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

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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
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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
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NOTES______________________________
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Vascular AccessSurveillanceIs it wo
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Monitoring Vs. SurveillanceClinical
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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 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: David Shavelle, MD September 27, 20
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
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