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

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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
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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______________________________
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NOTES______________________________
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When to Break the Guidelines in Vas
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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 and 112: Ischemic Steal Syndrome due to Hemo
Page 113 and 114: Figure 2: (From JACS 2000: Wixon et
Page 115 and 116: Theoretically the presence of a lar
Page 117: Treatment of Ischemic Steal Syndrom
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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