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

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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
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Program Book
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Needs AssessmentOver 370,000 patien
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ACKNOWLEDGEMENTSWe would like to th
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No relevant financial relationships
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2:25 pm Vascular Access Infections,
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ESRD in 2012: Socio-economicImpactJ
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Geographic variations in adjustedin
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Adjusted all-cause & cause specific
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ESRD-International ComparisonsPreva
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Outcomes for first-time wait-listed
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NOTES______________________________
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Vascular Access Planning andPreoper
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• Veins not circular but ovoid, m
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VENOGRAM+ -CFDI+ 17(true positive)-
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• Thorough preoperative assessmen
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NOTES______________________________
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Options and Strategies forUpper Ext
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Cimino (radiocephalic) AVFPotential
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Two Stage BBAVFStage 1 anastomosis
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Brachial Artery-Brachial Vein AVFSu
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Forearm AV GraftsLarge surface area
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Comparison of brachial-basilic AVfi
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Racial differences in AVfistula rat
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THANK YOU!46
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Lower ExtremityDialysis AccessAhmed
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Lower Extremity Dialysis AccessWhat
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Lower Extremity Dialysis AccessData
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Lower Extremity Dialysis AccessData
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Thank You!LLUMC56
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NOTES______________________________
Page 61 and 62: NOTES______________________________
Page 63 and 64: When to Break the Guidelines in Vas
Page 65 and 66: efore initiation of dialysis. It fu
Page 67 and 68: NOTES______________________________
Page 69 and 70: Vascular AccessSurveillanceIs it wo
Page 71 and 72: Monitoring Vs. SurveillanceClinical
Page 73 and 74: Vascular Access Surveillance• Obs
Page 75 and 76: Vascular Access SurveillanceRandomi
Page 77 and 78: Vascular Access SurveillanceRandomi
Page 79 and 80: So why does preemptiveangioplasty n
Page 81 and 82: • ConclusionAccess Surveillance
Page 83 and 84: Management of the Non-MaturingArter
Page 85 and 86: Specific Definition• “…use of
Page 87 and 88: AVF Maturation in Clinical Practice
Page 89 and 90: Hemodialysis Fistula MaturationCons
Page 91 and 92: Physical Exam of AVF• Has an accu
Page 93 and 94: Significant Accessory VeinsSurgical
Page 95 and 96: Venous Stenosis in AVF Body/Outflow
Page 97 and 98: Deep or Excessively Tortuous AVF•
Page 99 and 100: Robert Hye, MD September 27, 2012Ka
Page 101 and 102: Influence of Access Type onInfectio
Page 103 and 104: Prevention of HemodialysisAccess In
Page 105 and 106: Summary of CatheterManagement in CR
Page 107 and 108: Partial versus Total GraftExcision
Page 109 and 110: Infected Autogenous DialysisFistula
Page 111: Ischemic Steal Syndrome due to Hemo
Page 115 and 116: Theoretically the presence of a lar
Page 117 and 118: Treatment of Ischemic Steal Syndrom
Page 119 and 120: performing a femoral-femoral bypass
Page 121 and 122: Ligation may still be an option for
Page 123 and 124: arterio-venous fistula. Acta Chir S
Page 125 and 126: David Shavelle, MD September 27, 20
Page 127 and 128: Definitions• Early (Primary) Fail
Page 129 and 130: Dual-Sheath TechniqueStep 1: Thromb
Page 131 and 132: Role of Stent Placement• Stenting
Page 133 and 134: ComplicationsPulmonary Embolism~10%
Page 135 and 136: PrePostMedical Therapy• Clopidogr
Page 137 and 138: Karen Woo, MD September 27, 2012Ass
Page 139 and 140: Dilation occurs over several years
Page 141 and 142: Replace with interposition graft◦
Page 143 and 144: Heparin Proximal and distal control
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Page 147 and 148: Perioperative variableOperative tim
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Page 151 and 152: POLICY ON CULTURAL AND LINGUISTIC C
Page 153 and 154: KECK SCHOOL OF MEDICINE OF THE UNIV
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