persistent and/or resistantthrombus at inflow segmentmay require more aggressivePTA and/or thrombectomy• Continued poor inflow may besecondary to stenosis withinnative radial/brachial artery,prior to proximal anastomoticsiteBittl J J Am Coll Cardiol Intv 2010:3;1-11Resistant ThrombusBittl J J Am Coll Cardiol Intv 2010:3;1-11Step 4: Completion venography• Complete venography of central veins,body of AVG/graft and inflow segments• Central venous stenosis• Residual thrombus• Residual stenosis (at PTA site)• Central venous stenosis – usuallyrequires stent placement secondary tosignificant recoil post PTA129

Role of Stent Placement• Stenting provides no clear benefit over PTA controversial• FLAIR study• Eliminates possibility of using stentedsegment for surgical revision• Stents reserved for: several recoil, centralvenous stenosis, perforation or stenosis insurgically inaccessible veins• 190 patients with severe venous stenosis• Randomized to PTA vs PTA + stent graft• Multi-center• AVDG ONLY (no fistulas)• Primary objective: stent graft was not inferior to PTA for 6-month primary patencyN Engl J Med 2010;362:494-503.Primary Endpoint: 6 mo patencyp < 0.00151%23%N Engl J Med 2010;362:494-503.130

Endovascular Intervention:Success Rates560 patients1437proceduresSuccess= 30 days ofsuccessful dialysis throughtreated access siteCatheter Cardiovasc Interv 2010.Fistulasn = 703Dialysis Graftsn = 734Stenosedn = 46489% successThrombosedn = 14780% successStenosedn = 23796% successThrombosedn = 46294% successLong Term Success RatesFistula 20%Graft 5%Catheter Cardiovasc Interv 2010.Complications• Access site hematomas• Perforation• ~1% of cases• May be increased with use of cutting balloons• Associated with poor short graft patency• Usually requires use of covered stents(Fluency, WallGraft or Viabahn)• Pulmonary embolism• secondary to ineffective thrombus removal• Stroke• intra-cardiac shunt (ASD, PFO)• Peripheral embolism131

ComplicationsPulmonary Embolism~10%132

Left Arm AngiogramCut-off of left brachial artery3.0 mm Spider FilterThrombusremoved withSpider Filter133

PrePostMedical Therapy• Clopidogrel (Plavix) vs Placebo• 877 pts at 9 centers with newly created fistula• Randomized to clopidogrel vs placebo• Primary endpoint: fistula thrombosis at 6 wks• 12.2% vs 19.5%, p 0.018• Secondary endpoint: failure of fistula for dialysis(pump rate > 300 mL/min during 8 of 12 dialysissessions)• 62% vs 60%, p NS• Clopidogrel ↓frequency of early thrombosis ofnew fistulas but does not ↑proportion of fistulasthat become suitable for dialysisJAMA. 2008;299(18):2164-2171Medical Therapy• Dipyridamole (Persantine) vs placebo• 649 pts at 13 centers with newly placed AVDG• Dipyridamole + aspirin (Aggrenox) vs placebo• Primary endpoint: loss of primary unassisted patency(patency without thrombosis or need for intervention)at 1 year) 28% vs 23%, p 0.001.• Secondary endpoint: cumulative graft failure anddeath No difference• Combination dipyridamole + aspirin had a significant,but modest effect in improving graft patencyN Engl J Med 2009;360:2191-201.134

Medical TherapyMedian duration of patency:5.8 months 4.3 months (1.5 months)N Engl J Med 2009;360:2191-201.Thank You135

Karen Woo, MD September 27, 2012Assistant Professor of Surgery3:45 pm – 4:05pmDivision of Vascular Surgery &Endovascular TherapyANEURYSMAL FISTULA REDUCTION ANDRECONSTRUCTIONLECTURE OBJECTIVESAt the end of this lecture, participants will be able to:1. Treat aneurysmal degeneration of arteriovenous fistulas.2. Identify treatment options for aneurysmal arteriovenous fistulas.3. Evaluate complications associated with aneurysmal arteriovenousfistulas.

Karen Woo, MDDivision of Vascular Surgery andEndovascular TherapyUniversity of Southern California Pseudoaneurysms more commonthan true aneurysms No clear size definition Three times native vessel diameter◦ Not including areas immediately beforeor after aneurysm a◦ Minimum diameter 2 cm Incidence in literature 5-30%a. Paslinsky G, et al. J Vasc Surg 2011;53:1291-1297 Several theories◦ Repeated punctures• Reasonable explanation for focalaneurysms◦ Central or outflow vein stenosis• Account for

Dilation occurs over several years Mean time approx four years Dialysis centers refer only forproblems◦ Size at time of referral varies widelya. Skin breakdown Pain Infection Thrombosis Poor flow Steal syndrome Venous hypertension High output congestive heart failure Cannulation difficulty◦ Aneurysmal segments lined with muralthrombus◦ Difficult to find flow channel with needle◦ May be referred for “thrombosed” fistuladue to dark thrombus found in needle138

Infection◦ Superficial skin infection with poorquality skin◦ Thrombus becomes seeded with bacteria• Infection of thrombus and aneurysm wall• Acute bleeding and intravascular infection NKF-DOQI guidelines◦ Intervention should be performed forpresence of aneurysm◦ Aneurysmal segment should not becannulated Ligation with/without resection◦ Simplest◦ Requires new dialysis to be created Resection and re-anastomosis◦ Requires adequate length formobilization and tension-freeanastomosis◦ Ideal for small, localized aneurysms139

Replace with interposition graft◦ PTFE• converts access into prosthetic• Increased infection• Decreased patency◦ Saphenous vein a• Series of seven with 18 month follow-up• Six patent, one thrombosisa. Paslinsky G, et al. J Vasc Surg 2011;53:1291-1297 Oversew, wrap with braided metal mesh a◦ 1 patient◦ 15 months- no recurrence Oversew, wrap with polyethyleneterephthalate b◦ Reduce intimal hyperplasia◦ Four patients◦ One required removal for infection◦ No long term follow upa. Grauhan O, et al. Eur J Vasc Endovasc Surg 2001;21:274-5.b. Balaz P, et al. J Vasc Access 2008;9:81-4. Plication without resection a◦ 15 patients◦ No early thrombosis/ graft failure◦ No long term follow-up Surgical staplers b◦ Excess wall resected◦ Staple line oversewn◦ 12 patients, 29 month follow-up◦ Two recurrencea. Lo HY. Ann Acad Med Singapore 2007;36:851-3.b. Pierce GE, et al. Vasc Endovascular Surg 2007;41:55-60140

More commonly used for AV graftpseudoaneurysms Converts AV fistula into AV graft◦ Increased infection◦ Increased thrombosis Requires adequate landing zone forendograft Pre-operative evaluation withvenogram◦ Correct venous outflow stenoses General anesthesia Tunneled catheter placed at time ofoperation Skin incision made along length offistula Fistula circumferentially dissected out◦ Arterial anastomosis to normal fistula141

Heparin Proximal and distal control Aneurysm opened longitudinally Excess length resected Back wallanastomosis◦ Running 6-0Prolene142

20 Fr redrubber catheter Excess wallresected Fistulareconstructed Excess skinresected◦ Including skinbreakdown orthin skin Skin closed intwo layers143

144

19 patients over a 4 year period a Median age 47 (IQR 29) 13 (68%) Male 9 (47%) with history of renaltransplanta. Woo K, et al. J Vasc Surg 2010;51:921-5 Location◦ 18 (84%) upper arm• 14 brachiocephalic• 2 basilic vein transposition◦ 3 forearm• 2 radialcephalic• 1 basilic vein transpositiona. Woo K, et al. J Vasc Surg 2010;51:921-5 Median time since original fistulacreation◦ 4 years (IQR 3) Indication for operation◦ 4 (21%) bleeding◦ 10 (53%) skin breakdown◦ 2 (11%) infection145

Perioperative variableOperative time (mean)188 minutesEstimated blood loss 268 cc (range 50-1000)Follow up (median) 23 months (IQR 22)Length of stay (mean)Time to removal oftunneled hemodialysiscatheter (mean)1.1 days10 weeks Patency at 3 years◦ Primary: 93%◦ Secondary 89% One recurrent infection◦ Required resection Three repeat percutaneousangioplasty of outflow stenosis◦ 9, 15 and 30 months One abandoned at 16 months◦ Pre-op failure of multiple angioplasties ofcephalic arch stenosis◦ Cephalic vein was transected at shoulderand anastomosed to axillary vein◦ Subsequent re-stenosis all at veno-venoanastomosis146

One late thrombosis at 15 months◦ Secondary to hypotension from cardiacfailure One late infection at 27 months◦ Required fistula ligation Two late unrelated deaths 11 alive and followed at time of study◦ Functional fistulas◦ No recurrences147

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POLICY ON CULTURAL AND LINGUISTIC COMPETENCE 2011‐12Keck School of Medicine of USCOffice of Continuing Medical EducationPOLICY ON CULTURAL AND LINGUISTIC COMPETENCYIN CONTINUING MEDICAL EDUCATIONThe Accreditation Council of Continuing Medical Education (ACCME) expects accredited providersto operate business and management policies and procedures of their CME program so that theirobligations and commitments are met. As part of this accreditation requirement, the ACCMEexpects that accredited providers located in California will be in compliance with all applicableCalifornia state laws regarding continuing medical education delivered in California, including CAA.B. 1195, enacted in 2005.In accordance with A.B. 1195, the Keck School of Medicine of the University of Southern CaliforniaOffice of Continuing Medical Education has adopted a policy of incorporating cultural and linguisticcompetency in the formulation and planning of Continuing Medical Education (CME) courses inorder to maintain, develop, or increase the knowledge, skills, and professional performance that aphysician uses to provide care, or improve the quality of care provided for patients.These educational activities should include, but are not limited to, any of the following criteria:1. Have a scientific or clinical content with a direct bearing on the quality or cost-effectiveprovision of patient care, community or public health, or preventive medicine;2. Concern quality assurance or improvement, risk management, health facility standards, or thelegal aspects of clinical medicine;3. Concern bioethics or professional ethics;4. Are designed to improve the physician-patient relationship.A.B. 1195 has provided three ways to comply with the law:1. Cultural competency is defined as a set of integrated attitudes, knowledge, and skills thatenables a health care professional to care effectively for patients from diverse cultures,groups, and communities. Items to be addressed include linguistic skills, cultural informationto establish therapeutic relationships, cultural data in diagnosis and treatment, and culturaland ethnic data applying to the process of clinical care. To comply with the culturalcompetency requirement, an activity should include the following:a. applying linguistic skills to communicate effectively with the target population;b. utilizing cultural information to establish therapeutic relationships;c. eliciting and incorporating pertinent cultural data in diagnosis and treatment;d. understanding and applying cultural and ethnic data to the process of clinical care.2. Linguistic competency is defined as the ability of a physician to provide patients who do notspeak English or who have limited ability to speak English with direct communication in thepatient’s primary language. To comply with the linguistic competency requirement, an1149

POLICY ON CULTURAL AND LINGUISTIC COMPETENCE 2011‐12activity may incorporate translation/interpretation resources and/or strategies into activitymaterials.3. A review and explanation of relevant federal and state laws and regulations regardinglinguistic access. At the activity site, KSOM OCME will provide supporting documents andresources to the physicians, including, but not limited to, handouts, websites, patienteducation, and local resources.Continuing medical education activities that are exempt from these requirements include thoseactivities solely dedicated to research and other activities that do not contain patient care components(such as leadership).Documentation of compliance will be presented on the application and/or planning form for theCME activity. This policy will be included in the planning packet for activity directors and facultyso that the program and presentations will comply with the law.June, 20062150

KECK SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTHERN CALIFORNIAOFFICE OF CONTINUING MEDICAL EDUCATIONCULTURAL AND LINGUISTIC COMPETENCE RESOURCES FORHEALTH CARE PROVIDERSCultural and Linguistic Competence in Health CareCenter for Effective Collaboration and PracticeIt is the mission of the Center for Effective Collaboration and Practice to support and promote a reoriented nationalpreparedness to foster the development and the adjustment of children with or at risk of developing serious emotionaldisturbance. To achieve that goal, the Center is dedicated to a policy of collaboration at Federal, state, and local levels thatcontributes to and facilitates the production, exchange, and use of knowledge about effective practices.http://cecp.air.org/cultural/default.htmNational Center for Cultural Competence (NCCC)The mission of the National Center for Cultural Competence (NCCC) is to increase the capacity of health and mental healthprograms to design, implement, and evaluate culturally and linguistically competent service delivery systems.http://www11.georgetown.edu/research/gucchd/nccc/NCCC Conceptual Framework and ModelThe NCCC embraces a conceptual framework and model for achieving cultural competence based on the work of Cross etal. (1989). http://www11.georgetown.edu/research/gucchd/nccc/foundations/frameworks.htmlDefining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health CarePublic Health Rep 2003; 118: 293-302, July, 2003 / August, 2003, FEATURE ARTICLEhttp://www.med.umich.edu/multicultural/ccp/projects.htm#publicationsStudy On Measuring Cultural Competence in Health Care Delivery Settings: A Review of the LiteratureA literature assessment, sponsored by HRSA, that synthesizes and examines the measurement of cultural competence, asrelated to health care. This review will serve as a basis for decisions about the scope, content, and value of the culturalcompetence measurement profile to be developed.Sponsoring organization: U.S. Department of Health and Human Serviceshttp://www.hrsa.gov/culturalcompetence/measures/default.htmLet Everyone ParticipateProvides information on Federal programs and activities regarding language access to Federal agencies, recipients ofFederal funds, and community individuals and organizations. Also provides demographic data. http://www.lep.gov/Cultural Competency Continuing Education ProgramsAn information portal of the most recent cultural competency materials and program developments. The website offerscontinuing medical education (CME) credit and equips family physicians with awareness, knowledge, and skills to bettertreat the increasingly diverse U.S. population they serve.Sponsoring organization: U.S. Department of Health and Human Services http://www.thinkculturalhealth.org/DiversityRxPromotes language and cultural competence to improve the quality of health care for minority, immigrant, and ethnicallydiverse communities. http://www.diversityrx.org/HTML/DIVRX.htm151Page 1 of 62/20/2009

KECK SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTHERN CALIFORNIAOFFICE OF CONTINUING MEDICAL EDUCATIONNational Alliance for Hispanic HealthMission is to improve the health and well being of Hispanics. The Alliance informs consumers, supports health and humanservice providers in the delivery of quality care, improves the science base for accurate decision making by promotingbetter and more inclusive research, promotes appropriate use of technology, ensures accountability, advocates on behalfof Hispanics, and promotes philanthropy. Information in English and Spanish. http://www.hispanichealth.org/National Center for Cultural CompetenceMission is to increase the capacity of health and mental health programs to design, implement, and evaluate culturally andlinguistically competent service delivery systems. Information available in Spanish.http://www.mchgroup.org/nccc/index.htmlNational Center on Minority Health and Health DisparitiesThe mission is to promote minority health and to lead, coordinate, support, and assess the NIH effort to reduce andeliminate health disparities. NCMHD will conduct and support basic, clinical, social, and behavioral research, promoteresearch infrastructure and training, foster emerging programs, disseminate information, and reach out to minority andother health disparity communities. http://www.nih.gov/about/almanac/organization/NCMHD.htmNational Council on Interpreting in Health CareA multidisciplinary organization based in the United States whose mission is to promote culturally competent professionalhealth care interpreting as a means to support equal access to health care for individuals with limited English proficiency.http://www.ncihc.org/Think Cultural HealthProvides cultural competency continuing education programs and other resources for physicians, pharmacists, and nursesto better meet the cultural and linguistic needs of an increasingly diverse patient population. Offers a free onlineaccredited educational program for health care providers. http://www.thinkculturalhealth.org/Assessment ToolsNational Center for Cultural Competence (HRSA grantee Web site):http://www11.georgetown.edu/research/gucchd/nccc/Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile(HRSA-funded Web site):http://www.hrsa.gov/culturalcompetence/indicators/Provider’s Guide to Quality & Culture (not a U.S. Government Web site):http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=EnglishCultural Competency: Tools and Resources (University of Michigan)http://www.med.umich.edu/multicultural/ccp/tools.htmProviders Guide to Quality and Culture (Management Sciences for Health)http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=EnglishCulture-/Language-Specific SitesAfrican-AmericanBe Safe Workbook: A Cultural Competency Model for African Americans (HRSA grantee Web site)http://www.aidsetc.org/pdf/p02-et/et-17-00/be_safe.pdfAmerican Indian/Alaska Native/Native HawaiianClinician's Guide: Working with Native Americans Living with HIV (HRSA grantee Web site)http://www.aidsetc.org/pdf/curricula/clin_guide_native_am.pdfNative American HIV Care: A Training Platform (HRSA grantee Web site)152Page 2 of 62/20/2009

KECK SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTHERN CALIFORNIAOFFICE OF CONTINUING MEDICAL EDUCATIONhttp://www.mpaetc.org/scripts/prodview.asp?idproduct=95Changing Directions: Strengthening the Shield of Knowledge (HRSA grantee Web site)http://www.aidsetc.org/aidsetc?page=et-04-01Native Hawaiian Healthhttp://www.nativehawaiianhealth.net/ (HRSA grantee Web site)Asian American/Pacific IslanderProvider’s Guide to Quality & Culture Asian American and Pacific Islander Seminars (Not a US Government web site)http://erc.msh.org/aapi/index.htmlShaman and Physicians Partner for Improving Health for Hmong Refugees (HRSA grantee Web site)http://www11.georgetown.edu/research/gucchd/nccc/documents/Cultural_Broker_Guide_English.pdf#search=%22Shaman%20and%20Physicians%20Partner%20for%20Improving%20Health%20for%20Hmong%20Refugees%22Hispanic/Latino/SpanishPuertas de Diversidad: Culturally Guided Interventions with Latinos (HRSA grantee Web site)http://www.mpaetc.org/scripts/prodview.asp?idproduct=102USA-Mexico Border Health Cultural Competency Page (HRSA grantee Web site)http://borderhealth.raconline.org/topics/topic.php?topic=cultural%20competencyTraining Providers Who Serve Mono/Bilingual Spanish Speaking Clients(HRSA grantee Web site) http://www.aidsetc.org/ppt/pacific_latinos.pptLatino Be Safe Workbook: A Cultural Competency Model for Latinos (HRSA grantee Web site)http://www.aidsetc.org/pdf/p02-et/et-17-00/be_safe_latino.pdfWhy The Difference InitiativeDesigned to increase provider awareness about disparities in health care. The website also provides a Speaker’sKit to help physicians talk to patients about cardiovascular care.Sponsoring organization: Kaiser Family Foundation http://www.kff.org/whythedifference/The Cross Cultural Health Care ProgramServes as a bridge between communities and health care institutions to ensure full access to quality health carethat is culturally and linguistically appropriate. Provides a combination of cultural competency trainings,interpreter trainings, research projects, and community coalition building. Sponsoring organization: CrossCultural Health Care Program http://www.xculture.org/Physician Toolkit and Curriculum: Resources to Implement Cross-Cultural Clinical Practice Guidelines for MedicaidPractitionersThis toolkit aids healthcare providers in the practical application of the Cross-Cultural Clinical Practice Guidelines.It introduces the basic fundamentals of cross-cultural practice and offers steps and processes essential todelivering quality care to culturally diverse populations.Sponsoring organization: HHS Office of Minority Health http://www.omhrc.gov/assets/pdf/checked/toolkit.pdfAssessment of Organizational Cultural CompetenceSurvey tool to assist organizations in assessing their level of cultural competency.Sponsoring organization: Association of University Centers on Disabilitieshttp://www.aucd.org/councils/multicultural/Cultural_Competence_Survey.htmThe Provider's Guide to Quality and CultureDesigned to assist healthcare organizations throughout the United States in providing high quality, culturallycompetent services to multi-ethnic populations.Sponsoring organization: Health Resources and Services Administrationhttp://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English153Page 3 of 62/20/2009

KECK SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTHERN CALIFORNIAOFFICE OF CONTINUING MEDICAL EDUCATIONDictionary of Health Related Terms, 3rd Edition (English - Spanish)An instrument for health care personnel and other professionals working with the Latino population in the UnitedStates. Purpose is to strengthen communication between Spanish-speaking populations and the health workersserving them, and facilitate dialogue by reducing cultural and linguistic barriers.Sponsoring organization: California Office of Binational Border Health http://www.uctv.tv/calpen_spanish/English-Spanish.pdfA Guide to Planning and Implementing Cultural Competence Organizational Self-AssessmentA guide of self-assessment activities including the development of knowledge and products, dissemination, andthe provision of technical assistance and consultation.Sponsoring organization: National Center for Cultural Competencehttp://www11.georgetown.edu/research/gucchd/nccc/documents/ncccorgselfassess.pdfA Guide to Choosing and Adapting Culturally and Linguistically Competent Health Promotion MaterialsProvides guidance on how to assure that health promotion materials reflect the principles and practices of culturaland linguistic competence.Sponsoring organization: National Center for Cultural Competencehttp://www11.georgetown.edu/research/gucchd/nccc/documents/Materials_Guide.pdfHablamos JuntosMission is to improve communication between health care providers and their patients with limited Englishproficiency. To accomplish this they develop affordable models that will help doctors, hospitals and their staffcare for a changing patient population by funding ten demonstration sites in regions with established or emergingfast-growing Latino populations. Also includes resources on interpreter services, signage, and developing Spanishlanguage materials.Sponsoring organization: Robert Wood Johnson Foundation http://www.hablamosjuntos.org/default.aspLimited English Proficiency (LEP) and Hispanic Worker InitiativeProvides a variety of resources regarding multilingual and multicultural strategies for serving job seekers andworkers with limited English proficiency.Sponsoring organization: Employment and Training Administration http://www.doleta.gov/reports/dpld_lep.cfmSpecial PopulationsGay, Lesbian, Bisexual, Transgenderhttp://www.aidsetc.org/pdf/p02-et/et-17-00/msm_toolkit.pdfGay and Lesbian Medical Associationhttp://www.glma.org/Children with Special Health Care Needshttp://www.familyvoices.org/diversity_statement.htmGeriatricCurriculum In Ethnogeriatric EducationThis second edition of the five modules in the Core Curriculum in Ethnogeriatrics was developed by members ofthe Collaborative of Ethnogeriatric Education in 1999 and 2000, with support from the Bureau of HealthProfessions, Health Resources and Services Administration. The first edition of the Curriculum was reviewed,revised, and expanded by working groups from the membership of the Collaborative. This group is composed offaculty from 31 Geriatric Education Centers throughout the United States which serve as regional resourcecenters for geriatric education for multiple health care disciplines. The modules were developed to serve as abasic generic curriculum in ethnogeriatrics. Ethnic specific information is included as examples of the conceptsonly. http://www.stanford.edu/group/ethnoger/index.htmlThe content of this site introduces a clinical tool for ethnogeriatric education, the ETHNICS Mnemonic. Each module154Page 4 of 62/20/2009

KECK SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTHERN CALIFORNIAOFFICE OF CONTINUING MEDICAL EDUCATIONcontains the clinical tool in both an English and Spanish version and reference materials. It can be used as asupplement to the Core Curriculum in Ethnogeriatrics.http://www.med.fsu.edu/geriatrics/ethnogeriatric/default.aspDiversity, Healing, and Health CareA cooperative project of On Lok SeniorHealth and the Stanford Geriatric Education Center (Division of Family andCommunity Health, Stanford University School of Medicine), and partially funded through a grant from the Bureauof Health Professions, U.S. Department of Health and Human Services. Diversity, Healing and Healthcarepresents cultural and religious information relevant to healthcare providers. It is not intended to be a completeview of any culture or religion, but rather 'sound bytes' to provide information that may impact communicationbetween health care providers and patients who are from different cultures. Content experts, including clinicians,patients, diversity trainers, clergy, and educators have reviewed the information.http://www.gasi.org/diversity.htmHomeless PopulationNational Health Care for the Homeless CouncilAlthough many people think that culture refers only to the knowledge, attitudes, beliefs, and behaviors influenced by raceor ethnicity, the concept also includes factors such as age, gender, socioeconomic status, level of education, physicalcapacity, spirituality and religion, sexual orientation, and regional influences. This broad definition takes into account whatHealth Care for the Homeless (HCH) providers strive to do on a daily basis: skillfully deal with the individual concernspresented by each client.http://www.nhchc.org/cultural.htmlFarm Workers/Migrant Workershttp://www.farmworkerhealth.org/pubs.jsp#http://www.ncfh.org/http://www.bphc.hrsa.gov/migrant/default.htmPublicationsBridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker ProgramsA guide to implement cultural broker programs in health care settings, particularly those that employ or serve asplacement sites for National Health Service Corps scholars and clinicians in service. Sponsoring organization: NationalCenter for Cultural CompetenceDate: 2004http://www11.georgetown.edu/research/gucchd/nccc/documents/Cultural_Broker_Guide_English.pdf#search=%22Shaman%20and%20Physicians%20Partner%20for%20Improving%20Health%20for%20Hmong%20Refugees%22Compendium of Cultural Competence Initiatives in Health CareSummaries of the activities accomplished by public and private sector organizations that seek to reduce cultural andcommunication barriers to health care.Sponsoring organization: Kaiser Family FoundationDate: 01 / 2003http://www.kff.org/uninsured/6067-index.cfmCultural Competence in Serving Children and Adolescents With Mental Health ProblemsDiscusses the need for culturally competent systems of mental health care and describes what such systems shouldinclude.Sponsoring organization: Substance Abuse and Mental Health Services Administrationhttp://www.mentalhealth.samhsa.gov/publications/allpubs/CA-0015/default.aspCultural Competence in the Prevention and Treatment of Obesity: Latino AmericansDiscusses weight management among Latino AmericansAuthor(s): John P. ForeytSponsoring organization: Kaiser PermanenteJournal citation: Permanente Journal Volume: 7 Issue: 2 Date: 2003http://xnet.kp.org/permanentejournal/spring03/latino.html155Page 5 of 62/20/2009

KECK SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTHERN CALIFORNIAOFFICE OF CONTINUING MEDICAL EDUCATIONCultural Competence Standards in Managed Care Mental Health Services: Four Underserved/Underrepresented Racial/Ethnic GroupsDesigned to provide readers with the tools and knowledge to help guide the provision of culturally competent mentalhealth services within today's managed care environment. Document derived from experts from four core racial/ethnicpopulations: Hispanics, American Indians/Alaska Natives, African Americans, and Asian/Pacific Islanders.Sponsoring organization: Substance Abuse and Mental Health Services AdministrationDate: 01 / 2001http://www.mentalhealth.samhsa.gov/publications/allpubs/sma00-3457/Cultural Competence Works: Using Cultural Competence to Improve the Quality of Health Care for Diverse Populations and AddValue to Managed Care ArrangementsIdentifies and describes successful programs that address the needs of underserved, culturally diverse communities,including interpreter services, cultural competence training for staff, targeted outreach programs, and other culturallyappropriate interventions.Sponsoring organization: Health Resources and Services Administrationhttp://minority-health.pitt.edu/archive/00000278/Cultural Competence: It All Starts at the Front DeskDiscusses how developed policies, training, and direct resources targeted for support staff in health care organizations willdevelop the attitudes, behaviors, skills, and knowledge necessary to serve families in culturally and linguistically competentways.Sponsoring organization: National Center for Cultural Competencehttp://www11.georgetown.edu/research/gucchd/nccc/documents/FrontDeskArticle.pdfImproving Cultural Competency in Children's Health CareReport describes the practical changes in processes to make healthcare providers and the systems in which they workmore effective in responding to the needs of diverse children and how health care delivery organizations can track theirprogress.Sponsoring organization: National Initiative for Children's Healthcare QualityDate: 07 / 2005http://www.hablamosjuntos.org/resources/pdf/NICHQ_Improving_Cultural_Competency_in_Childrens_Health_Care.pdf#search=%22Improving%20Cultural%20Competency%20in%20Children's%20Health%20Care%22National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final ReportProvides a list and discussion of the National Standards for Culturally and Linguistically Appropriate Services in Health Careas issued by the U.S. Department of Health and Human Services' Office of Minority Health (OMH) to ensure that all peopleentering the health care system receive equitable and effective treatment in a culturally and linguistically appropriatemanner. These standards for culturally and linguistically appropriate services or CLAS are proposed as a means to correctinequities that currently exist in the provision of health services and to make these services more responsive to theindividual needs of all patients/consumers.Sponsoring organization: Health Resources and Services AdministrationDate: 03 / 2001http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15Teaching Cultural Competence in Health Care: A Review of Current Concepts, Policies and PracticesReports the findings of an environmental scan that will serve to inform the development of Cultural CompetenceCurriculum Modules (CCCM) for family physicians. This work is supported by the Office of Minority Health (OMH) of theU.S. Department of Health and Human Services (DHHS) and represents the first effort to create such training materials atthe national level.Date: 03 / 2002http://www.omhrc.gov/assets/pdf/checked/em01garcia1.pdf#search=%22Teaching%20Cultural%20Competence%20in%20Health%20Care%3A%20A%20Review%20of%20Current%20Concepts%2C%20Policies%20and%20Practices%22156Page 6 of 62/20/2009